Lecture 7: Adolescent Medicine Flashcards
(32 cards)
1
Q
Understanding normal development
A
- Tasks of Adolescence
- Transition from childhood to adulthood
- Identity, Autonomy, Mastery of Self
- Adolescence is a very dynamic time
- Must understand what is normal to define what is abnormal
- Intervention and prevention strategies are most effective when they are developmentally based – one size does NOT fit all
2
Q
Adolescent basics (10-24 years)
A
- most teenagers are healthy
- most unhealthy lifetime habits start during adolescence
- most deaths are related to developmental/psychosocial issues
- adolescents MUST be interviewed alone to maximize
- confidentiality
- therapeutic rapport
- disclosures
- ensuring confidentiality has caveats
- suicidal intent
- duty to warn (homicidal intent, mandated reporting, etc.)
- disclosure of physical or sexual abuse to law enforcement
- at this point, the adolescent must be granted the right to have a confidential exam
3
Q
confidentiality
A
- If any of these things are disclosed, you are mandated by law to inform authorities: suicide, physical or sexual abuse
- You are not mandated to report on an someone over 18
- The provider has to submit the CPS case
4
Q
cognitive development
A
- 19 years
- 10 years
- ability to think abstractly
- ability to analyze situations logically
- ability to think realistically about the future, goal setting
- moral reasoning
- entertain hypothetical situations, use of metaphors
- need guidance for rational decision making
5
Q
adolescent stages: early (~10-13 years - middle school)
A
- characteristics
- greatly self-conscious; need for privacy & preoccupation with body – beginnings of emancipation (separation from parents)
- mood swings
- EGOCENTRIC; rule and limit testing – “invicibility”
- same sex friendships
- profoundly concrete, no consideration of tomorrow – focus on present and near future
- risks for youth in this stage
- focus on here and now
- don’t plan, don’t abstract
- may not see or comprehend danger
- strategies
- concrete – repeat, repeat, repeat
- time for processing – look for the light bulb
- role play
- provide examples of immediate cause and effect
6
Q
adolescent stages - middle (~14-17 years)
A
- characteristics
- autonomy with limit-testing
- development of identity – peer scene; concern with appeal to opposite/same sex
- self-involved (high expectations & poor self-concept)
- development of ideals and selection of role models
- examination of inner experiences
- focus of history = interaction with family, school and peers
- risks
- high risk experimentation is common
- perceived risk may be favorable
- saving face with peers
- prone to negative role models
- separation from adults
- strategies
- peer advocacy – positive peer pressure, take a step back
- provide healthy, positive role modeling – mentoring
- structure – provide options for experimentation, time to explore limits
- opportunities for leadership and responsibility (autonomy)
- be open, non-judgmental in communication – provide options and choices
- don’t engage in power struggles
- focus on building life skills (decision-making, values clarification, communication (feelings, thoughts)
7
Q
adolescent stages - late (“young adult”)
A
- Characteristics
- realize vulnerabilities and limitations
- planning for future – higher level of concern for future and one’s role in life
- capable of useful insight, abstract thinking and independent decision-making
- greater concern for others
- established sexual identity
- focus of visit = patient’s responsibility for their own health
- risks
- life choices reflect exposure, options, experience, social environment
- irreversible consequences of earlier developmental issues (e.g., chronic disease)
- strategies
- validate decision making process
- look at choices, assist with options
- provide opportunities to explore self and skills, help with scenarios
- work with greater sense of altruism
8
Q
HEADSS
A
- designed to open a dialogue between practitioner and adolescent
- great indicator for high risk behavior
- opportunity to reinforce and affirm positive behaviors
- HEADSS mnemonic
- H: home/family life and relationships
- E: education/employment/life goals and plans
- A: activities/fun/friends/gang activity
- D: diet/body image/drugs-substance use/tobacco/alcohol
- S: sexual activity (debut, # partners, orientation,etc.)/sexual assault
- S: suicidal (and homicidal) ideation and depression
9
Q
exercise
A
- Consider how, in a clinical situation, to target health promotion measures to the individual adolescent:
- A 13 year old boy binge drinks every weekend with his friends.
- A 16 year old girl is having unprotected sex, and is sure she cannot become pregnant because her menses are irregular.
- An 18 year old boy rides a motorcycle without a protective helmet.
10
Q
puberty - the biologic task of adolescence
A
- The development of secondary sex characteristics
- The establishment of sexual dimorphism
- The development of reproductive capacity
- occurs in predictable, ordered sequence of events (Tanner staging)
- the trigger is internal biologic clock (pulsatile secretion of GnRH)
- change in body size and shape – timing is not the same for every person
- girls before boys, and boys longer than girls
11
Q
normal puberty facts
A
- Normal onset
- Females: 8.0 - 13.0 years
- Males: 9.0 to 14.0 years
- Entire process can take 3-7 years, with reproductive capability achieved with 2-3 years after onset.
- Terms:
- adrenarche: onset of adrenal (not testes) androgen production, resulting in pubarche
- results in pubic hair development
- gonadarche: onset of pubertal function of gonads (FSH/LH) – estrogen and testosterone start being produced
- pubarche: onset of sexual hair development (androgen)
- thelarche: onset of breast development (ovarian estrogen)
- menarche: onset of menstruation
- adrenarche: onset of adrenal (not testes) androgen production, resulting in pubarche
- Adrenarche precedes gonadarche by several years (2 years)
12
Q
growth spurt
A
- Period of peak height velocity (PHV, pubertal growth spurt)
- Acceleration of growth rate from 5 cm/yr to possibly 15 cm+ in just few months.
- Girls > boys, but ultimately gender disparity
- Early puberty – “all hands and feet”
- Girls PHV = Tanner 2-3. Boys PHV = Tanner 3-4
- Growth stops 2-3 years later.
13
Q
tanner staging (sexual maturity rating)
A
- Classifies level of pubertal maturation and determines normality
- Divided into 5 classes based on
- pubic hair/breasts in females
- pubic hair/genitalia in males
- Linear growth extremely variable in adolescence- poor reference point
- Record at initial general PE and yearly thereafter
14
Q
tanner staging (breast)
A
- Tanner 1 (prepubertal)
- No glandular tissue
- Areola conforms to general chest line
- Tanner 2 (thelarche)
- Breast bud, areola widens
- Tanner 3
- Larger with more elevation, extending beyond areolar parameter
- Areola enlarges, still in contour with breast
- Tanner 4
- Larger with more elevation
- Areola and papilla form mound projecting from breast contour
- Tanner 5
- Breast adult
- Areola and breast in same plane
15
Q
tanner staging (pubic hair/genitalia)
A
- Tanner 1 (prepubertal)
- No pubic hair
- Genitalia childlike
- Tanner 2
- Light, downy pubic hair
- Penis, testis slightly larger
- Scrotum more textured
- Tanner 3
- Pubic hair extends across pubis
- Penis larger in length
- Tanner 4
- Pubic hair more abundant and curling
- Genitalia resemble adult
- Scrotum darker
- Tanner 5 (adult)
- Pubic hair adult quality with extension to inner border of thighs
- Testis and scrotum adult in size
16
Q
female sexual development
A
- thelarche triggers breast buds
- Sexual development begins Tanner 2, mean age 10.5 yrs (8.0-12)
- Normal sequence: thelarche > PVH > pubarche > menarche
- Thelarche precedes pubarche (1-1.5 years) and menarche (2-3 years) (12.6 years Caucasian; 12.1 years AA)
- Growth spurt begins Tanner 2 and is approximately 99% complete by bone age 15 years
17
Q
male sexual development
A
- first sign of male puberty is testicular development
- Sexual development begins Tanner 2 (testicular enlargement), mean age 11.5 yrs (9-13)
- Tanner 4 usually associated with fertility, facial hair, voice change
- Typical sequence: testicular development > pubarche > PVH
- Growth spurt begins Tanner 2 and 99% complete at bone age 17 years.
18
Q
growth and height
A
- Arrest of previously normal pubertal growth rate in adolescent is abnormal and warrants thorough evaluation for endocrine, metabolic, and systemic disorders
- Height largely determined genetically, “target height” =
- Average of parents’ heights + 6.5 cm for boys
- Average of parents’ heights – 6.5 cm for girls
19
Q
normal variants of puberty
A
- Breast asymmetry
- Physiologic leukorrhea
- Typically begins 6 to 12 months before menarche
- Due to ovarian estrogen stimulation of uterus and vagina
- Discharge clear, no odor or irritation
- Irregular menses – physiologic adolescent anovulation
- 50% anovulatory cycles (immature axis) during first 2 years
- Menstrual regularity in 2/3 girls within 1 year menarche
- By 2 years, 10% girls irregular
- By 5 years, 75% cycles are ovulatory
- Gynecomastia
- Breast enlargement in boys
- Usually benign, self-limited (< 1-2 years)
- 50-60% of adolescent boys
- Often idiopathic, but consider other causes of severe or persistent
- Tanner 3, mobile, tender, firm mass beneath areola
- Reassurance, reduction mammoplasty
20
Q
issues arising with puberty
A
- Anemia
- Acne
- Treatment based upon severity (comedonal, inflammatory, nodular, cystic)
- moderate or severe acne in early puberty, usually with other signs of androgen excess, consider endocrinologic disorder
- Psychological changes
- Depression: girls > boys
- lack of synchrony between the timing of pubertal development and chronologic age exists
- early female
- late male
- Musculoskeletal injuries
- greatest risk to epiphyseal growth plates occurs during PHV
- Abnormal uterine bleeding
21
Q
delayed puberty
A
-
Who should be evaluated?
- no sign of pubertal development by age 13 in girls (no thelarche)
- no sign of pubertal development by age 14 in boys
- accompanied by slowing of linear growth velocity – short stature may be first complaint
-
Is it normal variant or pathological?
- constitutional delay (“late bloomers”) – normal variant (>90% cases)
- THE MOST COMMON REASON FOR SHORT STATURE AND DELAYED PUBERTY IN KIDS
- Ask kid what age parents started puberty
- If bone age is inconsistent with the age, then it’s a concordance of delay
- family history; once puberty begins, catch up growth to target height occurs
- delayed bone age (between 1.5 – 4 years)
- THE MOST COMMON REASON FOR SHORT STATURE AND DELAYED PUBERTY IN KIDS
- central
- hypogonadotropic hypogonadism
- adrenarche occurs to some degree, but gonadarche does not
- may accompany chronic illnesses, anorexia nervosa (malnourishment), athletic amenorrhea, hypothyroidism
- gonadtropin (GnRH) deficiency
- larger syndrome or chronic illness (acquired)
- Consider congenital hypopituitarism
- CNS tumor (e.g., craniopharyngioma)
- hypogonadotropic hypogonadism
- gonadal
- hypergonadotropic hypogonadism (gonadal failure)
- Turner (XO) syndrome – suspect in any short female
- Kleinfelter syndrome (47, XXY)
- hypergonadotropic hypogonadism (gonadal failure)
- chronic disease (IBD, JRA, CF, SCD, SLE)
- constitutional delay (“late bloomers”) – normal variant (>90% cases)
22
Q
sports pre-participation exam
A
- Goals:
- Identify medical and musculoskeletal conditions that could make sports participation unsafe (with consideration of sport)
- Screen for underlying illness through medical and family hx, ROS and PE
- Opportunity for general health assessment and preventive care
- Entry into medical care – promotes provider-patient relationship
23
Q
sports exam
A
- NEED TO EXCLUDE CARDIAC PATHOLOGY
- 50 of 51 states (including the District of Columbia) require some form of physical evaluation before participation in sports at the high school level.
- History most important aspect, with 3 key elements:
- Cardiac system
- Neurologic system
- Musculoskeletal system
- Consider sport for which athlete is being screened
- Sports are graded, based on level of contact (high, moderate, low)
- Injury patterns generally associated with contact grade
24
Q
classification of sports according to contact/collision
A
-
Consider:
- Macrotraumatic/acute traumatic injury
- one-time, kinetic energy force applied to body common in high contact sports (soccer, football, lacrosse)
- Focus on h/o concussion, fracture, ligamentous injury
- Microtraumatic or overuse injury
- seen frequently in repetitive use sports (running, swimming)
- More common in moderate and low contact sport categories
- Example: Tennis elbow, shin splints
- AAP opposes participation in boxing for children, adolescents and young adults
- AAP recommends limiting bodybuilding and power lifting until adolescent achieves Tanner 5
- Macrotraumatic/acute traumatic injury
25
review of cardiac system history
* **Cardiac system**
* **Sudden cardiac death comprise majority of sport-related fatalities**
* **Most common causes: hypertrophic cardiomyopathy (\>50%), Marfan syndrome, total anomalous pulmonary venous system, long QT syndrome**
* **Currently, ECG not universally recommended**
* **Most important questions to include (\*\*) in Hx or ROS:**
* **Syncope** **or near syncope _during or after_ exercise?**
* **Discomfort****, pain, tightness or pressure in chest _during_ exercise?**
* **Palpitations** **during exercise?**
* **Lightheadededness****, shortness of breath, or fatigue more than expected during exercise?**
* **H/O heart problems** **or past testing for heart?**
* **Family member** **died of heart problems or unexplained death before 50 yo, or current family member with heart disease?**
* **Family member with unexplained fainting or drowning?**
* **H/O concussions, injuries, fractures?******
* Syncope
* During exercise, concerning for cardiac disorder –
* anatomical (HCM)
* conduction (prolonged QT, Wolfe-Parkinson-White syndrome)
* If occurs while standing or sitting with no other pertinent hx, NOT contraindication
* If present during exercise, CONTRAINDICATION with immediate cardiology referral
26
review of medical history: asthma and recent mononucleosis
* Asthma
* 85% of asthmatics = exercise-induced
* Incidence 10-35%, & likely underdiagnosed
* Entertain in anyone with h/o wheezing, SOB during activity
* Consider spirometry and PFT to assess degree of obstruction
* Recent Mononucleosis
* Mono-induced splenomegaly can result in splenic rupture (high or moderate contact sports)
* If h/o mono within 1 month, pt. at risk since spleen size peaks within 3-4 weeks
* If PE suspicious for palpable spleen, order ultrasound or CT before clearance.
27
review of medical history: unilateral organ, seizure disorder, current meds, menstrual hx, ergogenic aids
* **Unilateral organ** (kidney, testicle)
* Single kidney – _contraindication to high-contact sports_
* Moderate contact sports – require protective “flak” jacket
* Single testicle – require mandatory protective cup use for all sports
* **Seizure disorder**
* Not direct contraindication if well controlled (no seizure in last year)
* If ongoing seizure activity, warrant special attention, especially if aquatic sports
* h/o seizure within past 6 months, concern
* **Current Medications** – important to document
* linked to arrhythmias:
* tricyclic antidepressants (imipramine), macrolide antibiotics (erythromycin), OTC decongestants (pseudoephrine), illicit drugs (cocaine, amphetamines)
* **Menstrual history**
* Screen for amenorrhea – female athlete triad
* Anorexia, amenorrhea, osteoporosis
* Consider bone density studies via DEXA
* **Ergogenic aids**
* Steroid use
* Nutritional supplement – incidence increasing
* “Have you ever taken a substance to enhance your athletic performance?”
28
physical exam
* Focus on sports readiness
* Height and weight:
* Indicate growth and development - general fitness (eg, obesity) and pathology (eg, eating disorders).
* Risks for competing at certain levels. A common minimum weight for varsity football participation is 120 lb
* Blood pressure (BP):
* Certain sports may cause significant BP elevations, and this may be a reason to limit an athlete's participation.
* Evaluate more than once, consider normal BPs for the age
* Consider secondary hypertension related to steroid use
* Grade III hypertension requires removal from athletics until controlled. Grade IV is contraindication.
29
physical exam visual acuity, skin
* **Visual acuity**
* poor vision can affect performance and increase likelihood of injury.
* Visual acuity (20/40 for clearance)
* **Skin**
* Wrestling, disqualify athletes who have infectious dermatoses:
30
physical exam: cardiac, abdomen, genitalia (mandatory for males)
* **Cardiac**
* murmurs or irregular rhythms?
* HOCM: systolic murmur along the left sternal border, accentuated by Valsalva maneuvers and standing; the murmur decreases with handgrip and squat maneuvers.
* **Abdomen**
* Organomegaly (splenomegaly)
* **Genitalia (mandatory for males)**
* Tanner staging classify athletes by maturity; thus, developmental delays can be detected.
* Single testicle & hernias.
* Tanner staging correlates better with skeletal maturity (vs. physical size)
* Growth plate fractures – muscular force exerted by testosterone-rich muscles across cartilaginous physes predisposes
31
physical exam: musculoskeletal
* “two minute” orthopedic evaluation.
* Note the general body habitus & assess for symmetry.
* Assess cervical ROM.
* Assess shoulder function:
* shoulder shrugs (trapezius)
* abduction to 90° (deltoids), both against resistance
* internal and external rotation (glenohumeral joint).
* Forearms supination and pronation w/elbows flexed to 90°.
* Hands open and close his or her fists and spread the fingers.
* Lumbar spine extension (spondylolysis and spondylolisthesis).
* Scoliosis check, spine ROM and hamstring flexibility.
* Toe walk/heel walk (leg musculature symmetry, calf strength and balance).
* Duck walk (hips, knees, and ankles, strength and balance).
* Knee extension and patellar tracking.
* **Musculoskeletal**: source of most pathology
* Cervical spine injuries/pathology – cervical radiographs
* Down’s Syndrome – atlantoaxial instability
* Spine problems –
* Scheurmann khyphosis/scoliosis
* Scoliosis: females\>males
* Kyphosis: males\>females
* spondylolysis/sponndylolithesis – pain with extension
* Discogenic back pain – low back pain
* Pain with flexion=discogenic; pain with extension=posterior element overuse; rotational pain=paraspinous muscle pain
* Shoulder (problems in overhead sports) –
* rotator cuff overuse
* shoulder instability
* Knee
* Focus on h/o knee pain
* Persistent pain with flexion, swelling – 4-view knee series to r/o osteochondritis dessicans
* Screen for ligamentous instability
* Ankle
* Chronic problems related to repetitive sprains and subsequent instability
32
conditions that contraindicate sports participation
* Active myocarditis or pericarditis
* Hypertrophic cardiomyopathy
* Severe hypertension until controlled by therapy (static resistance activities, such as weight lifting, are particularly contraindicated)
* Long QT interval syndrome
* History of recent concussion and symptoms of postconcussion syndrome (no contact or collision sports)
* Poorly controlled convulsive disorder (no archery, riflery, swimming, weight lifting or power lifting, strength training or sports involving heights)
* Recurrent episodes of burning upper-extremity pain or weakness, or episodes of transient quadriplegia until stability of cervical spine can be assured (no contact or collision sports)
* Sickle cell disease (no high-exertion, contact or collision sports)
* Eating disorder where athlete is not compliant with therapy and follow-up, or where there is evidence of diminished performance or potential injury because of eating disorder
* Acute enlargement of spleen or liver
