Adolescent Issues, Tanner Staging
Neisseria gonorrhoeae; immediate ortho eval and IV antibiotics
A 15 yr old boy comes to the urgent care complaining of L knee pain. He can't put weight on it and it is tender, edematous, warm, and erythematous. You also note he has a decrease in ROM. He is sexually active. You are suspicious that he has a septic joint. What is the causative agent and how will you treat?
Osgood-Schlatter disease
A 12 yo boy comes to the walk-in clinic complaining of L knee pain x4 weeks. He is on a traveling basketball team and just came back from a tournament but denies any trauma to the knee. Your exam shows mild edema and tenderness over his tibial tubercle. What is your diagnosis?
Slipped Capital Femoral Epiphysis (SCFE)
A 13 yo boy comes into the urgent care. You note that he is obese and limping. He complains of pain in his R knee. On exam, you find that his knees are normal but he has diminished ability to flex and internally rotate his R femur. You get an x-ray and consult ortho but have a good idea of what it is. What is your diagnosis?
gynecomastia; caused by estradiol
A 14-15 yr old boy is brought to your primary care office by his mother. He presents with a growth of his left pectoral region. Due to his age and his recent onset of puberty, what is your diagnosis? Why is this occurring?
Bulimia Nervosa
A young girl presents with dental decay, an irritated uvula. She is above average body weight for her age group. What is your diagnosis?
<5%
what BMI is concerning for an eating disorder?
10-13 yo
what age group is considered early adolescence?
17 yrs+
what age group is considered late adolescence?
14-16 yo
what age group is considered middle adolescence?
confidentiality, interviewing alone, HEADS assessment
what are 3 important factors in adolescent history taking?
pt readiness persistence family assistance age-appropriate group therapy
what are 4 general rules of thumb when treating a pt with a substance abuse problem?
gymnastics, figure skating, ballet
what are some "pro-thin" activities that cause anorexia nervosa?
genetics; abnormal serotonin/dopamine function; altered neuropeptides/gut peptides that decrease satiety and increase appetite suppression; increased estrogen
what are some medical reasons for developing an eating disorder?
widely spaced nipples, broad chest, cubitus valgus, edema of hands and feet as a newborn, congenital heart disease, horseshoe kidney, short 4th metacarpal and metatarsal, hypothyroidism, decreased hearing, normal mental development
what are some other signs/symptoms of Turner syndrome?
pre-existing poor body image, hx of dieting or sudden/drastic changes, risk taking behavior w/ alcohol, drugs, sex
what are some risk factors for developing an eating disorder?
elevated liver enzymes and lipids; it is teratogenic and pt must sign iPLEDGE; watch for depression
what are some side effects of Accutane?
tight/close/unhealthy relationship with mother (food only thing to control); parental distancing/withdrawal from pubertal daughter; puberty causes pt to no like changing body and want to reverse the changes
what are some social reasons for developing an eating disorder?
restricting type; binge-purge type
what are the 2 types of anorexia nervosa?
eyes/pupil cardiovascular respiratory temp neurological (peripheral/central) GI
what are the main physiological effects of drugs on the body?
ACTH, glucocorticoids, androgens, hydantoins, and isoniazid
what drugs cause drug induced acne?
anorexia nervosa
what eating disorder has the highest mortality rate?
<25th %
what is a normal BMI %?
when females grow pubic hair
what is adrenarche?
the first occurrence of menstruation; 10-16 yrs
what is menarche? what age does it occur at?
Home Education/employment Activities Depression/Diet/Drugs Sex/Sleep/Suicide/Supplements
what is the HEADS assessment?
P. acnes
what is the causative agent in adolescent acne?
plugging of sebaceous follicle > increased sebum production > proliferation of P. acnes in the follicle and inflammation
what is the pathogenesis for adolescent acne?
testosterone replacement; will help with development but will NOT fix azoospermia
what is the treatment for Klinefelter syndrome?
decrease activity, ice after exercise, NSAIDs, possible knee immobilization
what is your first line treatment for Osgood-Schlatter disease?
topical retinoid (retinoic acid, adapalene, tazarotene) 1x daily or in combo w/ benzoyl peroxide/azelaic acid
what is your first line treatment for acne?
Orchidometer
what tool can you use to measure testicle size in boys?
cystic acne
what type of acne requires prompt medical attention bc they can result in severe scar formation?
males = 10-12 yrs; weight doubles; 15-20% increase in height females = 8-11 yrs; weight doubles; 15-20% increase in height
when do males have their growth spurt? females?
Avoidant/Restrictive Food Intake Disorder
a disorder in which individuals avoid eating out of concern about aversive consequences or restrict intake of food with specific sensory characteristics
anorexia nervosa
A young girl presents with lanugo (fine/soft hair), thinning hair, low HR, hypothermia, and significant weight loss compared to her last wellness checkup. She was regularly menstruating but hasn't received her period in that past 3 months. What is your diagnosis?
Turner Syndrome
A 15 yr old is brought to the primary care office for a wellness check-up. She has not started her period yet (primary amenorrhea) and is below the 5th percentile for height. On exam, you find that she has hypertension, low posterior hairline, prominent and low set ears, and excessive nuchal skin. What is your diagnosis?
Epstein-Barr virus (EBV)
A 17yo comes into the office complaining of "just not feeling well." She has felt very tired for the past 2 weeks and has had a sore throat, fever and enlarged lymph nodes. She decided to come into the office because she developed a rash and is now having trouble eating solid foods. What is your diagnosis?
Klinefelter syndrome
A 24 yr old boy is brought to your primary care office for a wellness checkup. He has no signs of puberty. His dad reports that he is had delayed speech development, is shy, and doesn't do well in school. On exam you note that he is acting immature, has long limbs, and small testes/phallus. What is your diagnosis?
Patient Health Questionnaire (PHQ-9)
A brief 9-item self-report questionnaire used as a screening tool to assess severity of depression
Turner Syndrome
A chromosomal disorder in females in which either an X chromosome is missing, making the person XO instead of XX, or part of one X chromosome is deleted.
Klinefelter syndrome
A chromosomal disorder in which males have an extra X chromosome, making them XXY instead of XY.
Slipped Capital Femoral Epiphysis (SCFE)
A dislocation of the epiphyseal end of the femur, usually found in children and adolescents
drug-induced acne
A pt comes into your office with lesions over his abdomen, lower back, arms and legs. They are all in the same stage of pathogenesis. What is your diagnosis?
Early adolescence
A peds pt is having increased conflict with their parents. They are struggling with their sense of identity, want independence, and are interested in the present with limited thought of the future. What stage of adolescence are they in?
middle adolescence
A peds pt is having more abstract thoughts, is setting goals, and is self-involved. They are distancing themselves and seeking more independence. Their peers are very important to them. What stage of adolescence are they in?
Late adolescence
A peds pt is showing concern for their future, love, and relationships. They are critically thinking and have an improved identity/stability. They are demonstrating independence and their peers are important to them. What stage of adolescence are they in?
anorexia nervosa
An eating disorder characterized by an obstinate and willful refusal to eat, a distorted body image, and an intense fear of being fat
BP, BMI, risk factors and fam hx for lipid levels/diabetes/anemia, screening for cancer (cervical, testicular)
At wellness check ups what exams/basic info are you collecting?
5 A's: Ask, Advise, Assess, Assist, & Arrange Replacement therapy Smoking quit lines Can prescribe Bupropion, Clonidine
How do you treat tobacco abuse?
assay for heterophil antibodies (Monospot)
How would you diagnose Epstein-Barr virus (EBV)?
Supportive and symptomatic care avoid sports for 1-3 months (spleen enlargement) if tonsillar hypertrophy/pharyngitis try Decadron
How would you treat Epstein-Barr virus (EBV)?
SSRIs - Fluoxetine
How would you treat bulimia nervosa?
parotid pain and enlargement; tart candy, heat
If a pt with bulimia nervosa has sialadenitis how would you treat them?
PSYCH (parent-child interaction, school, youth, casa, happiness)
Mnemonic used to identify any psychosocial issues
SIG E CAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor symptoms, suicidal thoughts)
Mnemonic used to identify depression; 5 or more and 2+ weeks of symptoms are necessary for diagnosis
no
Should you ever secretly drug test a peds pt?
medical monitoring, nutritional therapy, individual and family psychotherapy (CBT)
What are some treatment options (medical, 3) for a peds pt with an eating disorder?
outpatient management, day treatment hospitalization, inpatient medical or psychiatric hospitalization, or residential treatment
What are the treatment options (locations, 4) for a peds pt with an eating disorder?
CAGE questionnaire Cut down, Annoyed, Guilty, Eye-Opener (1+)
What is a frequently used screening tool used to identify patients who may have alcohol abuse?
CRAFFT Questionnaire Car, Relax, Alone, Family/Friends, Forget, Trouble (2+)
What is a frequently used screening tool used to identify patients who may have drug or alcohol abuse?
thelarche (breasts bud); 8-11 yrs
What is the first sign of female puberty? At what age does this occur?
not needed; self resolves in 6mo-2yrs
What is the treatment for gynecomastia?
10-13.5 yrs
When does penile growth occur in males?
10-15 yrs
When does pubic hair grow in males?
10-12 yrs
When does scrotal and testicular growth occur in males?
Age at initiation partener, protection, pregnancy hx of STIs (self or partner) sexual abuse/rape sex for money/drugs (trafficking)
You are seeing a peds pt for a wellness visit. After you ask her parent to leave the room to begin your hx taking, she tells you she is sexually active. What questions do you have for her?
Gonorrhea/Chlamydia NAAT Syphilis HIV Hepatitis panel Trichomoniasis Bacterial vaginosis Herpes HPV
You are seeing a peds pt for a wellness visit. After you ask her parent to leave the room to begin your hx taking, she tells you she is sexually active. What tests do you want to have done on her?
Pediatric Symptom Checklist
a brief questionnaire that helps identify and assess changes in emotional and behavioral problem children; parent and pt reported
Epstein-Barr virus (EBV)
acute infection which causes sore throat, fever, fatigue, and enlarged lymph nodes; also called mononucleosis
bulimia nervosa
an eating disorder in which a person alternates binge eating (usually of high-calorie foods) with purging (by vomiting or laxative use) or fasting
russell's sign
calluses on the hand associated with bulimia nervosa
atypical anorexia nervosa
disorder characterized by all the criteria for anorexia nervosa except that despite significant weight loss, the weight of the affected individual remains within or above the normal range
LSD symptoms 30-60 min after ingestion peak high 2-4 hrs later resolved 10-12 hrs
drug associated with delusional ideation, bod distortion and paranoia; bad trips can happen that result in user becoming terrified or panicked
PCP (phencyclidine)
drug associated with hyperactivity, hallucinations, abusive language and nystagmus
SSRIs
drug that can help prevent relapse of an eating disorder once weight is regained
zinc
drug that improves neurotransmitter function and helps pt have a better appetite and mood
atypical antipsychotics Olanzapine, Risperidone, Quetiapine
drug that treat psychotic symptoms and behavior
Chromosomal Analysis (Karyotype)
how do you diagnoses Klinefelter syndrome?
systemic antibiotics (-cycline)
how do you treat moderate to severe inflammatory acne?
Oral Retinoid Isotretinoin (Accutane)
how do you treat severe cystic acne?
8-12 wks
how long does it take to see improvement in acne after initiating treatment?
1/wk for 3 mo
how often does binge eating and inappropriate compensatory behaviors need to occur for it to be considered bulimia nervosa?
bulimia nervosa bc those lab values indicate vomiting
if a pt has labs that show they are hypokalemic and in hypochloremic metabolic alkalosis what are you suspicious of?
2-3 weeks initiate nutrition gradually, correct dehydration, supervision pt may need NG/IV meals if they can't tolerate it orally
if a pt with an eating disorder is admitting to the hospital (inpatient) how long will they receive treatment? What is the treatment plan?
Osgood-Schlatter disease
inflammation of the tibial tubercle caused by repetitive running/jumping which causes traction and microstress fractures
closed comedones (whiteheads)
lesion caused by an obstruction in the neck of the sebaceous follicle; precursors of inflammatory lesions
Refeeding syndrome
metabolic alterations that may occur during nutritional repletion of starved patients; calories are increased too quickly > low PO4, low K, edema
substance abuse
overindulgence in or dependence on addictive substances like alcohol (!!), tobacco products (nicotine), and drugs
open comedones (blackheads)
predominant lesion in early acne that do not progress to inflammatory lesions
binge eating disorder
significant binge-eating episodes, followed by distress, disgust, or guilt, but without the compensatory purging, fasting, or excessive exercise that marks bulimia nervosa
