Basics In Adolescent Medicine: A Practical Manual Of Signs, Symptoms And Solutions

A Practical Manual of Signs, Symptoms and Solutions

Tomas J Silber, Harshita J Saxena

• Publisher: WSPC
• Year: 2014
• eBook ISBN: 9789814602259
• Topic: Biological Sciences
• Subtopic: Science General
• Index: Biological Sciences

This practical manual reviews salient topics in Adolescent Medicine. The volume is practitioner-centered, focusing on the symptoms that bring a teenager to the clinician. Every chapter begins with a very brief clinical vignette, highlighting the patient's chief complaint or primary issue of concern.

The handbook is divided into five primary sections: (1) Well Adolescent Care to include chapters such as the Annual Physical and Immunizations in Adolescence; (2) Common Problems of Adolescence such as Acne and Low Back Pain; (3) Reproductive Health Care issues such as Menstrual Disorders and Teen Pregnancy/Options Counseling; (4) Urgent Care matters including Acute Chest Pain and Scrotal Pathology: Pain and Masses; and finally, (5) Special Considerations to include chapters such as Cyberbullying and Sexting and Tobacco Use and Cessation Counseling.

Chapters follow a uniform format with vignette as described above, followed by multiple choice questions designed to test the readers knowledge. Salient features related to the chapter topic follow, including relevant clinical “pearls” such as history, physical exam, laboratory and diagnostic studies and treatment strategies. For each chapter, issues that are unique to managing illness in adolescents are highlighted to distinguish them from adults and younger children. When applicable, a broad differential diagnosis is provided to help guide the reader. Easy to read tables are included to highlight and clearly summarize key aspects of the topic and the chapters end with answers to the Board-Style questions presented at the start.

Contents:

• Well Adolescent Care:
  • The Annual Physical (Krishna White and Rita Hagler)
  • Adolescent Consent and Confidentiality (Kirsten B Hawkins)
  • Normal Nutrition through Adolescence (Erin Wolf-Barnett)
  • Immunizations in Adolescents (Lawrence J D'Angelo)
  • Taking Care of Adolescent Males (Daniel E Korin)
  • Taking Care of Lesbian, Gay, Bisexual, Transgender and Questioning (LGBTQ) Teens (William M Barnes and David S Reitman)
  • The Pre-Participation Sports Physical (Nailah Coleman)
  • Sports Supplements (Gregg Joseph Montalto)
  • Adolescent Driving (Tiffany L Meyer)
  • The Transition to College (Isabel Goldenberg and Harshita J Saxena)
  • The Adolescent Traveler and Immigrant (Natwarlal Shah)
• Common Problems:
  • Short Stature/Delayed Onset of Puberty (Karen Bernstein)
  • Tall Stature (Karen Bernstein)
  • Abnormal Weight Gain (Harshita J Saxena)
  • Abnormal Weight Loss/Malnutrition (Tomas J Silber)
  • Bulimia (Rosina Pellerano)
  • Anemia (Carleen Townsend-Akpan)
  • Headaches: Common, Chronic and Recurrent (Stephanie Addison)
  • Bell's Palsy (7th Nerve or Facial Nerve Palsy) (Jonathan Fanburg)
  • Asthma, Exercise Induced Bronchospasm (EIB) and Vocal Cord Dysfunction (VCD) (Anthony P Acquavella)
  • Gynecomastia (Amy L Weiss)
  • Recurrent or Chronic Abdominal Pain (Oscar Taube)
  • Constipation and Encopresis (Promise Ahlstrom)
  • Enuresis (Promise Ahlstrom)
  • Dysuria, Urinary Tract Infections and Pyelonephritis (Amy E Klamberg)
  • Proteinuria (Lawrence J D'Angelo)
  • Hematuria (Lawrence J. D'Angelo)
  • Low Back Pain (Alan Morrison)
  • Sports Medicine: Musculoskeletal Injuries (Nailah Coleman)
  • Acne (Karen Rosewater and Harshita J Saxena)
  • Vague Somatic Complaints (Tomas J Silber)
  • Sleep Disorders (Jose J Casas-Rivero)
  • Tics and Tourette Syndrome (Jonathan Fanburg)
  • Attention Deficit Hyperactivity Disorder (ADHD) (Barbara K Snyder)
  • Anxiety Disorders (Michele D Wilson)
  • Depression (Michele D Wilson)
• Reproductive Health Care:
  • Breast Pathology: Masses and Nipple Discharge (Amy L Weiss)
  • Dysmenorrhea, PMS and PMDD (Nneka A Holder)
  • Amenorrhea (Maria Trent)
  • Vaginal Bleeding (Maria Trent)
  • Vaginal Discharge (Karen E Simpson)
  • Pelvic Inflammatory Disease (PID)/Tuboovarian Abscess (TOA) (Avril Melissa Houston)
  • Urethritis in Males (Karen E Simpson)
  • Genital Warts: Condyloma Accuminata (Liana R Clark)
  • Genital Ulcer Syndrome (GUS) (Avril Melissa Houston)
  • Condoms (Mariana Kastrinakis)
  • Hormonal Contraception (Evelyn Simpkins Evans)
  • Emergency Contraception (EC) (Jennifer Maehr)
  • Teen Pregnancy and Options Counseling (Karen Soren)
• Urgent Care:
  • Heat Exhaustion and Heat Stroke (Noel V Pesce)
  • Syncope (Rick Place)
  • Concussion and Post Concussion Syndrome (Michael A Lee)
  • Acute Chest Pain (Dana Kornfeld and Rick Place)
  • Acute Abdominal Pain (Rick Place)
  • Hematemesis (Leslie A Hayes)
  • Bloody Stools: Melena or Hematochezia (Leslie A Hayes)
  • Scrotal Pathology: Pain and Masses (David S Reitman)
  • Hip Pain and Limping (Elizabeth G Cius)
  • Neurological Emergencies: Severe Headaches, Weakness, Incoordination and Altered Mental Status (Rick Place)
  • Seizures (Robyn Miller)
  • Adolescent Sexual Assault/Rape (KathyWoodwar)
  • The Suicidal Adolescent (Maureen E Lyon)
• Special Care:
  • Chronic Illness and Adherence to Treatment (Daniel N Davidow)
  • Difficult Conversations: Bad News, Disclosure and Advance Directives (Donna Marschall)
  • Screening for Violence and Abuse (Anisha Abraham)
  • Cyberbullying and Sexting (Sadhana Dharmapuri)
  • Tobacco Use and Cessation Counseling (Brooke Bokor)
  • Substance Use and Abuse (David S Reitman and Gregg Joseph Montalto)
  • Judicious Use of Psychopharmacologic Agents (Daniel N Davidow)

Readership: Medical students, residents, fellows and other health care professionals in training (such as nurse practitioners and physician's assistants) on their Adolescent Medicine rotations; physicians such as internists, general and family practitioners or pediatricians.

SECTION II

COMMON PROBLEMS

12

SHORT STATURE/DELAYED ONSET OF PUBERTY

Karen Bernstein

TEST YOUR KNOWLEDGE

16.The BEST initial step in the assessment of the cause of delayed puberty is to obtain:

A.Serum gonadotropin measurement

B.Karyotype

C.Bone age

D.Growth curve and assessment of sexual maturity

E.Thyroid stimulating hormone (TSH) measurement

17.What is the MOST likely diagnosis for a 16 year old tall thin male who has small testes and Tanner stage 5 pubic hair?

A.Kallman syndrome

B.Hypothyroidism

C.Kleinfelter’s Syndrome

D.Constitutional Delayed Puberty

E.Functional Gonadotropin Deficiency

“Joey is the shortest boy in his class. Will he ever grow ? Do you think we should start growth hormone?”

BACKGROUND

• The hypothalamic-pituitary-axis, quiescent from about 6 months of age, resumes activity during puberty prompting increased height velocity, development of secondary sex characteristics, and maturation of the seminiferous tubules and ovarian follicles leading to sperm and oocyte production.
• An increase in hypothalamic gonadotropin-releasing hormone (GnRH) triggers the release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary. LH and FSH then stimulate gonadal production of sex steroids.
• In females, this usually begins between the ages of 9–12 years, starting with breast enlargement, then pubic hair growth, followed by the “growth spurt” and menarche.
• In males these changes start between 10–13 years, beginning with testicular enlargement, then pubic hair growth, followed by penile enlargement, and peak height velocity growth.
• The majority of adolescents are found to have no pathology causing their growth delay, and when puberty begins, it progresses normally. However, there are many causes of delayed puberty that warrant further investigation (Table 1).

DEFINITIONS

• Delayed puberty is defined as no evidence of breast growth in girls by age 13, and failure of testicular enlargement in boys by age 14.
• In addition, the diagnosis of delayed puberty can be made in girls who have not achieved menarche by age 16, or the absence of menarche within 5 years of pubertal onset.
• Failure at any point along the hypothalamic-pituitary-gonadal axis can lead to delayed puberty.

ASSESSMENT

HISTORY

Neonatal/Past Medical History

• Congenital lymphedema suggests Turner Syndrome.
• Consider chronic diseases, previous surgeries, radiation exposure, chemotherapy or congenital anomalies.

Growth History

Pattern of growth and changes in the pattern, plotted appropriately on a growth curve, are key factors in leading to a diagnosis:

• A greater decline in weight than height is usually seen in nutritional deficiencies such as eating disorders, inflammatory bowel disease (IBD), celiac disease or other chronic illnesses.
• A greater slowing in height than weight is usually associated with an endocrinopathy such as hypothyroidism or gonadal dysgenesis.
• Teens growing consistently at or just below the third percentile may have constitutional growth delay.
• Girls whose growth curve has been below the third percentile may have Turner’s Syndrome even without usual clinical findings. This is especially so if parents are of normal height.
• Males with small testicles whose growth curves show tall stature and relatively thin body habitus may have Kleinfelter’s Syndrome.

Family History

• Determine parental and sibling heights, age of puberty onset and age of attained adult height. Adolescents with constitutional delayed puberty will often have a family history of “late bloomers.”
• Is there a history of medical problems or familial congenital anomalies. Anosmia or growth delay in male relatives on the mother’s side of the family suggests Kallmann syndrome. Consider hypothyroidism with a family history of autoimmune disorders.

Medications

• Methylphenidate or other stimulants may decrease appetite and cause weight loss or failure to grow.
• Psychotropic drugs such as antipsychotics frequently cause hyperprolactinemia.

Review of Systems

• A history of constipation or cold intolerance suggests hypothyroidism.
• Weight changes or dieting behaviors suggest an eating disorder.
• Excessive exercise or environmental stress may contribute to functional delayed puberty.
• Headaches or loss of peripheral vision suggest a pituitary adenoma.
• Sudden slowing down of growth and headaches can be due to a craniopharingioma.
• Anosmia is seen with Kallmann Syndrome.

PHYSICAL

Anthropometric Measurements

• Plot height and weight on a patient’s growth curve.
• Calculation of target height (Table 2):
• Most teens achieve an adult stature within 10 cm of their target height.
• A teen whose height percentile differs greatly from his/her genetic potential is considered inappropriately short and deserves a thorough evaluation.

General Appearance

• Dysmorhic features should be noted, including abnormal facies, ear placement, webbed neck, cubitus valgus and the size and shape of hands and feet.
• General examination of the heart, lungs, and abdomen should be performed looking for signs of chronic medical conditions.
• Dull dry skin, hair loss, decreased pulse rate, and/or goiter suggest hypothyroidism.

Breast

• Breast development should be noted and appropriately staged (Chapter 1, Table 2).

Genital

• Pubertal development is usually described by Tanner stage (Chapter 1, Table 2). The clinician must assess pubic hair, clitoris size, penis length, testicle volume and vaginal appearance (estrogen effect).
• Examination of the external genitalia is essential.
• A pelvic exam is unnecessary in most teens but should be considered for females with normal pubertal development and delayed menarche.

Neurologic Exam

• A neurologic exam should be performed to help rule out intracranial pathology.
• Visual field defects might be seen in a pituitary...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Author Contributors
• Foreword
• Preface
• Acknowledgments
• SECTION I: WELL ADOLESCENT CARE
• SECTION II: COMMON PROBLEMS
• SECTION III: REPRODUCTIVE HEALTH CARE
• SECTION IV: URGENT CARE
• SECTION V: SPECIAL CARE
• List of Questions & Answers