Peds: School-Age (4-11) and Adolescents

Question 1

Danger Signals

K______ Disease/Syndrome

Leukemia (2)

R____ Syndrome

_____ Syndrome: Atlantoaxial Instability

______ Seizures

St___ Murmur

Answer 1

Kawasaki Disease/Syndrome

Leukemia - ALL, AML

Reye’s Syndrome

Down Syndrome: Atlantoaxial Instability

Absence Seizures

Still’s Murmur

Question 2

Kawasaki Disease/Syndrome

Onset of high fever (up to ___.0°F) for __ or more days.

Presence of at least four of the following clinical signs: enlarged (1) in the neck, bright-red ____ (more obvious on groin area), bilateral _______ (dry, no discharge), oral mucosal changes (e.g., dry cracked lips, “_______ tongue”), and _____ hands and feet.

After fever subsides, skin _____ off hands and feet.

Treated with (2)

Answer 2

Onset of high fever (up to 104.0°F) for 5 or more days.

Presence of at least four of the following clinical signs: enlarged lymph nodes in the neck, bright-red rash (more obvious on groin area), bilateral conjunctivitis (dry, no discharge), oral mucosal changes (e.g., dry cracked lips, “strawberry tongue”), and swollen hands and feet.

After fever subsides, skin peels off hands and feet.

Treated with high-dose aspirin and intravenous (IV) gamma globulin.

Question 3

Kawasaki Disease/Syndrome

Most cases (75%) occur in children younger than age __ years.

Resolves within 1 to 3 weeks but may have serious sequelae, such as _____ dissection, dilation or aneurysms of the ______ arteries, and _____ loss.

Requires close follow-up with pediatric (1) for several years because effects may not be apparent until child is older (or an adult).

Answer 3

Most cases (75%) occur in children younger than age 5 years.

Resolves within 1 to 3 weeks but may have serious sequelae, such as aortic dissection, dilation or aneurysms of the coronary arteries, and hearing loss.

Requires close follow-up with pediatric cardiologist for several years because effects may not be apparent until child is older (or an adult).

Question 4

Leukemia

Complains of extreme f____ and weakness. P___ skin and easy br____.

May have (1) bleeding (pinpoint to small red spots).

May have bleeding g___ and n___bleeds. Some have b____ or joint pain, lymphadenopathy, or swelling in the abdomen.

(1) are the most common type of cancer in children and adolescents; the most common type in children is (1).

Answer 4

Complains of extreme fatigue and weakness. Pale skin and easy bruising.

May have petechial bleeding (pinpoint to small red spots).

May have bleeding gums and nosebleeds. Some have bone or joint pain, lymphadenopathy, or swelling in the abdomen.

Leukemias are the most common type of cancer in children and adolescents; the most common type in children is acute lymphocytic leukemia (ALL).

Question 5

Acute Lymphocytic Leukemia

_____ common form of leukemia in childhood (75%). Fast-growing cancer of the ____blasts, which are immature lymphocytes.

Peak occurrence at __ to __ years of age.

Complete blood count (CBC) will show very high (1) count (>50,000 cells/mm³).

(1) gender have slightly higher chance of cure compared with (1) gender.

African American and Hispanic children tend to have a ____ cure rate compared with children from other races.

Answer 5

Most common form of leukemia in childhood (75%). Fast-growing cancer of the lymphoblasts, which are immature lymphocytes.

Peak occurrence at 2 to 4 years of age.

Complete blood count (CBC) will show very high white blood cell (WBC) count (>50,000 cells/mm³).

Girls have slightly higher chance of cure compared with boys.

African American and Hispanic children tend to have a lower cure rate compared with children from other races.

Question 6

Acute Myelogenous Leukemia

Acute myelogenous leukemia (AML) is a fast-growing cancer of the bone morrow that affects immature or precursor blood cells, such as myeloblasts (1), monoblasts (2), erythroblasts (1), and megakaryoblasts (1).

Children with (1) syndrome who have AML tend to have better cure rates, especially if the child is younger than age 4 years.

Answer 6

Acute myelogenous leukemia (AML) is a fast-growing cancer of the bone morrow that affects immature or precursor blood cells, such as myeloblasts (WBCs), monoblasts (macrophages, monocytes), erythroblasts (RBCs), and megakaryoblasts (platelets).

Children with Down syndrome who have AML tend to have better cure rates, especially if the child is younger than age 4 years.

Question 7

Reye’s Syndrome

History of febrile _____ illness (chickenpox, influenza) and (1) or salicylate intake (e.g., Pepto-Bismol) in a child.

Theoretical risk of Reye’s syndrome after varicella immunization; avoid using aspirin before, during, and after immunization.

Abrupt onset with ____ progression.

_____ can occur within a few hours to a few days.

Mortality rate of up to 52%. Although most cases are in children, disease has been seen in teenagers and adults. This disease is now rare.

Answer 7

History of febrile viral illness (chickenpox, influenza) and aspirin or salicylate intake (e.g., Pepto-Bismol) in a child.

Theoretical risk of Reye’s syndrome after varicella immunization; avoid using aspirin before, during, and after immunization.

Abrupt onset with quick progression.

Death can occur within a few hours to a few days.

Mortality rate of up to 52%. Although most cases are in children, disease has been seen in teenagers and adults. This disease is now rare.

Question 8

Reye’s Syndrome Staging

• Stage 1:* Severe v_____, l_____/sleepy, elevated (2)
• Stage 2:* Deeply lethargic, restless, confused/del_____/combative, h____ractive reflexes, h_____ventilation
• Stage 3:* Obtunded or in light c_____, de_____ rigidity
• Stage 4:* Coma, s_____, de_____ rigidity, f___ pupils, ____ of reflexes
• Stage 5:* Seizures, deep coma, flaccid par_____, absent (1) reflexes (DTRs), respiratory ____, death

Answer 8

• Stage 1:* Severe vomiting, lethargic/sleepy, elevated alanine aminotransferase (ALT) and aspartate transaminase (AST)
• Stage 2:* Deeply lethargic, restless, confused/delirious/combative, hyperactive reflexes, hyperventilation
• Stage 3:* Obtunded or in light coma, decorticate rigidity
• Stage 4:* Coma, seizure, decerebrate rigidity, fixed pupils, loss of reflexes
• Stage 5:* Seizures, deep coma, flaccid paralysis, absent deep tendon reflexes (DTRs), respiratory arrest, death

Question 9

Down Syndrome: Atlantoaxial Instability

Up to 15% of Down syndrome patients have atlantoaxial instability =

Medical clearance is recommended for some _____ participation.

Children/adolescents (or older) with Down syndrome who want to participate in sports need _____ spine (1) (including lateral view).

Patients with atlantoaxial instability are restricted from playing ____ sports (e.g., basketball, tackle football, soccer) and other high-risk activities (e.g., trampoline jumping).

Persons with Down syndrome without evidence of atlantoaxial instability may participate in ___-impact sports and sports not requiring extreme bal_____.

Answer 9

Up to 15% of Down syndrome patients have atlantoaxial instability (excessive mobility at the articulation of C1 and C2).

Medical clearance is recommended for some sports participation.

Children/adolescents (or older) with Down syndrome who want to participate in sports need cervical spine x-rays (including lateral view).

Patients with atlantoaxial instability are restricted from playing contact sports (e.g., basketball, tackle football, soccer) and other high-risk activities (e.g., trampoline jumping).

Persons with Down syndrome without evidence of atlantoaxial instability may participate in low-impact sports and sports not requiring extreme balance.

Question 10

Medical Conditions That May Disqualify Youth From Sports Participation*

Answer 10

Question 11

Absence Seizures

Brief episodes during which child suddenly stops whatever they are doing and _____.

If in school, teacher may tell parent that child is day_____ and in____. A common type of pediatric seizure.

Also called ____ mal seizure.

First-line therapy is Rx(1).

Refer to pediatric (1).

Answer 11

Brief episodes during which child suddenly stops whatever they are doing and stares.

If in school, teacher may tell parent that child is daydreaming and inattentive. A common type of pediatric seizure.

Also called petit mal seizure.

First-line therapy is ethosuximide.

Refer to pediatric neurologist.

Question 12

Still’s Murmur

A _____ systolic murmur that is described as having a vib_____ or m_____ quality.

Becomes _____ in supine position or with fever. Minimal radiation.

Grade __ or __ intensity.

Most common in _____-age children. Usually resolved by ______.

Answer 12

A benign systolic murmur that is described as having a vibratory or musical quality.

Becomes louder in supine position or with fever. Minimal radiation.

Grade I or II intensity.

Most common in school-age children. Usually resolves by adolescence.

Question 13

Top Causes of Death: Age 5 to 9 Years

(Early School Age)

(1) neoplasms
(1) accidents

C______ abnormalities

Answer 13

Malignant neoplasms

Motor vehicle accidents

Congenital abnormalities

Question 14

Immunizations: Preschool Children (Age 4–6 Years)

Administer Vaccines :(3)

If history of (1) is documented on chart by health provider, do not need varicella.

Answer 14

Administer vaccines: Measles, mumps, rubella (MMR); varicella, inactivated poliovirus vaccine (IPV); and diphtheria, tetanus, acellular pertussis (DTaP)

If history of chickenpox is documented on chart by health provider, do not need varicella.

Question 15

School-age Children (Age 7–12 Years)

If child is aged 7 to 9 years with an incomplete immunization record for DTaP, give (1) as first catch-up dose, followed by (1) vaccine.

(1) booster should be administered to all 11- to 12-year-olds (regardless of whether it was used in a catch-up schedule).

Most common “middle school” vaccines at 11 to 12 years of age are (3)

HPV vaccine can be administered as young as age __ years.

Answer 15

If child is aged 7 to 9 years with an incomplete immunization record for DTaP, give Tdap as first catch-up dose, followed by tetanus diphtheria (Td) vaccine.

Tdap booster should be administered to all 11- to 12-year-olds (regardless of whether it was used in a catch-up schedule).

Most common “middle school” vaccines at 11 to 12 years of age are Tdap, meningococcal conjugate vaccine (MCV4; Menactra or Menveo), and human papillomavirus (HPV) vaccine (Gardasil).

HPV vaccine can be administered as young as age 9 years.

Question 16

Notes

HPV vaccine is recommended for ___ girls and boys. (1) vaccine is used for both genders.

If first dose of HPV given between __ and 14 years, only ___ doses are needed; ____ doses needed if series started at __ years or older.

Age 13 to 14 years (or older): Give Tdap if did not receive it at age __ to __ years.

If no history of varicella (1) (or the (1)), then give the varicella vaccine.

If child did not complete hepatitis A or B series, administer ____ dose and resume interval dosing. Do not restart hepatitis A or B series.

Answer 16

HPV vaccine is recommended for both girls and boys. Gardasil is used for both genders.

If first dose of HPV given between 9 and 14 years, only two doses are needed; three doses needed if series started at 15 years or older.

Age 13 to 14 years (or older): Give Tdap if did not receive it at age 11 to 12 years.

If no history of varicella immunization (or the disease), then give the varicella vaccine.

If child did not complete hepatitis A or B series, administer next dose and resume interval dosing. Do not restart hepatitis A or B series.

Question 17

Meningococcal Vaccines

There are six types of meningococcal vaccines; only two of them are discussed here.

• MenACWY-D (1): Youngest age is 9 months
• MenACWY-CRM (1): Youngest age is 2 months

Administer Menactra or Menveo vaccine first dose at age __ to __ years. If missing, catch-up age is 13 to 15 years. Booster (second dose) at age __ to __ years.

Also used for high-risk children with a_____, functional asplenia (_____ cell), splenectomy, H__ infection, and complement deficiencies.

Answer 17

There are six types of meningococcal vaccines; only two of them are discussed here.

• MenACWY-D (Menactra): Youngest age is 9 months
• MenACWY-CRM (Menveo): Youngest age is 2 months

Administer Menactra or Menveo vaccine first dose at age 11 to 12 years. If missing, catch-up age is 13 to 15 years. Booster (second dose) at age 16 to 18 years.

Also used for high-risk children with asplenia, functional asplenia (sickle cell), splenectomy, HIV infection, and complement deficiencies.

Question 18

Primary Series of Vaccination: Missing or Not Done

After Seventh Birthday (Never Been Vaccinated)

Tetanus (three doses): First dose should be (1), and then subsequent two doses should be given as (1)(repeat (1) every 10 years)

I___ (three doses)

Hepatitis __ (three doses)

Hepatitis __ (two doses)

M___ (two doses)

V_____ (two doses) if no history of chickenpox

H__ (two or three doses based on age given; administer if younger than age 26 years)

Answer 18

Tetanus (three doses): First dose should be Tdap, and then subsequent two doses should be given as Td (repeat Td every 10 years)

IPV (three doses)

Hepatitis B (three doses)

Hepatitis A (two doses)

MMR (two doses)

Varicella (two doses) if no history of chickenpox

HPV (two or three doses based on age given; administer if younger than age 26 years)

Question 19

Table 1. Routine and Catch-Up Immunizations: Age 7 Years and Older*

Answer 19

Question 20

4 Years Old (Preschool)

Fine Motor

• M____ pencil grasp
• Can copy a (1)
• Draws a person with ____ body parts

Gross Motor

• Rides a __cycle with training wheels
• H____ on both feet
• Dresses with _____ assistance

Other

• According to Piaget, children aged 1 and 4 years are at the (1) stage
• Ready to learn the al____, spell or read short words, and learn basic m___ concepts.

Answer 20

Fine Motor

• Mature pencil grasp
• Can copy a cross
• Draws a person with three body parts

Gross Motor

• Rides a bicycle with training wheels
• Hops on both feet
• Dresses with little assistance

Other

• According to Piaget, children aged 1 and 4 years are at the preoperational stage
• Ready to learn the alphabet, spell or read short words, and learn basic math concepts.

Question 21

5 Years Old (Preschool)

Fine Motor

• Copies (1)
• Can draw a person with ___ body parts
• Begins to print some l____ and n____

Gross Motor

• Can ride a (1) (use bike helmet)
• Hops on ___ foot
• Can dress and undress ____

Other

• Likes to ____ parents with certain household _____; likes to help adults

Answer 21

Fine Motor

• Copies square
• Can draw a person with six body parts
• Begins to print some letters and numbers

Gross Motor

• Can ride a bicycle (use bike helmet)
• Hops on one foot
• Can dress and undress self

Other

• Likes to help parents with certain household chores; likes to help adults

Question 22

6 Years Old (Kindergarten)

Fine Motor

• Copies a (1) (copies a (1) at age 7)
• Ties ____

Gross Motor

• Climbs t____
• S____

Other

• Begins more f_____ schooling with instruction in basic math and reading skills

Answer 22

Fine Motor

• Copies a triangle (copies a diamond at age 7)
• Ties shoes

Gross Motor

• Climbs trees
• Skips

Other

• Begins more formal schooling with instruction in basic math and reading skills

Question 23

7 to 11 Years Old (Middle Childhood)

Freud classified this age group under the “____ stage.”

The major task for this age group is to succeed in sc____ and interact with their p____ group. May have a “____” friend(s).

Some girls may start puberty at age __ years.

According to Piaget, this age group is in the (1) stage

Early ab_____ thinking starts at about age 11 years.

Starts to think of the f____.

Answer 23

Freud classified this age group under the “latency stage.”

The major task for this age group is to succeed in school and interact with their peer group. May have a “best” friend(s).

Some girls may start puberty at age 8 years.

According to Piaget, this age group is in the concrete operations stage

Early abstract thinking starts at about age 11 years.

Starts to think of the future.

Question 24

Jean Piaget’s Stages of Cognitive Development

Answer 24

Question 25

Autism Spectrum Disorder Autism spectrum disorder (ASD) is a n\_\_\_\_developmental disorder that affects the normal development of com\_\_\_\_\_ and s\_\_\_\_ skills. The exact cause is \_\_\_\_\_\_ Autism affects more (1) gender than (1) gender There are several theories about the cause, but they are \_\_proven (thimerosal, mercury, vaccines, etc.). Autism is ____ to diagnose before the age of 18 months.

Answer 25

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that affects the normal development of communication and social skills. The exact cause is unknown. Autism affects more boys than girls. There are several theories about the cause, but they are unproven (thimerosal, mercury, vaccines, etc.). Autism is hard to diagnose before the age of 18 months.

Question 26

Classic Case of Autism Spectrum Disorder Child who is extremely s\_\_\_\_\_ to noises, touch, smells, and/or textures. Will refuse to wear t\_\_\_\_ or rough-textured clothes because they feel “itchy.” Prefers to be al\_\_\_\_. Has poor \_\_\_contact. Does not int\_\_\_\_\_ with others. Slow-to-poor la\_\_\_\_\_ development. Has repeated body movements such as fl\_\_\_\_ arms. Some may appear to be progressing normally but suddenly re\_\_\_\_\_. Language, physical, and social skills disintegrate.

Answer 26

Child who is extremely sensitive to noises, touch, smells, and/or textures. Will refuse to wear tight or rough-textured clothes because they feel “itchy.” Prefers to be alone. Has poor eye contact. Does not interact with others. Slow-to-poor language development. Has repeated body movements such as flapping arms. Some may appear to be progressing normally but suddenly regress. Language, physical, and social skills disintegrate.

Question 27

Autism Spectrum Disorder Treatment Plan ## Footnote Refer to (1) or (1) for testing and evaluation. Intensive rehabilitation needed at younger ages (i.e., (3)) *Medications:* (1)Rx is an antipsychotic that is prescribed for some older patients.

Answer 27

Refer to psychiatrist or psychologist for testing and evaluation. Intensive rehabilitation needed at younger ages (i.e., occupational therapy [OT], physical therapy [PT], speech therapy). *Medications:* Risperidone (Risperdal) is an antipsychotic that is prescribed for some older patients.

Question 28

(1) Child has **_macrocephaly_** (\>50th percentile for age/sex) and **global developmental delays**. Skills and behavior acquisition slow compared with peers. **Hyperactive** behavior or **specific learning disabilities (particularly involving math and problem-solving)** can be seen. High correlation with **autism and anxiety**. Tends to **avoid eye contact**. Patient has a **_long face_** with **prominent forehead, jaw, and large or protruding ears.** **Large body** with flexible **_flat feet_.**

Answer 28

**Fragile X Syndrome**

Question 29

Fragile X Syndrome Treatment Plan ## Footnote Refer for molecular ______ testing. Refer patient to dev\_\_\_\_\_\_ pediatrician or psychiatrist/psychologist for interdisciplinary evaluation and \_\_\_\_modal interventions.

Answer 29

Refer for molecular genetic testing. Refer patient to developmental pediatrician or psychiatrist/psychologist for interdisciplinary evaluation and multimodal interventions.

Question 30

(1) Acute onset of fever, severe sore throat, headache, and anorexia. Multiple small blisters appear on the hands, feet, and around the rectum. Ulcers are present inside the mouth, throat, tonsils, and tongue. Child will complain of sore throat and mouth pain with acidic foods.

Answer 30

Hand–Foot–Mouth Disease

Question 31

Hand–Foot–Mouth Disease A common acute \_\_\_illness that mainly affects children younger than 10 years of age. Most common cause is the \_\_\_\_\_\_virus A16. Spread through? Patient is most contagious during the first ____ of the illness.

Answer 31

A common acute viral illness that mainly affects children younger than 10 years of age. Most common cause is the coxsackievirus A16. Spread through direct contact with nasal discharge, saliva, blister fluid, or stool. Patient is most contagious during the first week of the illness.

Question 32

Hand–Foot–Mouth Disease Treatment Plan ## Footnote Treatment is \_\_\_\_\_\_; \_\_\_\_-limited illness; complete recovery usually occurs within __ to _ days. Rx(1) ir Rx(1) for pain and fever every 4 to 6 hours; do not use \_\_\_\_. Use \_\_\_\_-water gargle (1/2 teaspoon salt in one glass of warm water). Drink c\_\_\_\_ fluids (\_\_\_ soda, orange or lemon juice, tomato juice).

Answer 32

Treatment is symptomatic; self-limited illness; complete recovery usually occurs within 5 to 7 days. Ibuprofen or acetaminophen for pain and fever every 4 to 6 hours; do not use aspirin. Use salt-water gargle (1/2 teaspoon salt in one glass of warm water). Drink cold fluids (avoid soda, orange or lemon juice, tomato juice).- **avoid acidic drinks!**

Question 33

Multiple small blisters appear on the hands, feet, and around rectum. Small ulcers inside the mouth, throat, tonsils, and tongue.

Answer 33

Hand–foot–mouth disease

Question 34

“Honey-colored” crusted lesions. Fragile bullae (bullous type).

Answer 34

Impetigo

Question 35

Koplik’s spots (small white papules) inside the cheeks (buccal mucosa) by the rear molars. Erythematous maculopapular rash that begins on face and spreads from head to feet but spares palms and soles.

Answer 35

Measles (rubeola)

Question 36

Generalized rash in different stages; new lesions appear daily for about 5 days. Papules → vesicles → pustules → crusts. Pruritic. Very contagious.

Answer 36

Varicella

Question 37

“Sandpaper” rash with sore throat. Strawberry tongue is not specific (also seen in Kawasaki disease).

Answer 37

Scarlet fever

Question 38

Ovoid white nits on hair hard to dislodge. Red papules that are very itchy and nits are initially located in the hairline area behind the neck and the ears.

Answer 38

*Pediculosis capitis* (head lice)

Question 39

Smooth waxlike round (dome-shaped) papules ranging in size from a pinhead to the size of a pencil eraser (2–5 mm). Central umbilication with white plug.

Answer 39

Molluscum contagiosum

Question 40

Maculopapular rash located in interdigital webs of hands, feet, waist, axillae, groin. Very pruritic, especially at night. Can resemble pimples, eczema, and insect bites.

Answer 40

Scabies

Question 41

Functional Constipation (Encopresis) Diagnosis using (1) Criteria Must meet ____ (or more) of the following criteria at least ___ per week (for at least __ month). Order (1) imaging of abdomen to check for retained stool

Answer 41

Rome IV criteria Must meet two (or more) of the following criteria at least once per week (for at least 1 month). Order a plain film (x-ray) of the abdomen to check for retained stool

Question 42

Rome IV Criteria (2 criteria, 1/week for 1 month) 1. History of with\_\_\_\_\_ of stool 2. History of \_\_\_ful or h\_\_\_ bowel movements 3. History of \_\_\_\_-diameter stools that may ob\_\_\_\_\_ the toilet 4. Presence of l\_\_\_\_ fecal mass in r\_\_\_\_ 5. \_\_\_or fewer defecations in toilet per week 6. At least one episode of fecal in\_\_\_\_\_ per week (thin fluid with feces that bypasses a large stool mass and leaks around it); ask patient whether fecal soiling of underwear

Answer 42

1. History of withholding of stool 2. History of painful or hard bowel movements 3. History of large-diameter stools that may obstruct the toilet 4. Presence of large fecal mass in rectum 5. Two or fewer defecations in toilet per week 6. At least one episode of fecal incontinence per week (thin fluid with feces that bypasses a large stool mass and leaks around it); ask patient whether fecal soiling of underwear

Question 43

Exam Tips ## Footnote All 11- to 12-year-old children should be vaccinated with single dose of quadrivalent (1) vaccine (MenACWY); brand names are (1) Immunizations are needed at age 11 to 12 years (3) *HPV vaccine (Gardasil):* Know that youngest age group for vaccination is __ years and it can be given up to age __ years. HPV may cause cancers of the c\_\_\_\_, v\_\_\_, vu\_\_\_, p\_\_\_, a\_\_\_, ph\_\_\_\_, and base of tongue and tonsils (oro\_\_\_\_) in both men and women.

Answer 43

All 11- to 12-year-old children should be vaccinated with single dose of quadrivalent meningococcal vaccine (MenACWY); brand names are Menactra and Menveo. Immunizations are needed at age 11 to 12 years (Tdap, HPV, MCV4). *HPV vaccine (Gardasil):* Know that youngest age group for vaccination is 9 years and it can be given up to age 26 years. HPV may cause cancers of the cervix, vagina, vulva, penis, anus, pharynx, and base of tongue and tonsils (oropharynx) in both men and women.

Question 44

Exam Tips ## Footnote Child at age of 11 years is at “(1)” thinking stage (Piaget). Recognize physical characteristics of fragile X syndrome = Recognize hand–foot–mouth disease, scabies, impetigo, varicella, and other childhood rashes. Rubeola is \_\_\_\_\_. \_\_\_\_\_\_spots are small white papules) inside the cheeks.

Answer 44

Child at age of 11 years is at “early abstract” thinking stage (Piaget). Recognize physical characteristics of fragile X syndrome = macrocephaly, flat feet, long face, prominent forehead, jaw, large or protruding ears Recognize hand–foot–mouth disease, scabies, impetigo, varicella, and other childhood rashes. Rubeola is measles. Koplik’s spots are small white papules) inside the cheeks.

Question 45

Adolescents Danger Signals A\_\_\_\_\_\_ Poisoning (Intentional Ingestion) Testicular _____ (Acute Scrotum) Testicular \_\_\_\_\_ \_\_\_\_\_\_ Lymphoma

Answer 45

Acetaminophen Poisoning (Intentional Ingestion) Testicular Torsion (Acute Scrotum) Testicular Cancer Hodgkin’s Lymphoma

Question 46

Acetaminophen Poisoning (Intentional Ingestion) Acetaminophen damages the \_\_\_\_, resulting in mild-to-severe fulminant liver failure. Acetaminophen is also known as *para\_\_\_\_\_* and sold as Tylenol and others. With acute overdose, serum acetaminophen concentration should be measured as soon as possible, but at least 4 hours must have passed since _______ to obtain accurate blood level (if \<4 hours, blood level is not accurate). Antidote is **(1)** given intravenously.

Answer 46

Acetaminophen damages the liver, resulting in mild-to-severe fulminant liver failure. Acetaminophen is also known as *paracetamol* and sold as Tylenol and others. With acute overdose, serum acetaminophen concentration should be measured as soon as possible, but at least 4 hours must have passed since ingestion to obtain accurate blood level (if \<4 hours, blood level is not accurate). Antidote is **N-acetylcysteine** given intravenously.

Question 47

Acetaminophen Poisoning Stages Match each description to Stage I-IV of overdose (1) Hepatic necrosis presents as jaundice, clotting disorders, hypoglycemia, and hepatic encephalopathy. Acute kidney injury with oliguria may develop. Most deaths from organ failure occur within 72 to 96 hours. (1) Patients are usually asymptomatic but may have nausea and vomiting and, with very large doses, lethargy and malaise. (1) Patients complain of right upper quadrant pain with abdominal pain, nausea, and vomiting; elevated liver function tests (LFTs), prothrombin time, and bilirubin concentrations; possible nephrotoxicity (elevated blood urea nitrogen [BUN], creatinine). (1) If patient survives, symptoms and signs of organ failure resolve.

Answer 47

* Stage III (72–96 hours after overdose):* Hepatic necrosis presents as jaundice, clotting disorders, hypoglycemia, and hepatic encephalopathy. Acute kidney injury with oliguria may develop. Most deaths from organ failure occur within 72 to 96 hours. * Stage 1 (up to 24 hours after overdose)* Patients are usually asymptomatic but may have nausea and vomiting and, with very large doses, lethargy and malaise. * Stage II (18–72 hours after overdose)* Patients complain of right upper quadrant pain with abdominal pain, nausea, and vomiting; elevated liver function tests (LFTs), prothrombin time, and bilirubin concentrations; possible nephrotoxicity (elevated blood urea nitrogen [BUN], creatinine). * Stage IV (4 days–3 weeks after overdose)* If patient survives, symptoms and signs of organ failure resolve.

Question 48

Testicular Torsion (Acute Scrotum) Pubertal male awakens with abrupt onset of \_\_\_lateral testicular pain that increases in severity. Pain may radiate to the lower a\_\_\_\_\_ and/or groin. Almost all patients (90%) also have (1) and (1) Ischemic changes result in severe scrotal ed\_\_\_\_, redness, and testicular pain. Ipsilateral (same side) (1)\* reflex is absent, and the testicle may be noted to be high riding with a transverse lie. Highest incidence is during adolescence. May be confused with torsion of appendix testis (more common in prepubertal boys, less nausea/vomiting, “\_\_\_dot sign”). Urinalysis (UA) is _____ for pyuria and bacteriuria. Doppler (1) is the initial diagnostic test. Testicle is not functional after __ hours if not repaired. Refer to ED. This is a surgical \_\_\_\_\_.

Answer 48

Pubertal male awakens with abrupt onset of unilateral testicular pain that increases in severity. Pain may radiate to the lower abdomen and/or groin. Almost all patients (90%) also have nausea and vomiting. Ischemic changes result in severe scrotal edema, redness, and testicular pain. Ipsilateral (same side) cremasteric reflex is absent, and the testicle may be noted to be high riding with a transverse lie. Highest incidence is during adolescence. May be confused with torsion of appendix testis (more common in prepubertal boys, less nausea/vomiting, “blue dot sign”). Urinalysis (UA) is negative for pyuria and bacteriuria. Doppler ultrasound is the initial diagnostic test. Testicle is not functional after 24 hours if not repaired. Refer to ED. This is a surgical emergency.

Question 49

Testicular Cancer Teenage-to-adult male complains of a “**\_\_\_\_ness**” in scrotum or a hardened m\_\_\_\_ that is usually pain\_\_\_. Some patients may have testicular discomfort or numbness, but ___ pain. The affected testicle has a f\_\_\_\_ texture. More common in males from the age of __ to __ years. **(1)** is a strong risk factor.

Answer 49

Teenage-to-adult male complains of a “**heaviness**” in scrotum or a hardened mass that is usually painless. Some patients may have testicular discomfort or numbness, but not pain. The affected testicle has a firm texture. More common in males from the age of 15 to 35 years. **Cryptorchidism** is a strong risk factor.

Question 50

Hodgkin’s Lymphoma Patient presents with enlarged and painless cervical, axillary, groin, or supraclavicular \_\_\_\_\_\_opathy associated with f\_\_\_\_ (Pel-Ebstein sign), fatigue, unexplained ____ loss, and night \_\_\_\_. May report having severe pain on or over malignant areas a few minutes after drinking \_\_\_\_. The ____ common cancers in teens aged __ to __ years are Hodgkin’s lymphoma (16%) and germ cell tumors (16%) such as testicular and ovarian cancer.

Answer 50

Patient presents with enlarged and painless cervical, axillary, groin, or supraclavicular lymphadenopathy associated with fever (Pel-Ebstein sign), fatigue, unexplained weight loss, and night sweats. May report having severe pain on or over malignant areas a few minutes after drinking alcohol. The most common cancers in teens aged 15 to 19 years are Hodgkin’s lymphoma (16%) and germ cell tumors (16%) such as testicular and ovarian cancer.

Question 51

Adolescence Defined as the onset of p\_\_\_\_ until s\_\_\_\_ maturity. **Top Three Causes of Death (15–19 Years Old)** 1. _____ (e.g., motor vehicle crashes) 2. _____ (e.g., intentional suffocation) 3. ______ (e.g., intentional firearm use)

Answer 51

Defined as the onset of puberty until sexual maturity. **Top Three Causes of Death (15–19 Years Old)** 1. Accidents (e.g., motor vehicle crashes) 2. Suicide (e.g., intentional suffocation) 3. Homicide (e.g., intentional firearm use)

Question 52

Puberty The period in life when secondary ____ characteristics start to develop because of hormonal stimulation. Girls’ ovaries start producing (2) Boys’ testes start producing (1). All of these changes result in rep\_\_\_\_\_\_\_ capability.

Answer 52

The period in life when secondary sexual characteristics start to develop because of hormonal stimulation. Girls’ ovaries start producing estrogen and progesterone. Boys’ testes start producing testosterone. All of these changes result in reproductive capability.

Question 53

Girls (1) puberty if puberty starts before age 8 years (1) puberty if no breast development (Tanner stage II) by age 12 years

Answer 53

Precocious puberty if puberty starts before age 8 years Delayed puberty if no breast development (Tanner stage II) by age 12 years

Question 54

Girls *Growth Spurt* ## Footnote Majority of physical changes occur between the ages of __ and __ years. Majority of skeletal growth occurs ____ menarche. Afterward, growth ____ down. Girls start their growth spurts approximately 2 years _____ than boys.

Answer 54

Majority of physical changes occur between the ages of 10 and 13 years. Majority of skeletal growth occurs before menarche. Afterward, growth slows down. Girls start their growth spurts approximately 2 years earlier than boys.

Question 55

Girls *Pubertal Timeline* (1) development → peak (1) acceleration → m\_\_\_\_\_. Most of a girl’s height is gained ____ menarche. Skeletal growth in girls is considered complete within __ years ____ menarche.

Answer 55

Breast development → peak growth acceleration → menarche. Most of a girl’s height is gained before menarche. Skeletal growth in girls is considered complete within 2 years after menarche.

Question 56

(1) Unilateral midcycle (about 14 days before the next period) pelvic pain that is caused by an enlarging ovarian follicle or the rupture of the follicle at the time of ovulation. Pain may last a few hours to a few days. May occur intermittently.

Answer 56

*Mittelschmerz (Ovulation Pain)*

Question 57

*Menarche* ## Footnote Average age? Age range? The first 1 to 2 years after the onset of menarche, it is common to have _____ periods because of irregular ovulation (may skip a month or longer intervals, lighter bleeding). After Tanner stage ___ starts (breast bud stage), girls start menses within __ years Delayed puberty is determined if no breast development by age __ or menarche does not begin by __ years.

Answer 57

Average age is about **12** years (12.34 years) in the United States (range ages 8–15 years). The first 1 to 2 years after the onset of menarche, it is common to have irregular periods because of irregular ovulation (may skip a month or longer intervals, lighter bleeding). After Tanner stage II starts (breast bud stage), girls start menses within 2 years. Delayed puberty is determined if no breast development by age 13 or menarche does not begin by 15 years.

Question 58

*Menstrual Cycle* ## Footnote Average duration is ___ days. In younger teens, cycles range from 21 to 45 days; in adults, they can range from 21 to 35 days. Average duration of menstrual bleeding is about __ to __ days (range 2–7 days). Day 1 of the menstrual cycle starts as sp\_\_\_\_\_; then, blood flow becomes h\_\_\_\_\_ for 2 to 3 days, and then bleeding lightens until it stops. The most fertile period in the cycle?

Answer 58

Average duration is 28 days. In younger teens, cycles range from 21 to 45 days; in adults, they can range from 21 to 35 days. Average duration of menstrual bleeding is about 3 to 5 days (range 2–7 days). Day 1 of the menstrual cycle starts as spotting; then, blood flow becomes heavier for 2 to 3 days, and then bleeding lightens until it stops. The most fertile period in the cycle is about 3 days before and during ovulation (days 11–14).

Question 59

*Dysmenorrhea* What is it caused by? Treatment (2)

Answer 59

Painful periods are due to severe menstrual cramps caused by high levels of **prostaglandins**. Treatment is use of **heating pads** and **NSAIDs** as ibuprofen (Advil, Motrin) and naproxen (Aleve).

Question 60

Boys and Puberty Precocious puberty if starts before age __ years Delayed puberty if no testicular enlargement by age ___ years ***Growth Spurt*** Boys’ growth spurts are approximately __ years ____ than girls’ (ages 11–15 years). ***Spermarche*** Average age is ___ years.

Answer 60

Precocious puberty if starts before age 9 years Delayed puberty if no testicular enlargement by age 14 years ***Growth Spurt*** Boys’ growth spurts are approximately 2 years later than girls’ (ages 11–15 years). ***Spermarche*** Average age is 13.3 years.

Question 61

Tanner Stages Boys ## Footnote Stage I: Prepuberty Stage II: Stage III: Stage IV: Stage V: Adult pattern

Answer 61

Stage I: Prepuberty Stage II: **Testes** begin to **enlarge**, with increased **rugation** of scrotum Stage III: **Penis elongates**; testicular/scrotal growth continues; scrotal color starts to darken Stage IV: **Penis thickens** and increases in length; testes are larger and scrotal skin darkens Stage V: Adult pattern

Question 62

Tanner Stages Girls ## Footnote Stage I: Prepuberty Stage II: Stage III: Stage IV: Stage V: Adult pattern

Answer 62

Stage I: Prepuberty Stage II: **Breast bud** (onset of thelarche, or breast development) Stage III: Breast tissue and areola are in **one mound** Stage IV: Areola/nipples separate and form a **secondary mound** Stage V: Adult pattern

Question 63

Pubic Hair (Both Genders) ## Footnote Stage I: Prepuberty Stage II: Sp\_\_\_\_\_ growth of st\_\_\_\_ hair that is easily counted Stage III: Hair is d\_\_\_\_\_ and starts to \_\_\_\_ Stage IV: Hair is curly but not on medial thigh yet as in adult; hair is c\_\_\_\_\_\_ Stage V: Adult pattern; hair spreads to medial th\_\_\_\_ and lower ab\_\_\_\_\_

Answer 63

Stage I: Prepuberty Stage II: Sparse growth of straight hair that is easily counted Stage III: Hair is darker and starts to curl Stage IV: Hair is curly but not on medial thigh yet as in adult; hair is coarser Stage V: Adult pattern; hair spreads to medial thigh and lower abdomen

Question 64

Tanner Stage Table

Answer 64

Question 65

Immunization Schedule for Adolescents For patients who did not complete immunization or were not immunized as infants.

Answer 65

Question 66

Immunization Schedule for Adolescents For patients who did not complete immunization or were not immunized as infants.

Answer 66

Question 67

Exam Tips ## Footnote *Meningococcal vaccine is recommended for \_\_\_*, starting at age \_\_-\_\_ years (not just for (1)) CDC recommends HPV vaccine for both females and males until age __ years. Antidote of acetaminophen poisoning is intravenous (IV) (1)

Answer 67

*Meningococcal vaccine is recommended for all*, starting at age 11 to 12 years (not just for college freshmen living in dormitories). CDC recommends HPV vaccine for both females and males until age 26 years. Antidote of acetaminophen poisoning is intravenous (IV) *N*-acetylcysteine.

Question 68

Exam Tips ## Footnote Recognize presentation of testicular torsion (1) and testicular cancer (1) Hodgkin’s lymphoma presents as enlarged (1) with f\_\_\_, \_\_\_sweats, and p\_\_ (lymph nodes) after drinking \_\_\_\_\_. (1): Government program to report clinically adverse events of vaccines

Answer 68

Recognize presentation of testicular torsion (acute unilateral pain, N/V, reddened, swollen, high riding testicle, absent cremasteric reflex) and testicular cancer (heaviness, firm, painless mass, 15-35 yo) Hodgkin’s lymphoma presents as enlarged lymph nodes with fever, night sweats, and pain (lymph nodes) after drinking alcohol. *Vaccine Adverse Event Reporting System (VAERS):* Government program to report clinically adverse events.

Question 69

Elevated Alkaline Phosphatase Why do children have higher levels of ALP?

Answer 69

Children and adolescents normally have higher blood levels compared with adults because of growing bone. It is produced by the osteoblasts.

Question 70

Right to Consent and Confidentiality No parental (or guardian) consent is necessary for the following: C\_\_\_\_\_\_\_ Treatment for (1) Diagnosis and management of p\_\_\_\_\_\_\_\_

Answer 70

Contraception Treatment for STDs Diagnosis and management of pregnancy

Question 71

Emancipated Minor Criteria These minors may give full consent as an adult without parental involvement: (2)

Answer 71

Legally married Active duty in the armed forces

Question 72

Confidentiality Confidentiality can be broken in the following situations: G\_\_\_\_\_ wounds and s\_\_\_\_ wounds, which must be reported to the police (regardless of victim’s age) Child ____ (actual or suspected abuse), which must be reported to the authorities S\_\_\_\_\_ ideation and/or attempt (discharge to parents/guardians or hospital) H\_\_\_\_\_\_\_ ideation or intent (especially mental health providers)

Answer 72

Gunshot wounds and stab wounds, which must be reported to the police (regardless of victim’s age) Child abuse (actual or suspected abuse), which must be reported to the authorities Suicidal ideation and/or attempt (discharge to parents/guardians or hospital) Homicidal ideation or intent (especially mental health providers)

Question 73

Health Promotion During a physical examination or wellness visit, assess teenager for high-risk behaviors. Intensive behavior counseling is recommended. The following are high-risk behaviors to screen for: * Sexual activity:* Use of c\_\_\_\_, birth \_\_\_\_\_, intimate partner \_\_\_\_\_(e.g., rape), signs/symptoms of S\_\_\_ * Safety:* Driver safety; seat\_\_\_/h\_\_\_\_ use; access to g\_\_\_/gun safety; sm\_\_\_\_, al\_\_\_\_l, and drug use * \_\_\_\_\_ history:* Family, peers, school performance, work Mental health: Signs/symptoms of d\_\_\_\_\_and anti\_\_\_\_\_ behaviors (e.g., gangs)

Answer 73

* Sexual activity:* Use of condoms, birth control, intimate partner violence (e.g., rape), signs/symptoms of STDs * Safety:* Driver safety; seatbelt/helmet use; access to guns/gun safety; smoking, alcohol, and drug use * Social history:* Family, peers, school performance, work Mental health: Signs/symptoms of depression and antisocial behaviors (e.g., gangs)

Question 74

Exam Tips ## Footnote Recognize presentation of testicular torsion = How should you interview/gather health history from an adolescent? No parental consent is needed for health services related to sexual activity (\_\_\_ testing, p\_\_\_\_\_tests, birth ____ prescriptions). If not related to sexual activity, then need ____ consent (dysmenorrhea, headache, upper respiratory infection [URI]). Memorize the criteria for an emancipated minor (2). Do not confuse the right to confidentiality with emancipated minor status.

Answer 74

Recognize presentation of testicular torsion = unilateral testicular pain increasing in severity, n/v, edema, redness, pain, absent cremasteric reflex, pain may radiate to lower abdomen/groin, high riding testicle with transverse lie Adolescent health history is obtained from both parent and child initially; then the adolescent is interviewed alone without the parent. No parental consent is needed for health services related to sexual activity (STD testing, pregnancy tests, birth control prescriptions). If not related to sexual activity, then need parental consent (dysmenorrhea, headache, upper respiratory infection [URI]). Memorize the criteria for an emancipated minor (legally married, in armed forces). Do not confuse the right to confidentiality with emancipated minor status.

Question 75

Exam Tips ## Footnote Puberty starts at Tanner stage __ in girls (breast \_\_\_) or boys (\_\_\_\_\_\_ enlargement and scrotal \_\_\_\_/color starts to become darker). Puberty ends at Tanner stage __ (adult stage). Tanner stage III in boys is ______ of the penis (testes continue to grow). Only Tanner stages __ to __ need to be memorized for the exam. There is __ need to memorize pubic hair changes for either gender. Memorize only the ____ changes (girls) and the _____ changes (boys). There will be ___ question about Tanner staging (girl or boy).

Answer 75

Puberty starts at Tanner stage II in girls (breast bud) or boys (testicular enlargement and scrotal rugation/color starts to become darker). Puberty ends at Tanner stage V (adult stage). Tanner stage III in boys is elongation of the penis (testes continue to grow). Only Tanner stages II to IV need to be memorized for the exam. There is no need to memorize pubic hair changes for either gender. Memorize only the breast changes (girls) and the genital changes (boys). There will be one question about Tanner staging (girl or boy).

Question 76

Delayed Puberty Absence of secondary sexual characteristics by the age of \_\_ years for girls (such as a breast bud) or at the age of \_\_\_ years for boys. The child remains in Tanner stage __ (prepubertal).

Answer 76

Absence of secondary sexual characteristics by the age of 13 years for girls (such as a breast bud) or at the age of 14 years for boys. The child remains in Tanner stage I (prepubertal).

Question 77

Delayed Puberty Labs ## Footnote Serum pr\_\_\_\_\_ test. Check (1) level. If level is elevated, next step is to order a (1) of the sella _____ (location of (1) gland inside the skull).

Answer 77

Serum pregnancy test. Check prolactin level. If prolactin level is elevated, next step is to order a CT scan of the sella turcica (location of pituitary gland inside the skull).

Question 78

Delayed Puberty Labs For ______ amenorrhea (no menses by age 15 years), rule out (1) by checking hormone levels (3). Rule out chromosomal disorders, absence of uterus/vagina, and imperforate hymen. X-ray of the hand is used for estimating “bone \_\_\_”: * When the long-bone epiphyses (growth plates) are \_\_\_\_, skeletal growth is finished. * Refer to pediatric (1) if no growth spurt, delayed puberty, others.

Answer 78

For primary amenorrhea (no menses by age 15 years), rule out hypogonadism by checking hormone levels (e.g., follicle-stimulating hormone [FSH], luteinizing hormone [LH], thyroid-stimulating hormone [TSH]). Rule out chromosomal disorders, absence of uterus/vagina, and imperforate hymen. X-ray of the hand is used for estimating “bone age”: * When the long-bone epiphyses (growth plates) are fused, skeletal growth is finished. * Refer to pediatric endocrinologist if no growth spurt, delayed puberty, others.

Question 79

* Primary amenorrhea* * =*

Answer 79

No menarche by the age of 15 years in the presence of normal growth and secondary sex characteristics. Nearly half of cases are caused by chromosomal disorders (43%) such as Turner syndrome.

Question 80

* Secondary amenorrhea* * =* Most common cause (1) Other causes include?

Answer 80

No menses for more than three cycles or 6 months if previously had menses. Most common cause is pregnancy. Others are ovarian disorders, stress, anorexia, and polycystic ovary syndrome (PCOS)

Question 81

Secondary Amenorrhea Associated With Exercise and Underweight ## Footnote Excessive exercise and/or sports participation has a higher incidence of amenorrhea (and infertility) because of relative _____ deficiency. *“Female athlete triad”*:

Answer 81

Excessive exercise and/or sports participation has a higher incidence of amenorrhea (and infertility) because of relative caloric deficiency. *“Female athlete triad”*: Anorexia nervosa/restrictive eating, amenorrhea, and osteoporosis

Question 82

Primary and Secondary Amenorrhea Labs ## Footnote (1) test (serum human chorionic gonadotropin [HCG]) Serum (1) level (rule out prolactinoma-induced amenorrhea) Serum (1); also (2) (rule out premature ovarian failure) If amenorrhea for more than 6 months, measure _____ density

Answer 82

Pregnancy test (serum human chorionic gonadotropin [HCG]) Serum prolactin level (rule out prolactinoma-induced amenorrhea) Serum TSH; also FSH and LH (rule out premature ovarian failure) If amenorrhea for more than 6 months, measure bone density

Question 83

Primary and Secondary Amenorrhea Treatment Plan ## Footnote Educate about increasing _____ intake and decreasing \_\_\_\_\_ Prescribe c\_\_\_\_\_ with vitamin __ 1,200 to 1,500 mg daily and vitamin __ 400 IU daily

Answer 83

Educate about increasing caloric intake and decreasing exercise Prescribe calcium with vitamin D 1,200 to 1,500 mg daily and vitamin E 400 IU daily

Question 84

Complications of Amenorrhea ## Footnote O\_\_\_\_\_/O\_\_\_\_\_\_ (stress fractures) Myocardial a\_\_\_\_\_, arr\_\_\_\_\_ (sudden death), \_\_\_\_cardia, h\_\_\_\_tension H\_\_\_glycemia, dehydration, electrolytes L\_\_\_\_\_ (fine, downy hair), (1) (hair loss), (1) (dry skin), inf\_\_\_\_\_ \_\_\_\_ body mass index (BMI), c\_\_\_\_xia, \_\_\_emia, respiratory f\_\_\_\_\_

Answer 84

Osteopenia/osteoporosis (stress fractures) Myocardial atrophy, arrhythmia (sudden death), bradycardia, hypotension Hypoglycemia, dehydration, electrolytes Lanugo (fine, downy hair), telogen effluvium (hair loss), xerosis (dry skin), infertility Low body mass index (BMI), cachexia, anemia, respiratory failure

Question 85

Anorexia Nervosa ## Footnote Usual onset is during adolescence. Involves an irr\_\_\_\_ preoccupation with and intense f\_\_\_\_ of gaining \_\_\_\_\_. *Two types:* Patient engages in re\_\_\_\_\_ (dieting, excessive exercise) or ____ eating and p\_\_\_\_\_. Some examples of purging are excessive use of laxatives, enemas, diuretics, and vomiting.

Answer 85

Usual onset is during adolescence. Involves an irrational preoccupation with and intense fear of gaining weight. *Two types:* Patient engages in restriction (dieting, excessive exercise) or binge eating and purging. Some examples of purging are excessive use of laxatives, enemas, diuretics, and vomiting.

Question 86

Anorexia Nervosa Clinical Findings ## Footnote Marked weight loss (BMI ≤\_\_\_\_), \_\_\_\_cardia (40–49 beats/min), vital signs unstable, \_\_\_\_tension L\_\_\_\_\_ (increased lanugo, especially in the face, back, and shoulders) O\_\_\_\_\_ or \_\_\_\_\_\_ S\_\_\_\_\_ feet (low \_\_\_\_), dizziness, abdominal bl\_\_\_\_\_\_

Answer 86

Marked weight loss (BMI ≤18.5), bradycardia (40–49 beats/min), vital signs unstable, hypotension Lanugo (increased lanugo, especially in the face, back, and shoulders) Osteoporosis or osteopenia Swollen feet (low albumin), dizziness, abdominal bloating

Question 87

Exam Tips ## Footnote Recognize how anorexic patients present (i.e., l\_\_\_\_ peripheral \_\_\_\_, \_\_\_\_hea, significant weight loss \>\_\_% of body weight). Increased risk of osteoporosis or osteopenia. For birth control, avoid (1) and other \_\_\_\_\_\_\_-only contraceptives, because they can cause bone loss. Low ______ level results in peripheral \_\_\_\_\_.

Answer 87

Recognize how anorexic patients present (i.e., lanugo, peripheral edema, amenorrhea, significant weight loss \>10% of body weight). Increased risk of osteoporosis or osteopenia. For birth control, avoid Depo Provera and other progesterone-only contraceptives, because they can cause bone loss. Low albumin level results in peripheral edema.

Question 88

(1) Excessive growth of breast tissue in males. Can involve one or both breasts. Physiologic condition is benign and is more common during infancy and adolescence. _____ in up to 40% of pubertal boys (peaks at age 14). Most cases resolve spontaneously within 6 months to 2 years.

Answer 88

Gynecomastia Excessive growth of breast tissue in males. Can involve one or both breasts. Physiologic gynecomastia is benign and is more common during infancy and adolescence. Normal in up to 40% of pubertal boys (peaks at age 14). Most cases resolve spontaneously within 6 months to 2 years.

Question 89

Classic Case of Gynecomastia Adolescent male is brought in by a parent who is concerned about gradual onset of en\_\_\_\_\_ breasts or \_\_symmetrical breast tissue (one may be larger). Child is emb\_\_\_\_\_ and scared about breast changes. Affected breast may be _____ to palpation.

Answer 89

Adolescent male is brought in by a parent who is concerned about gradual onset of enlarged breasts or asymmetrical breast tissue (one may be larger). Child is embarrassed and scared about breast changes. Affected breast may be tender to palpation.

Question 90

Gynecomastia Objective Findings Round, ru\_\_\_\_, and m\_\_\_ mound (d\_\_\_like) under the areola of both breasts. Skin has __ dimpling, redness, or changes. If mass is irregular, fixed, or hard, or rapid growth in breast size or if suspect secondary cause, refer to sp\_\_\_\_\_.

Answer 90

Round, rubbery, and mobile mound (disklike) under the areola of both breasts. Skin has no dimpling, redness, or changes. If mass is irregular, fixed, or hard, or rapid growth in breast size or if suspect secondary cause, refer to specialist.

Question 91

Gynecomastia Treatment Plan ## Footnote Evaluate for T\_\_\_\_\_\_ stage (check testicular size, pubic hair, axillary hair, body odor). *Check for ____ use:* Both illicit and prescription (e.g., steroids, cimetidine, antipsychotics). Rule out serious etiology (e.g., testicular or adrenal t\_\_\_\_\_, brain tumor, hypo\_\_\_\_\_). Recheck patient in __ months to monitor for changes.

Answer 91

Evaluate for Tanner stage (check testicular size, pubic hair, axillary hair, body odor). *Check for drug use:* Both illicit and prescription (e.g., steroids, cimetidine, antipsychotics). Rule out serious etiology (e.g., testicular or adrenal tumors, brain tumor, hypogonadism). Recheck patient in 6 months to monitor for changes.

Question 92

(1) Bilateral enlarged breast is due to fatty tissue (adipose tissue). Common in obese boys and men. Both breasts feel soft to touch and are not tender. No breast bud or disklike breast tissue is palpable. Labs?

Answer 92

Pseudogynecomastia None. Diagnosed by clinical presentation.

Question 93

Adolescent Idiopathic Scoliosis \_\_\_\_\_ curvature of the spine that may be accompanied by spinal r\_\_\_\_\_. More common in (1) gender (80% of patients). Painless and asymptomatic. Scoliosis will most likely worsen (66% of cases) if it starts in the beginning of the growth \_\_\_\_\_. Rapid worsening of curvature is indicative of secondary cause (e.g., (1) or (1) syndrome, cerebral palsy, myelomeningocele).

Answer 93

Lateral curvature of the spine that may be accompanied by spinal rotation. More common in girls (80% of patients). Painless and asymptomatic. Scoliosis will most likely worsen (66% of cases) if it starts in the beginning of the growth spurt. Rapid worsening of curvature is indicative of secondary cause (e.g., Marfan or Ehlers–Danlos syndrome, cerebral palsy, myelomeningocele).

Question 94

Classic Case Scoliosis Teen complains that one hip, shoulder, breast, or scapula is _____ than the other. \_\_complaints of pain. Screening Test (1) Bend forward with both arms h\_\_\_\_\_ free. Look for \_\_symmetry of spine, scapula, thoracic, and lumbar curvature. Check height. Measure the ___ angle (degree of spinal curvature). Full-spine (1) are used to measure degree of curvature.

Answer 94

Teen complains that one hip, shoulder, breast, or scapula is higher than the other. No complaints of pain. Adam’s Forward Bend Test Bend forward with both arms hanging free. Look for asymmetry of spine, scapula, thoracic, and lumbar curvature. Check height. Measure the Cobb angle (degree of spinal curvature). Full-spine x-rays are used to measure degree of curvature.

Question 95

Scoliosis Treatment Parameters ## Footnote * Curves Observe and monitor for changes in spinal curvature* * Curves of ___ to __ degrees:* (1) (e.g., Milwaukee brace) * Curves \>\_\_\_ degrees:* (1) correction with Harrington rod used on spine and other options

Answer 95

* Curves \<20 degrees:* Observe and monitor for changes in spinal curvature * Curves of 20 to 40 degrees:* Bracing (e.g., Milwaukee brace) * Curves \>40 degrees:* Surgical correction with Harrington rod used on spine and other options

Question 96

Scoliosis Management ## Footnote Check ______ stage (Tanner stages II–V). Order spinal (1) (posterioanterior [PA] view) to measure ____ angle. Refer ___ patients with scoliosis to a pediatric (1) specialist.

Answer 96

Check Tanner stage (Tanner stages II–V). Order spinal x-ray (posterioanterior [PA] view) to measure Cobb angle. Refer all patients with scoliosis to a pediatric orthopedic specialist.

Question 97

Osgood–Schlatter Disease A common cause of knee pain in young a\_\_\_\_\_\_. Caused by _____ of the knee. Repetitive stress on the patellar t\_\_\_\_\_ by the _______ muscle causes pain, tenderness, and swelling at the tendon’s _____ site (the tibial tuberosity). Usually affects one knee but can be bilateral. Most common during rapid (1) in teenage males who are physically active and/or play sports that stress the patellar tendon (e.g., basketball, soccer, running). Condition abates when _____ stops.

Answer 97

A common cause of knee pain in young athletes. Caused by overuse of the knee. Repetitive stress on the patellar tendon by the quadriceps muscle causes pain, tenderness, and swelling at the tendon’s insertion site (the tibial tuberosity). Usually affects one knee but can be bilateral. Most common during rapid growth spurts in teenage males who are physically active and/or play sports that stress the patellar tendon (e.g., basketball, soccer, running). Condition abates when growth stops.

Question 98

Classic Case of Osgood–Schlatter Disease **A 14-year-old male athlete undergoing a rapid (1) complains of a tender bony _____ over the \_\_\_erior t\_\_\_\_\_of one knee.** The pain is worsened by some ______ (squatting, kneeling, jumping, climbing up stairs). The knee pain improves with ____ and avoidance of aggravating activity. Reports the presence of _____ mass on the (1) that is slightly t\_\_\_\_\_. Almost all cases resolve ______ within a few weeks to months. Rule out avulsion _____ (tibial tubercle) if acute onset of pain posttrauma (order lateral x-ray of knee).

Answer 98

A 14-year-old male athlete undergoing a **rapid growth spurt** complains of a **tender bony mass over the anterior tubercle of one knee.** The pain is worsened by some activities (squatting, kneeling, jumping, climbing up stairs). The knee pain improves with rest and avoidance of aggravating activity. Reports the presence of **bony mass on the anterior tibial tubercle** that is slightly tender. Almost all cases resolve spontaneously within a few weeks to months. Rule out avulsion fracture (tibial tubercle) if acute onset of pain posttrauma (order lateral x-ray of knee).

Question 99

Osgood–Schlatter Disease Treatment Plan Follow **(1) mnemonic**: Rest affected knee. Use ice pack three times/day for 10 to 15 minutes. \_\_\_\_\_\_\_\_ aggravating activities or sport will typically reduce or resolve pain. Adolescent may continue to play based on degree of pain after sports participation. Play does ____ necessarily worsen the condition. Use Rx(1) or Rx(1) for pain as needed. \_\_\_\_\_\_\_\_ strengthening and quadriceps/hamstring stretching exercises aimed at stabilizing the knee joint may also be beneficial.

Answer 99

Follow RICE: Rest affected knee. Use ice pack three times/day for 10 to 15 minutes. Avoiding aggravating activities or sport will typically reduce or resolve pain. Adolescent may continue to play based on degree of pain after sports participation. Play does not necessarily worsen the condition. Use acetaminophen (Tylenol) or NSAIDs for pain as needed. Quadriceps strengthening and quadriceps/hamstring stretching exercises aimed at stabilizing the knee joint may also be beneficial.

Question 100

(1) A condition in which **males are born with an extra X chromosome** (i.e., 47, XXY). Condition occurs approximately in 1 in 1,000 live births. It is one of the causes of primary **_hypogonadism**_ (deficiency in testosterone). _**Testicles are small_** and firm with **small penis**. **_Tall stature_**, **wider hips, _reduced facial and body hair_,** and **_higher risk of osteoporosis_** (compared with normal males). Treatment includes **testosterone** replacement and fertility treatment.

Answer 100

Klinefelter Syndrome

Question 101

(1) **Females with complete or partial absence of the second sex chromosome (45, X)**. Occurs in approximately 1 in 2,500 live-born females. Congenital **_lymphedema**_ of hands and feet, _**webbed neck_** , **high-arched palate**, and **short fourth metacarpal.** **Short stature** (height usually below 50th percentile). **Ovarian failure**, cardiovascular and renal issues, ear malformations, and other health problems, as well as amenorrhea due to premature ovarian failure (infertility).

Answer 101

Turner’s Syndrome

Question 102

Exam Tips ## Footnote Scoliosis treatment needed for a ≥\_\_\_-degree curve; for curves Screening test for scoliosis is the (1) For Klinefelter syndrome, understand how patient looks = Know the Osgood–Schlatter presentation = Understand the difference between gynecomastia and pseudogynecomastia =

Answer 102

Scoliosis treatment needed for a ≥20-degree curve; for curves \<20 degrees, observe for worsening. Screening test for scoliosis is the Adam’s forward bend test. For Klinefelter syndrome, understand how patient looks = tall stature, small testicles and penis, reduced facial and body hair, higher risk of osteoporosis (males with extra X chromosome, tx is testosterone replacement) Know the Osgood–Schlatter presentation = tender bony mass over anterior tibial tubercle, worse with activity, improved with rest Understand the difference between gynecomastia and pseudogynecomastia = gynecomastia you feel a mobile, rubbery disklike mound, is physiologic and benign, most resolve spontaneously - pseudogynecomastia is due to fatty tissue, common in obese men, both breasts soft to touch and not tender (no breast bud or disklike breast palpable)