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Pediatrics BRS > Chapter 3 - Adolescent > Flashcards

Chapter 3 - Adolescent Flashcards

1
Q

Describe the timing, hormonal regulation, extent and duration of the pubertal growth spurt.

A
  • it occurs 18-24 months earlier in females
  • during this period GH, insulin, thyroid hormone, and sex steroids drive growth
  • nearly 50% of adult weight and 25% of adult height are gained during this period
  • on average, it lasts 2-3 years
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2
Q

How long does puberty last and when does it typically begin for boys and girls?

A

it usually begins at age 9.5 in girls and 6-12 months later in boys, lasting 3-4 years

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3
Q

Define adrenarche. How is this different from puberty.

A
  • the onset of adrenal androgen steroidogenesis that occurs about two years before the maturation of the hypothalamic-pituitary-gonadal axis
  • true puberty doesn’t occur until gonadotropins (LH, FSH, sex steroids) increase
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4
Q

What is the first sign of puberty in boys and girls?

A

testicular enlargement in boys and thelarche in girls

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5
Q

Describe the timeline of puberty in boys.

A
  • adrenarche occurs about two years before maturation of the HPG axis
  • true puberty, when gonadotropins increase, then begins around age 10-11
  • the first sign of puberty is testicular enlargement between ages 11-12 and then genitalia progress through the tanner stages
  • facial and axillary hair growth begin approximately two years after growth of pubic hair
  • the process typically takes 3-4 years
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6
Q

Describe the timeline of puberty in females.

A
  • adrenarche occurs about two years before maturation of the HPG axis
  • true puberty, when gonadotropins increase, then begins at roughly 9.5 years old with thelarche
  • pubic hair generally follows thelarche
  • menarche occurs at a mean age of 12.5 years and 2-3 years after thelarche
  • the process typically takes 3-4 years
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7
Q

What is the role of FSH in males and females?

A
  • induce spermatogenesis

- induce development of ovarian follicles and stimulate estrogen production by granulosa cells

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8
Q

What is the role of LH in males and females?

A
  • induces testicular Leydig cells to produce testosterone

- stimulates ovarian theca cells to produce androgens, the corpus luteum to produce progesterone, and ovulation

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9
Q

What is the role of testosterone in males?

A
  • increase linear growth and muscle mass
  • induce development of the penis, scrotum, and seminal vesicles as well as growth of pubic, axillary, and facial hair
  • deepen the voice and increase libido
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10
Q

What is the role of testosterone in females?

A

stimulate linear growth and growth of pubic and axillary hair

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11
Q

What is the role of estradiol in males?

A

increase the rate of epiphyseal fusion

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12
Q

What is the role of estradiol in females?

A
  • stimulate breast development
  • trigger the mid cycle LH surge and ovulation
  • stimulate labial, vaginal, and uterine development
  • stimulate growth of the proliferative endometrium and conversion to a secretory endometrium
  • low levels stimulate linear growth and high levels increase the rate of epiphyseal fusion
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13
Q

What is the role of adrenal androgens in males and females?

A

stimulates growth of pubic hair and linear growth

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14
Q

Describe the tanner stages.

A
  • I is pre-pubertal, II is 8-11.5 years old, III is 11.5-13, IV is 13-15, and V is over 15
  • hair: none, sparse, coarsening, coarse but sparing medial thigh, coarse across medial thigh
  • breast: flat with raised nipple, breast bud, mound forms, mound on mound with raised areola, adult contour with flattened areola
  • penis: pre-pubertal, testicular enlargement, increase in length, increase in width and glands, adult
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15
Q

Describe the age of and psychosocial development that occurs during early adolescence.

A
  • typically seen between 10-13 years of age
  • there is a shift towards independence with declining interest in family activities, conflicts with parents, and mood/behavior changes
  • preoccupation with pubertal body changes
  • same-sex peer relationships
  • beginnings of abstract thinking and lack of impulse control with increased risk-taking
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16
Q

Describe the age of and psychosocial development that occurs during middle adolescence.

A
  • typically seen between 14-17 years of age
  • there is an increase in conflicts with parents, diminished preoccupation with pubertal changes, increased preoccupation with methods for improving one’s physical appearance, intense peer group involvement, initiation of romantic relationships, additional abstract thinking and risk taking
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17
Q

Describe the age of and psychosocial development that occurs during late adolescence.

A
  • typically seen between 18-21 years of age
  • they develop a self distinct from parents and are now more willing to take parental advice, comfortable with body image, abstract thought is developed, fewer risk-taking behaviors, able to articulate future goals
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18
Q

Which female adolescents should receive an annual pelvic exam?

A
  • those who are sexually active
  • those with a history of pelvic pain, vaginal discharge, or abnormal bleeding
  • those who are over the age of 18
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19
Q

What are the three leading causes of death in adolescents 15-19?

A
  • unintentional injuries
  • homicide
  • suicide
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20
Q

What are nine risk factors for suicide or depression in adolescents?

A
  • family or peer conflicts
  • substance abuse
  • significant loss
  • divorce or separation of parents
  • poor school performance or learning disability
  • physical or sexual abuse
  • family history
  • previous suicide attempt
  • physical illness
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21
Q

What are the behavioral, physical, and psychological signs of depression in adolescents?

A
  • behavioral: missing school, change in school performance, acting out, lack of interest, desire to be alone, and substance abuse
  • physical: abdominal pain, headaches, weight loss, overeating, insomnia, anxiousness, diminished appetite, fatigue
  • psychological: sadness, feelings of hopelessness, low self-esteem, excessive self-criticism, feeling worthless
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22
Q

What are the criteria for diagnosing depression?

A

five of nine symptoms almost every day for at least two weeks, which impair normal functioning

  • depressed or irritable moood
  • diminished interest or pleasure
  • weight gain or loss
  • insomnia or hypersomnia
  • psychomotor agitation or retardation
  • fatigue or energy loss
  • feelings of worthlessness
  • diminished ability to concentrate
  • recurrent thoughts of suicide or depression
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23
Q

What are the criteria for dysthymia?

A

two of five symptoms while depressed, lasting more than one year

  • poor appetite or overeating
  • insomnia or hypersomnia
  • diminished energy
  • difficulty concentrating
  • feelings of hopelessness
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24
Q

What are signs that an adolescent may be using illicit substances?

A
  • mood or sleep disturbances
  • truancy or a decline in school performance
  • changes in friends and family relationships
  • diminished appetite or weight loss
  • depression
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25
Q

What is the difference between problem drinking, binge drinking, and alcoholism?

A
  • problem drinking is being intoxicated six or more times within one year or having problems in areas attributable to drinking
  • binge drinking is defined as five or more consecutive drinks at one sitting
  • alcoholism is defined as a preoccupation with and impaired control over drinking, despite adverse consequences
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26
Q

What is the CAGE questionnaire?

A

it is a screening tool for alcoholism

  • have you ever felt the need to cut down on drinking?
  • have people annoyed you by criticizing your drinking?
  • have you ever felt guilty about drinking?
  • have you ever had a drink first thing in the morning (i.e. eye opener)?
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27
Q

What are the health risks of smoking cigarettes?

A
  • coronary artery disease and stroke
  • various cancers
  • chronic lung disease and asthma
  • peptic ulcer disease
  • pregnancy complications such as stillbirth, low birth weight, and higher-than-normal infant mortality
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28
Q

What are the health risks of smokeless tobacco?

A
  • oral cancers
  • gingival recession
  • low birth weight and premature delivery
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29
Q

What are the physical effects of marijuana?

A
  • tachycardia and mydriasis
  • sleepiness, impaired cognition, and auditory or visual hallucinations
  • conjunctival erythema, dry mouth, and increased appetite
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30
Q

What are the long-term consequences of marijuana use?

A
  • asthma
  • impaired memory and learning
  • truancy
  • diminished interpersonal interactions
  • depression
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31
Q

Give two ways in which we define obesity.

A

as a body weight 20% greater than ideal body weight or as a BMI greater than 95% for age and sex

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32
Q

What sorts of health effects are associated with obesity, particularly during adolescence?

A
  • earlier pubertal development
  • poor body image, depression, and low self-esteem
  • orthopedic problems
  • gall bladder disease
  • HTN, cardiovascular disease, hypercholesterolemia and elevated triglycerides, and type 2 diabetes mellitus
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33
Q

What are the diagnostic criteria for anorexia nervosa?

A
  • refusal to maintain body weight with a weight at least 15% below ideal for age and sex
  • intense fear of weight gain
  • disturbed body image
  • absence of three consecutive menstrual cycles
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34
Q

What exam and lab findings are consistent with a patient who has anorexia nervosa?

A
  • hypothermia, hypotension, and bradycardia
  • delayed growth and puberty
  • anemia
  • low thyroxine, calcium, magnesium, phosphorus, and sex steroids
  • elevated BUN and liver enzymes
35
Q

What are the diagnostic criteria for bulimia nervosa?

A
  • recurrent episodes of binge eating at least twice weekly for three months
  • lack of control over eating during binging with anxiety, guilt, or sadness often occurring afterwards
  • purging, fasting, rigorous exercise, or diet pills
  • disturbed body image
36
Q

What exam and lab findings are consistent with a patient who has bulimia nervosa?

A
  • trauma to palate and hands from vomiting, loss of dental enamel, and parotid swelling
  • low chloride, low potassium, and high BUN with excessive vomiting
37
Q

Adolescent pregnancy is associated with what health problems and other poor outcomes?

A
  • infant health problems like low birth weight and higher-than-usual infant mortality
  • maternal health problems like anemia, HTN, and preterm labor
  • dropping out of school or unemployment
38
Q

What is a vaginal diaphragm? What are the advantages and disadvantages?

A
  • it is a mechanical barrier placed against the cervix and used in combination with spermicide
  • advantages: spontaneity since it can be inserted up to 6 hours before intercourse
  • disadvantages: need for fitting, difficult to place, risk for UTI
39
Q

What is a cervical cap? What are the advantages and disadvantages?

A
  • a cuplike diaphragm placed tightly over the cervix
  • advantages: leave in place for up to 48 hours
  • disadvantages: need for fitting, risk for UTI, need for follow-up Pap smear to screen for cervical dysplasia
40
Q

How do copper and progesterone IUDs work? What are the advantages and disadvantages?

A
  • copper interfere with sperm transport and motility while progesterone induce endometrial atrophy
  • advantages: convenience and privacy
  • disadvantages: lack of protection against STDs, uterine bleeding and cramping, higher initial cost, risk for PID
41
Q

How do oral contraceptives work? What are the advantages and disadvantages? What are the absolute and relative contraindications?

A
  • they inhibit ovulation and thicken cervical mucus
  • advantages: regulation of menstrual bleeding, possible protection against endometrial and ovarian cancer, improved acne
  • disadvantages: headache, weight gain, amenorrhea, breakthrough bleeding, mood changes, nausea, lack of STD protection, need for daily pill ingestion
  • absolute contraindications are pregnancy, breast or endometrial cancer, stroke, CAD, or liver disease
  • relative contraindications are hypertension, migraines, diabetes, sickle cell anemia, elevated lipids, smoking
42
Q

Depo contraception lasts for how long? What are the disadvantages?

A
  • three months

- irregular bleeding, weight gain, lack of STD protection

43
Q

What are seven risk factors for STDs in adolescents?

A
  • lack of barrier contraception
  • young age at initiation of sexual intercourse
  • spontaneous sexual encounters
  • multiple sexual partners
  • concurrent substance abuse
  • homosexual or bisexual teens
  • cervical ectopy
44
Q

What is vaginitis?

A

an infection of the vaginal epithelium caused by trichomonas vaginalis, a sexually transmitted protozoan, bacterial vaginosis, or candida

45
Q

Trichomonas vaginalis

A
  • a sexually transmitted protozoan that causes vaginitis
  • presents with malodorous, profuse, yellow-green discharge, a strawberry cervix, dyspareunia, and vulvar inflammation with itching
  • diagnosed with wet-mount saline microscopy demonstrating motile protozoa, positive culture, and vaginal pH greater than 4.5
  • treat patient and partners with oral metronidazole
46
Q

Bacterial vaginosis

A
  • the most common cause of vaginitis in adolescents, it is caused by a change in the vaginal flora (not an STD)
  • a reduction of lactobacilli, increases the concentration of Cardnerella vaginalis, Mycoplasma hominid, and anaerobic gram-negative rods
  • presents with gray-white thin vaginal discharge that has a fishy odor; there is little vaginal or vulvar inflammation
  • diagnosed with a positive whiff test using 10% potassium hydroxide, identification of clue cells, and a vaginal pH greater than 4.5
  • treated with oral metronidazole; partners don’t require treatment
47
Q

Candidal vulvovaginitis

A
  • a non-sexually transmitted cause of vaginitis
  • it presents with a white, curd-like discharge and vulvar inflammation with sever itching
  • diagnosis based on positive culture, fungal hyphae present on wet-mount or potassium hydroxide microscopy, and a normal vaginal pH less than 4.5
  • treat with oral fluconazole; partners don’t require treatment
48
Q

How can Trichomonad vaginalis, bacterial vaginosis, and candida vulvovaginitis be differentiated?

A
  • T. vaginalis has a yellow-green discharge and vulvar inflammation, pH is elevated above 4.5, and it is sexually transmitted so partners require treatment
  • Bacterial vaginosis has a white discharge with a fishy odor, no vulvar inflammation, pH elevated above 4.5, and it isn’t sexually transmitted so partners don’t require treatment
  • Candidal vulvovaginitis has a white, curd-like discharge as well as itching and vulvar inflammation, pH is normal below 4.5, and it isn’t sexually transmitted
49
Q

What is cervicitis?

A

an inflammation of the mucous membranes of the endocervix, most often by C. trachomatis or N. gonorrhoeae

50
Q

C. trachomatis cervicitis

A
  • an inflammation of the mucous membranes of the endocervix, caused by an inctracellular bacterium
  • presents with a purulent endocervical discharge, edematous erythematous cervix, and dysuria and urinary frequency
  • complicated by PID, tuboovarian abscess, infertility, ectopic pregnancy, chronic pelvic pain, perihepatitis, and neonatal conjunctivitis or pneumonia
  • treated with doxycycline, erythromycin, or azithromycin as well as presumptive treatment of N. gonorrhoeae
  • diagnosed via PCR or culture
51
Q

N. gonorrhoeae cervicitis

A
  • an inflammation of the mucous membranes of the endocervix, caused by a gram-negative intracellular diplococcus
  • presents with a mucopurulent endocervical discharge, dysuria and urinary frequency, and dyspareunia
  • complicated by PID, tuboovarian abscess, chronic pelvic pain, neonatal conjunctivas, perihepatitis, and infertility
  • diagnosed with culture on Thayer-Martin media, by Gram stain, of with PCR
  • treated with ceftriaxone and presumptive co-infection with C. trachomatis
52
Q

Pelvic Inflammatory Disease

A
  • an ascending infection in which pathogens from the cervix spread to the uterus and fallopian tubes
  • most commonly caused by N. gonorrhoeae or C. trachomatis and more common in the first half of the menstrual cycle since menstruation enhances spread
  • diagnosis requires lower abdominal pain or tenderness, uterine or cervical motion tenderness, and adnexal tenderness as well as one of the following: fever, elevated WBC, inflammatory pelvic mass, elevated ESR or CRP, evidence of gonorrhea or chlamydia cervicitis
53
Q

Urethritis

A
  • an inflammation of the urethra, which can be characterized as gonococcal or non-gonococcal
  • presents with dysuria, urinary frequency, and mucopurulent urethral discharge
  • diagnosed based on discharge, more than five WBCs per field on gram stain of urethral secretions, more than 10 WBCs per field on first-void urine specimen, or positive leukocyte esterase test on first-void urine specimen
54
Q

Genital Warts

A
  • the most common STD, which are caused by low-risk HPV infection, and are termed condylomata acuminata
  • present with itching, pain, dyspareunia, and visible warts
  • diagnosed based on visual inspection
55
Q

Which HPV serotypes are most likely to cause cervical carcinoma?

A

16 and 18

56
Q

Genital ulcers can be caused by what three organisms?

A
  • HSV1 and HSV2
  • syphilis
  • chancroid (H. ducreyi)
57
Q

HSV-1 and HSV-2 Genital Ulcers

A
  • present as multiple, shallow, painful ulcers with inguinal adenopathy and constitutional symptoms
  • diagnosed based on visual inspection and Tzanck smear
  • treated with oral acyclovir until resolution
58
Q

Primary Syphilis

A
  • presents as a single, painless ulcer that is well-demarcated
  • diagnosed with reactive nontreponemal tests, FTA-ABS, or dark field microscopy
  • treated with intramuscular penicillin or oral doxycycline if allergic
59
Q

Haemophilus ducreyi

A
  • a sexually transmitted organism that causes genital ulcers that must be distinguished from HSV-1 or 2 and from primary syphilis
  • presents as multiple, painful ulcers with red, irregular borders as well as painful, fluctuant inguinal adenopathy
  • diagnosed with visual inspection and a positive culture
  • treated with oral azithromycin, erythromycin, or intramuscular ceftriaxone
60
Q

How do the genital ulcers of HSV, syphilis, and H. ducreyi differ?

A
  • HSV are multiple and painful, accompanied by constitutional symptoms and inguinal adenopathy
  • syphilitic are single, painless, and well-demarcated with inguinal adenopathy
  • chancroid (ducreyi) are multiple and painful with red, irregular borders and painful inguinal adenopathy
61
Q

How long is the typical menstrual cycle? What is a normal duration of menstrual flow and amount blood loss?

A
  • length is 21 to 35 days
  • duration is 2-8 days
  • blood loss is 30-80 mL
62
Q

What is the follicular phase of the menstrual cycle?

A
  • that which begins with the onset of menstrual flow and ends with ovulation, typically spanning 7-22 days
  • it is triggered by a pulsatile release of GnRH, which induces release of LH and FSH
  • FSH induces maturation of ovarian follicles, which produce growing amounts of estradiol causing endometrial thickening and eventually and LH surge
63
Q

What is the ovulation phase of the menstrual cycle?

A
  • a midcycle event triggered by a surge in LH secondary to peaking estradiol levels
  • the ruptured follicle gives rise to a functioning corpus luteum
64
Q

What is the luteal phase of the menstrual cycle?

A
  • begins after ovulation and ends with menstrual flow, lasting 12-16 days
  • progesterone produced by the corpus lute creates a secretory endometrium and stabilizes the endometrium
  • without fertilization and hCG to support the corpus lute, it involutes, which leads to diminishing progesterone and estradiol and endometrial sloughing
65
Q

Define dysmenorrhea. What is the difference between primary and secondary dysmenorrhea?

A
  • pain associated with menstrual flow
  • primary refers to pain not associated with any pelvic abnormality
  • secondary refers to pain associated with an abnormality like endometriosis, PID, etc.
66
Q

What is believed to be the cause of primary dysmenorrhea?

A

an increased production of prostaglandins by the endometrium, which results in excessive uterine contractions and other systemic effects

67
Q

Dysmenorrhea

A
  • pain associated with menstrual flow
  • can be primary (due to excess production of prostaglandins) or secondary (to some uterine abnormality)
  • presents with spasms of pain in the lower abdomen, nausea, vomiting, diarrhea, headache, or fatigue
  • treat with NSAIDs or oral contraceptives
68
Q

What is amenorrhea? How does primary differ from secondary?

A
  • it is the absence of menstrual flow
  • primary refers to an absence by age 16 in an adolescent with normal secondary sex characteristics or by age 14 in an adolescent without secondary sex characteristics
  • secondary refers to the absence for either three menstrual cycles or 6 months after regular menstrual cycles have occurred
69
Q

When do menstrual cycles become regular?

A

1-2 years after menarche

70
Q

How should amenorrhea be worked up?

A
  • history and physical
  • pregnancy test
  • TSH and thyroxine levels as well as fasting prolactin level
  • FSH and LH levels (high indicate ovarian failure and low indicate hypothalamic or pituitary suppression or failure)
71
Q

Define polymenorrhea.

A

uterine bleeding that occurs at regular intervals of less than 21 days

72
Q

Define menorrhagia.

A

prolonged or excessive uterine bleeding that occurs at regular intervals

73
Q

Define metrorrhagia.

A

uterine bleeding that occurs at irregular intervals

74
Q

Define menometrorrhagia.

A

prolonged or excessive bleeding that occurs at irregular intervals

75
Q

Define oligomenorrhea.

A

uterine bleeding that occurs at regular intervals, o more often than every 35 days

76
Q

What are possible causes of dysfunctional uterine bleeding (metrorrhagia, oligomenorrhea, etc.)?

A
  • anovulatory cycles
  • complications of pregnancy
  • infections
  • blood dyscrasias (vWD and ITP)
  • cervical or vaginal polyps
  • uterine abnormalities
  • medications
  • foreign bodies
  • trauma or sexual assault
77
Q

How do anovulatory cycles contribute to dysfunctional uterine bleeding?

A
  • the endometrium becomes excessively thickened and unstable due to unopposed estrogen
  • as a result, bleeding occurs spontaneously and frequently, and it is often prolonged because of weaker-than-usual uterine and vascular contractions
78
Q

How should gynecomastia be treated during adolescence?

A

it is normally found in about 60% of male adolescents and does not typically require intervention as it will usually resolve within 12-15 months

79
Q

Testicular Torsion of the Spermatic Cord

A
  • the most common and serious cause of acute painful scrotal swelling
  • presents with sudden onset pain, nausea and vomiting, absent cremasteric reflex, swollen testicle, and pain relief on elevation of the affected testicle
  • diagnosis can be confirmed by decreased uptake on radionuclide scan or decreased flow on doppler ultrasound
  • managed with surgical detorsion and fixation of BOTH testes within 6 hours
80
Q

Torsion of Testicular Appendage

A
  • presents with acute or gradual onset pain most pronounced at the upper pole of the testicle and “blue dot sign,” a cyanotic appendage visible through the skin
  • diagnosed with normal or increased radionuclide uptake or blood flow on doppler ultrasound
  • managed with rest and analgesia as it typically resolves in 2-12 days
81
Q

Epididymitis

A
  • typically an infection with C. trichromatic or N. gonorrhoeae in sexually active males
  • presents with acute onset of scrotal pain and swelling as well as urinary frequency, dysuria, urethral discharge, and a swollen, tender epididymis
  • diagnosed based on WBCs on urinalysis or positive culture of urethral discharge; US shows increased blood flow and increased uptake of radionuclide
82
Q

Indirect Inguinal Hernia

A
  • a hernia that begins with tissue entering the internal inguinal ring lateral to the inferior epigastric vessels
  • goes through the internal inguinal ring, through the external inguinal ring, and into the scrotum
  • follows the path of descent of the testes and is covered by all three layers of the spermatic fascia (internal, cremasteric, external)
  • occurs in infants due to failure of the processes vaginalis to close, particularly in males
83
Q

Hydrocele

A
  • a collection of fluid within the tunica vaginalis (a serous membrane covering the testicle and internal surface of the scrotum)
  • when it presents in infants, it is often associated with incomplete closure of the processus vaginalis, leaving communication between the scrotum and peritoneal cavity
  • in adults, it is more often associated with blocked lymphatic drainage
  • presents as a scrotal swelling that can be transilluminated
84
Q

Varicocele

A
  • a dilation of the spermatic vein due to impaired drainage
  • usually left sided because the left vein drains into the left renal vein while the right vein drains directly into the IVC
  • presents as a “bag of worms” appearance upon standing examination that is less obvious when supine and will not be transilluminated
  • seen in a large percentage of infertile males because it leaves lots of warm blood in the sac for longer periods

Pediatrics BRS (20 decks)

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