* Definition of adolescence is the period that bridges childhood and adulthood. It begins at about 11-12yo and for most ends at 18-21yo. Puberty occurs during adolescence.
* Major events of puberty include growth spurt, body composition changes, organ system changes, sex organ changes, secondary sex characteristics, hormone changes.
* Most common causes of mortality in adolescence is motor vehicle accidents, then suicide (girls attempt more frequently, boys are more successful), homicide especially in African Americans, and cancer is 4th.
* Common causes of morbidity in adolescence are unintended pregnancy, sexually transmitted diseases, smoking, dropping out of school, depression, run away, physical violence, crime/juvenile delinquency.
* Major outcomes of puberty are achieving adult size and appearance, clear distinction of sexes, and achieving the ability to reproduce.
* Features of puberty include similar sequence of changes, variable timing of changes, variable rates of changes, permanence of changes, physical reflects hormonal.
* Features of early adolescence (10-15) are physical changes and concerns, sense of being “center stage,” sense of invulnerability, wide mood swings, rejection of childhood things, beginnings of emancipation, non-parent adult role models, comparing self to peers, concrete thinkers, sometimes feel awkward, more comfortable with same-sex peers. * Features of middle adolescence are more independence, sense of identity, more comfortable with their bodies, mood swings continues, peers group is important, abstract thinking is beginning to develop, dating and
experimenting, relationships are one-sided (what can I get out of this relationship), puberty is almost complete, testing or showing-off of new body, idealism and commitment to causes.
* Features of late adolescence are less self-centered, mainly independent decisions/actions, established, realistic, self-identity, realization of vulnerability and limitations, definition of adult role in society and family, intimate dating, relationships with others are less one-sided, think about future.
* 14yo girl who has not yet achieved menarche presents to the physician with her concerned mother. The mother is afraid that her daughter is not normal. Exam shows a well nourished individual in the 50th percentile for height and weight, breast exam shows enlarged areolar diameter but no separation of contours, pubic hair is increased in amount and is curled but not course in texture. The mother and daughter wait anxiously for your opinion. Answer is don’t worry about it, give it some time.
* 15yo boy brought in by mother because she sees breast enlargement, one-sided gynecomastia. She wants to know if her son has breast cancer. They’ll describe the Tanner stage and you can say don’t worry about it.
* Sequence of puberty in girls: breast buds appear, pubic hair appears, growth spurt, axillary hair, pubic hair matures, breasts mature, menarche (first period), adult height.
* First sign of puberty in girls is breast bud development.
* Menarche around 12-13yo depending on family, late event in puberty, growth rate slowing down, bleeding often irregular, many reasons for delay. Ask mother how old she was when she had menarche.
* Menarche delay can occur in the physically active too, such as a marathon runner.
* Sequence of puberty in boys: growth of testicles, pubic hair appears, growth of penis and scrotum, axillary hair, first ejaculations, growth spurt, facial hair.
* First sign of puberty in boys is testicular enlargement.
* Female Tanner I is pre-adolescent. Tanner II is breast budding (areola, papilla) * Tanner III is areolar enlargement with no separation of contours.
* Tanner IV is areola with papilla and secondary mound. * Tanner V is mature female breast.
* Pubic hair Tanner I is no pubic hair. Tanner II is long and straight, sparse. * Tanner III is curling and darker pubic hair.
* Tanner IV is adult but not on thighs. Tanner V is onto the thighs. * Male Tanner I is pre-adolescent. Tanner II is enlargement of testicles.
* Tanner III is growth in length and circumference of penis. Tanner IV is larger, darkening of scrotal skin. * Tanner V is adult penis, scrotum, and testicles.
* Puberty starts at 11-12 in boys, 10-11 in girls. Growth spurt is 14 in boys, 12 in girls.
* Spermarche is 13-14, menarche is 12-13. Length of puberty is 3-4 years in boys, 4-5 years in girls.
* Common concerns about puberty include starting too late or too early, unequal development of breasts, breast tissue in boys, acne, dandruff, body odor, “I’m not normal.”
* Boy brought in by mother because of unilateral breast enlargement. Exam shows normal sized testicles (not Klinefelter). Re-assure mother that this is normal.
* Teenager may come in complaining of a cold for a couple of days. This isn’t normal, probably not the real problem. They’ll either wait until the end and say “by the way…” or you can approach the issue. Are you taking anything for your acne? We can help you with that.
* Complications of adolescence are related to growth and development, morbidity and mortality. * Females may have amenorrhea, dysfunctional uterine bleeding, dysmenorrhea, STDs in both sexes. Sexually Transmitted Diseases
* 16yo girl presents to her physician because of fever, chills, pain, and swelling in the small joints of her hands. There is a maculopapular rash seen on her upper and lower extremities.
* Gonorrhea is an infection caused by Neisseria gonorrhea affecting mucous membranes and the GU tract. * Gonorrhea can affect the oropharynx, rectum, and conjunctiva.
* Clinical presentation varies, may have urethritis, cervicitis, dysuria, may be asymptomatic. May disseminate. * Boys may have a purulent discharge and burning with urination. Girls may have purulent discharge, suprapubic pain, and dysuria. Cervix can be inflamed. Rectal gonorrhea can be asymptomatic.
* Culture of discharge is the test of choice. Culture blood if you suspect disseminated gonorrhea. * Check for other STDs, like chlamydia.
* Treatment of choice for gonorrhea is ceftriaxone, usually given IM injection.
* Treatment can also include azithromycin or doxycycline PO because you worry about chlamydia. * Complications include disseminated disease, abscesses, pelvic inflammatory disease, Fitz-Hugh-Curtis. * Fitz-Hugh-Curtis syndrome is caused by adhesions from gonorrhea infection, “violin string” sign seen on exploratory laparotomy, patient may complain of RUQ pain with or without salpingitis. The RUQ pain is due to seeding of the liver capsule.
* 17yo boy presents to the ED with a persistent penile discharge. He states that he visited his family physician last week for the same problem. At that time, they gave him an IM shot of penicillin. However, that did not help and he wants a second opinion.
* Chlamydia can cause a variety of diseases in adolescence such as a non-gonococcal urethritis. * Patient may be asymptomatic or can present with urethritis, cervicitis, Fitz-Hugh-Curtis, PID. * Girls may have a mucoid discharge, boys may be asymptomatic.
* Testing should include chlamydial cultures, can do antigen detection kits.
* Treatment is azithromycin or doxycycline. If pregnancy, give erythromycin (tetracycline contraindicated). * Treatment should be for all sexual partners.
* 15yo presents to her physician because she has a yellow foul-smelling vaginal discharge. Exam shows a strawberry cervix.
* Trichomonas vaginalis is an STD more commonly seen in girls with multiple partners, can be transmitted to the neonate during the birth process, usually self limited.
* Usually patients complains of pruritus and foul-smelling foamy/frothy vaginal discharge, can have cervical hemorrhages (strawberry cervix).
* Saline prep wet mount can show trichomonas moving or “vibrating” on the slide. * Treatment is metronidazole, treat all sexual partners.
* 17yo sexually active boy presents to the physician because of painful ulcerations on his glands penis and on the staff of his penis. He has multiple sexual partners and does not use condoms. Fever and inguinal adenopathy are also found on exam.
* Herpes simplex affects the skin, eye, oral mucosa, CNS, genital tract. Type I may cause genital disease but is usually non-genital infection of the mouth, lips, eyes, and CNS (temporal lobe encephalitis).
* HSV meningitis can be caused by someone with an oral lesion kissing the child.
* Type II HSV is the sexually transmitted form, seen in teenagers and adults. Present with fever, regional adenopathy, and dysuria. Girls have vesicle ulcers on the vulva or vagina, cervix is primary infection site. * Test is the Tzanck smear (or stain) showing multinucleated giant cells or inclusion cells.
* Treatment is acyclovir. Valacyclovir is another option that does not have to be taken as often. Acne Vulgaris
* A mother brings her 15yo daughter to the dermatologist because she has developed pimples. The mother says the child’s face breaks out because she drinks soda pop. The daughter is argumentative about this but admits she drinks soda everyday at lunch. The mother would like you to tell her daughter to stop drinking soda. Exam shows open and closed comedones, and pimples on her forehead, nose, and cheeks.
* Tell the mother soda is not good for the child, but has nothing to do with acne.
* Diet has nothing to do with acne. Acne is caused by dirt, hormones, and bacteria (Propionibacterium acnes). * Types of acne include open and closed comedones, papules, pustules, and nodulocystic.
* Physical exam shows the variety of lesions, can be anywhere (face, back). * Test of choice is your eyeballs, just look at it and determine that it is acne.
* Treatment includes keeping skin clean by washing a couple of times a day with a mild soap. Cleaning several times a day can irritate the skin and worsen the acne. Avoid make-up, as it plugs pores.
* Treatment does not involve dietary change, no need to eliminate soda, chocolate, greasy foods.
* Topical preparations are a good start, such as benzyl peroxide or tretinoin topically. Apply topical tretinoin at night because it can cause photosensitivity. Also topical antibiotics.
* Systemic therapy is indicated if there is severe acne or not responding to topicals. Drug of choice is tetracycline, tell patient to avoid pregnancy.
* Next step is hormonal therapy, such as anti-androgen like spironolactone. Last step is systemic isotretinoin, and you have to get a pregnancy test prior to starting therapy. May need patient to sign an agreement about pregnancy. * Corticosteroids can help as well as dermal abrasion.
* Complications of acne include scaring, secondary infection/inflammation from popping zits, medication effects. --- Kaplan Videos (2001) – Congenital Malformation with Dr. Eduardo Pino, MD
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