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Adolescents

Acetaminophen Poisoning (Intentional Ingestion)

  • Also known as paracetamol; sold as Tylenol and others.
  • Liver damage leading to mild-to-severe fulminant liver failure.
  • Stages after overdose:
    • Stage I: up to 24\ \text{hours} after overdose – patients usually asymptomatic but may have nausea, vomiting; with very large doses, lethargy and malaise.
    • Stage II: 18-72\ \text{hours} – right upper quadrant pain with abdominal pain, nausea, vomiting; elevated LFTs, prolonged prothrombin time, elevated bilirubin; possible nephrotoxicity (elevated BUN, creatinine).
    • Stage III: 72-96\ \text{hours} – hepatic necrosis with jaundice, clotting disorders, hypoglycemia, hepatic encephalopathy; acute kidney injury with oliguria may develop; most deaths from organ failure occur within 72–96 hours.
    • Stage IV: 4\ \text{days} - 3\ \text{weeks} – if patient survives, organ failure signs resolve.
  • Management:
    • For acute overdose, serum acetaminophen concentration should be measured as soon as possible, but at least 4\ \text{hours} must have passed since ingestion to obtain accurate blood level; if <4\ \text{hours}, blood level is not accurate.
    • Antidote: N-acetylcysteine given intravenously.

Hodgkin’s Lymphoma

  • Presentation: enlarged and painless cervical, axillary, groin, or supraclavicular lymphadenopathy with fever (Pel-Ebstein sign), fatigue, unexplained weight loss, night sweats.
  • May report severe pain on or over malignant areas a few minutes after drinking alcohol.
  • Tip: Hodgkin lymphoma presents as enlarged lymph nodes with fever, night sweats, and occasionally pain (lymph nodes) after drinking alcohol.
  • Epidemiology: most common cancers in teens 15–19 years are Hodgkin’s lymphoma and germ cell tumors (testicular and ovarian).

Testicular Cancer

  • Demographics: teenage-to-adult male.
  • Presentation: heaviness in scrotum or a hardened, usually painless mass; some may have testicular discomfort or numbness; affected testicle has a firm texture.
  • Risk factors: cryptorchidism.
  • Age range: most common in males aged 15-35\,\text{years}.

Testicular Torsion (Acute Scrotum)

  • Onset: pubertal male with abrupt unilateral testicular pain that increases in severity; may radiate to lower abdomen/groin.
  • Associated symptoms: almost all patients (~90\%) have nausea and vomiting.
  • Findings: ischemic changes cause severe scrotal edema, redness, and testicular pain; ipsilateral cremasteric reflex is absent; testicle may be high riding with a transverse lie.
  • Incidence: highest during adolescence.
  • Differential: torsion of appendix testis (more common in prepubertal boys; less nausea/vomiting; “blue dot sign”).
  • Investigations: urinalysis negative for pyuria/bacteriuria; Doppler ultrasound is the initial diagnostic test.
  • Prognosis: testicle can become nonfunctional if not repaired within 24\ \text{hours}; surgical emergency. Refer to ED.

Normal Findings in Adolescence

  • Defined: onset of puberty until sexual maturity.

Puberty

  • Definition: period when secondary sexual characteristics develop due to hormonal stimulation.
  • Hormones:
    • Ovaries produce estrogen and progesterone.
    • Testes produce testosterone.
  • Key learning point (tip): Puberty starts at Tanner stage II (girls: breast bud; boys: testicular enlargement and scrotal rugation/color becomes darker) and ends at Tanner stage V (adult).
  • Memorization guidance: Only Tanner stages II to IV needed for exam.

Girls

  • Precocious puberty: puberty starts before age 8\ \text{years}.
  • Delayed puberty: no breast development (Tanner stage II) by age 12\ \text{years}.
  • Growth spurt:
    • Majority of physical changes occur between ages 10-13\,\text{years}.
    • Majority of skeletal growth occurs before menarche; growth slows afterward.
    • Girls start growth spurts about 2\ \text{years} earlier than boys.
  • Pubertal Timeline (summary):
    • Breast development leads to peak growth acceleration, then menarche occurs.
    • Most of a girl’s height is gained before menarche.
    • Skeletal growth in girls is complete within 2\ \text{years} after menarche.

Ovulation Pain (Mittelschmerz)

  • Definition: unilateral midcycle pain around 14\ \,\text{days} before next period, caused by enlarging ovarian follicle or rupture at ovulation.
  • Duration: may last from a few hours to a few days; may occur intermittently.

Menarche

  • Typical age: about 12\ \,\text{years} in the United States (range 8-15\,").
  • Post-onset: first 1–2 years often irregular due to irregular ovulation (skip a month or longer, lighter bleeding).
  • After Tanner II (breast bud) onset: menses start within ~2\,\text{years}.
  • Delayed menarche definitions: no menses by age 15\,\text{years} or absence of breast development by 13\,\text{years}.

Menstrual Cycle

  • Average duration: 28\ \text{days}.
  • In younger teens: cycles 21-45\,\text{days}; in young adults: 21-35\,\text{days}.
  • Bleeding duration: 3-5\,\text{days} (range 2-7\,\text{days}).
  • Day 1: spotting; peak flow lasts 2-3\,\text{days}; then lightening until stop.
  • Most fertile window: about 3\text{ days before and during ovulation} (days 11-14).

Dysmenorrhea

  • Cause: painful periods due to high levels of prostaglandins.
  • Management: heating pads and NSAIDs (e.g., \text{ibuprofen}, \text{naproxen}).

Tip on Adolescent Health History

  • Obtain from parent/guardian and adolescent initially; then interview the adolescent alone without parent.

Boys

  • Precocious puberty: starts before 9\ \text{years}.
  • Delayed puberty: no testicular enlargement by age 14\,\text{years}.
  • Growth spurt: boys’ growth spurts occur ~2\,\text{years} later than girls (ages 11-15\,\text{years}).
  • Spermarche: average age 13.3\,\text{years}.

Tanner Stages (Girls and Boys)

  • Stage I: Prepuberty (Girls: breasts; Boys: penis & testes; Pubic hair: none).
  • Stage II: Girls—breast buds; Boys—testes enlarge; scant pubic hair.
  • Stage III: Girls—breast and areola; Boys—penis lengthens; pubic hair darker/curvier.
  • Stage IV: Girls—breasts and areola; Boys—penis thickens; pubic hair darker, coarser, thicker.
  • Stage V: Girls—adult breasts; Boys—adult penis/testes; pubic hair adult pattern.

US Health Statistics (Adolescents)

  • Top 3 Causes of Death (15–19 years):
    1) Accident
    2) Suicide
    3) Homicide

Immunization Schedule for Adolescents (11–18 years)

  • Tip: Meningococcal vaccine recommended for all starting at age 11-12\,\text{years} (not only for college freshmen in dorms).
  • VAERS: Vaccine Adverse Event Reporting System for reporting adverse events.

Tdap / DTaP

  • All 11–12-year-olds: Tdap booster; then Td or Tdap every 10\,\text{years} for lifetime.
  • Age 13–14 (or older): if not received at 11–12, give Tdap.

HPV (Gardasil)

  • Minimum age: 9\,\text{years}.
  • All 11–12-year-olds: give to girls and boys; two doses 6\text{ months apart}.
  • Age 15–45 years: three-dose series at intervals of 0, 1-2, 6\text{ months}.

Meningococcal Vaccines

  • All 11–12-year-olds: single dose of MenACWY; booster at age 16.
  • Catch-up: ages 13–18; if first dose at 13–15, booster at 16–18; if first dose at 16, no booster.
  • Clinical discretion: young adults 16–23 at increased risk may be vaccinated with Bexsero or Trumenba.

Influenza (inactivated)

  • Vaccinate everyone from age 6\text{ months} and older annually.

Hepatitis B (Recombivax HB)

  • Catch-up: give remaining doses if not completed.

Hepatitis A (HAVRIX, VAQTA)

  • Catch-up: give second dose if not completed.

MMR

  • Catch-up: give second dose if not completed.

Varicella

  • If no reliable history of chickenpox, review live-virus precautions.

Pearl

  • Children and adolescents normally have higher blood levels of alkaline phosphatase compared with adults because of growing bone; produced by osteoblasts.

Legal Issues: Right to Consent and Confidentiality

  • No parental/guardian consent is necessary for treatment of sexually transmitted infections (STIs).
  • Consent laws vary by state for contraceptive services and prenatal care.
  • Emancipated Minor Criteria: can give full consent as an adult without parental involvement if…
    • Legally married
    • Active duty in the armed forces
    • Living separately from parents and self-supporting
  • Confidentiality can be breached in:
    • Gunshot/stab wounds (report to police) regardless of age
    • Child abuse (actual or suspected) – report to authorities
    • Suicidal ideation/attempt (discharge to parents/guardians or hospital)
    • Homicidal ideation or intent (especially mental health providers)

Health Promotion for Adolescents

  • Screen for high-risk behaviors during health visits and provide intensive behavior counseling.
  • High-risk behaviors to screen for:
    • Sexual activity: condom use, contraception, intimate partner violence, signs/symptoms of STIs
    • Safety: driver safety, seatbelt/helmet use, access to guns, gun safety, smoking, alcohol, drug use
    • Social history: family, peers, school performance, work
    • Mental health: signs/symptoms of depression and antisocial behaviors (e.g., gangs)
  • Tip: No parental consent is needed for STI testing; consent laws vary by state for contraception and prenatal care. If the visit is not related to sexual activity, parental consent may be required for other issues (e.g., dysmenorrhea, headache, URI).
  • Emphasize memorizing emancipated minor criteria; don’t confuse right to confidentiality with emancipated minor status.

Adolescent Idiopathic Scoliosis

  • Definition: lateral curvature of the spine with possible spinal rotation; more common in girls (≈80%).
  • Presentation: often painless; classic case is a teen with one hip, shoulder, breast, or scapula higher than the other.
  • Screening: Adams Forward Bend Test – patient bends forward; assess asymmetry of spine/scapula/thorax, height.
  • Cobb angle: measure degree of curvature on full-spine X-ray.
  • Treatment parameters:
    • Curve < 20°: observe
    • Curve 20°–40°: bracing (e.g., Milwaukee brace)
    • Curve > 40°: surgical correction (Harrington rod, other options)
  • Management:
    • Check Tanner stage (II–V)
    • Order PA spinal X-ray to measure Cobb angle
    • Refer to pediatric orthopedic specialist
  • Tip: Treat scoliosis ≥ 20°; observe if < 20°; Adams test is the screening method.

Anorexia Nervosa

  • Typical onset: during adolescence.
  • Definition: irrational preoccupation with fear of gaining weight; restrictive diet or binge/purge patterns (purging via laxatives, enemas, diuretics, vomiting).
  • Clinical findings:
    • Marked weight loss (BMI ≤ 18.5)
    • Bradycardia (40–49 bpm)
    • Vital signs instability; hypotension
    • Lanugo (fine downy hair) on face, back, shoulders
    • Osteoporosis or osteopenia
    • Swollen feet (low albumin), dizziness, abdominal bloating
  • Tip: Recognize presentations (lanugo, peripheral edema, amenorrhea, weight loss >10% body weight). Increased risk of stress fractures, osteoporosis/osteopenia.

Delayed Puberty

  • Definition: absence of secondary sexual characteristics by age 13\,\text{years} in girls or by 14\,\text{years} in boys.
  • Workup/Labs:
    • Serum pregnancy test
    • Prolactin level (if elevated, CT scan of sella turcica to evaluate pituitary)
    • Primary amenorrhea evaluation: rule out hypogonadism with FSH, LH, TSH
    • Rule out chromosomal disorders, absence of uterus/vagina, imperforate hymen
    • Hand X-ray to estimate bone age (epiphyses fused → skeletal growth finished)
    • Refer to pediatric endocrinologist if no growth spurt, delayed puberty, etc.

Gynecomastia

  • Definition: excessive growth of breast tissue in males; can be unilateral or bilateral.
  • Physiologic gynecomastia is benign and common during infancy and adolescence; up to ~40% of pubertal boys; often resolves spontaneously within 6\ \text{months to 2}\,\text{years}.
  • Classic case: adolescent male with gradual breast enlargement; mass is round, rubbery, mobile under the areola; skin normal.
  • Red flags: irregular, fixed, hard mass; rapid growth; consider secondary etiology; refer to specialist.
  • Evaluation: assess Tanner stage; check for drug use (steroids, cimetidine, antipsychotics); rule out testicular/adrenal tumors, brain tumor, hypogonadism; recheck in 6 months.

Klinefelter Syndrome

  • Definition: males with an extra X chromosome (47, XXY).
  • Incidence: ~1 in 1,000 live births.
  • Features: primary hypogonadism; small firm testicles; tall stature; wider hips; reduced facial/body hair; higher risk of osteoporosis.
  • Management: testosterone replacement and fertility treatment.

Osgood-Schlatter Disease

  • Definition: common cause of knee pain in young athletes; overuse of the knee.
  • Mechanism: repetitive stress on patellar tendon at tibial tuberosity during rapid bone growth; pain, tenderness, swelling at tendon insertion.
  • Affected population: one knee commonly; can be bilateral; common during rapid growth spurts in active teens in sports like basketball, soccer, running.
  • Classic case: 14-year-old athlete with tender bony mass over anterior tibial tubercle; pain worsened with squatting, kneeling, jumping; improves with rest.
  • Diagnosis: rule out avulsion fracture post-trauma (order lateral knee X-ray).
  • Treatment (RICE): Rest, ice 10–15 minutes 3 times/day; avoid aggravating activities; continue activity based on pain; analgesia with acetaminophen or NSAIDs; quadriceps strengthening and stretching.

Amenorrhea: Primary and Secondary

  • Primary amenorrhea: No menarche by age 15\,\text{years} in the presence of normal growth and secondary sexual characteristics; about 43% due to chromosomal disorders (Turner syndrome).
  • Secondary amenorrhea: No menses for >3 cycles or >6 months if previously menstruating; most common cause is pregnancy; other causes include ovarian disorders, stress, anorexia, PCOS.
  • Exercise and underweight association: excessive exercise or sport participation increases risk of amenorrhea due to relative caloric deficiency; female athlete triad = anorexia nervosa/restrictive eating + amenorrhea + osteoporosis.
  • Labs in amenorrhea:
    • Serum HCG (pregnancy test)
    • Prolactin
    • TSH (thyroid disease)
    • FSH and LH (premature ovarian failure or hypogonadism)
  • If amenorrhea >6 months: measure bone density.
  • Treatment:
    • Educate about increasing caloric intake and decreasing exercise
    • Calcium with vitamin D (1,200–1,500 mg daily) and vitamin E (400 IU daily)
  • Complications: osteopenia/osteoporosis (stress fractures); myocardial atrophy and arrhythmias; bradycardia, hypotension; hypoglycemia, dehydration; electrolyte disturbances; lanugo, telogen effluvium, xerosis; infertility; low BMI.
  • Pseudogynecomastia: bilateral breast enlargement due to fatty tissue (adipose tissue) in obese males; no breast tissue or buds.

Turner Syndrome

  • Definition: females with complete or partial absence of second sex chromosome (45, X).
  • Incidence: ~1 in 2,500 live-born females.
  • Features: congenital lymphedema of hands/feet; webbed neck; high-arched palate; short stature (often below 50th percentile).
  • Ovarian failure, cardiovascular and renal issues, ear malformations; amenorrhea due to premature ovarian failure (infertility).
  • Tip: Understand the difference between gynecomastia and pseudogynecomastia.

Final Notes

  • The material covers clinical presentation, pathophysiology, diagnostics, management, and ethical considerations related to adolescent health across multiple organ systems and life stages.
  • Emphasize recognizing pattern-based presentations (e.g., scoliosis screening, gynecomastia vs. pseudogynecomastia, amenorrhea workup) and immediate actions (e.g., testicular torsion requires urgent ED evaluation).