Pediatric Board Review Course Notes: Adolescent Medicine

1. 2018 PEDIATRIC BOARD REVIEW COURSEADOLESCENT MEDICINE WARREN M. SEIGEL M.D., M.B.A., F.A.A.P., F.S.A.H.M. Chairman, Department of Pediatrics Director of Adolescent Medicine Coney Island Hospital Brooklyn, NY Chairman, New York State American Academy of Pediatrics (NYS AAP) District II

2. CASE #1 Katherine is a 14 year old female who presents for a routine examination for sports. She has no complaints. Her past medical history and family history are unremarkable. On physical examination, you note that she has Tanner 3 breasts and pubic hair.

3. Which of these would indicate sexual maturity rating (Tanner) stage 3 development in a female? • Fine hair on the upper lip • Acne • Darkly pigmented, slightly curly pubic hair • Breast and papilla elevated as a small mound • Menstruation 5

4. PUBERTY • Physical changes associated with development • Sequence of change is similar for all adolescents • Variations in tempo and timing are common • Physical changes reflect underlying hormonal changes

5. GIRLS Breast Buds Pubic Hair Appears Growth Spurt Axillary Hair Pubic Hair Matures Breasts Mature Menarche (First Period) Adult Height BOYS Testicular enlargement Growth of penis/scrotum Appearance of pubic hair Axillary Hair First ejaculations Growth spurt Facial hair Adult Height SEQUENCE OF PUBERTY

6. Features of Female Development • Onset: 10 years (8-13) • Growth spurt: Tanner 2 - 3 • Height Achieved: 4 inches/year • Menarche: 12 years • Acne: common at Tanner 3 - 4

7. A 13 year old boy is seen in your office because of breast enlargement over the past 6 months. He denies pain, galactorrhea and marijuana use. He is taking no medications. Physical examination reveals sexual maturity rating (Tanner) stage 2 genitalia and pubic hair growth and asymmetric breast buds beneath each nipple, with the left measuring 1 cm and the right 3 cm. Of the following, the most appropriate INITIAL management for this boy is: 5 1. Head CT with contrast 2. MRI of the abdomen 3. Serum beta-human chorionic gonadotropin level 4. Reassurance that this is a normal occurrence 5. Ultrasonography of the testes

8. Features of Male Puberty • Onset: 9-13 years (average = 12) • Peak Height Velocity: Tanner 3 - 4 • First Ejaculations: Tanner 3 • Average Height Gained: 5-7 inches/year • Strength Peak: Tanner 4 – 5 Gynecomastia occurs in approximately 60%

9. CASE #1(continued) Later in the course of your history, you find out that Katherine has tried tobacco, drinks alcohol “on weekends with my friends” and “smokes weed once in a blue”.

10. Adolescence is best described as the period: 1. Immediately before, during, and after puberty 2. Of physiologic adjustment to maturity 3. Of psychosocial transition from childhood to adulthood 4. Of maximal physical growth 5. Of maximal sexual development 6

11. FEATURES OF EARLY ADOLESCENCE(Am I Normal?) • 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 • Same-Sex Friendships • Concrete Thinking

12. FEATURES OF MIDDLE ADOLESCENCE(Am I Liked?) • Puberty (Almost) Complete • Testing/Showing Off “New Body” • Independence-Dependence Conflicts • Strong Peer Attachments • Concern With Sexual Appeal • Experimentation/Risk-Taking • Abstract Thinking Begins

13. FEATURES OF LATE ADOLESCENCE(Am I Loved?) • Definition of Adult Role in Society • Definition of Adult Role in Family • Mainly Independent Decisions, Actions • Established, Realistic, Self-Identity • Realization of Vulnerability, Limitations • Abstract Thinking Well Established

14. High Risk Behaviors • Alcohol • 63.2% acknowledge use • Tobacco • 32.3% acknowledge use • 10.8% currently smoking • Marijuana • 38.6% acknowledge use • 10.8% currently smoking • Cocaine • 5.2% acknowledge use • 3.0% currently use • Inhalants • 7% acknowledge use • Prescription Drugs • 16.8% acknowledge use

15. CASE # 2 Jonathon is a 16 year old male who comes to your office complaining of a clear urethral discharge and burning on urination for the past 1 week. He admits to being sexually active, the last time being 10 days ago.

16. The MOST prevalent sexually transmitted infection (STI) among adolescents and young adults in the US is: • Chlamydia • Genital herpes • Gonorrhea • HPV • Syphilis 4

17. CHLAMYDIA TRACHOMATIS • MALES • Asymptomatic • Urethritis • Epididymitis • FEMALES • Asymptomatic • Cervicitis

18. CHLAMYDIA: SIGNS AND SYMPTOMS • MALE: Burning, Urethral Discharge, Pain in Epididymis • FEMALE: Vaginal/Cervical Discharge, Pelvic Pain, Painful Intercourse, Burning MAY BE NO SYMPTOMS IN MALE OR FEMALE.

19. CHLAMYDIA TRACHOMATIS • DIAGNOSIS • Culture: “gold standard” • Leukocyte esterase; urine dip in males • Enzyme linked assay (EIA or ELISA) • Direct Fluorescent Antibody (DFA) • DNA probes • Nucleic Acid Amplification Tests (NAATs)

20. CHLAMYDIA TRACHOMATIS • TREATMENT • Azithromycin 1 gm single dose by mouth • Doxycycline 100 mg by mouth twice daily for 7 days • PARTNER TREATMENT!!! • Follow-up “Test of Cure” recommended

21. An 18 year old girl complaining of heavy menstrual periods that last 8-10 days. Physical examination reveals a creamy, greenish vaginal and cervical discharge that contains many leukocytes and Gram negative diplococci in pairs. A pregnancy test is negative and syphilis serology is pending. Of the following, the BEST antibiotic therapy for this patient is: • Amoxicillin • Amoxicillin and Erythromycin • Ceftriaxone • Ceftriaxone and Azithromycin • Spectinomycin and Doxycycline 3

22. GONORRHEA: SIGNS AND SYMPTOMS • MALE: Yellow “Drip” from Penis, Burning, Pain in Epididymis • FEMALE: Vaginal/Cervical discharge, Heavy Menses, Painful Intercourse, Burning, Frequency MAY BE NO SYMPTOMS IN MALE OR FEMALE

23. Neisseria Gonorrhea • MALE • Urethritis • Epididymitis • FEMALES • Asymptomatic • Cervicitis • Bartholin’s gland abscess • Pelvic Inflammatory Disease (PID)

24. NEISSERIA GONORRHEA • DIAGNOSIS • Culture: “Gold Standard” • Leukocyte esterase suggestive in males • DNA probes, PCR, EIA are all available • Nucleic Acid Amplification Tests (NAATs)

25. NEISSERIA GONORRHEA • TREATMENT • Ceftriaxone 250 mg IM in single dose • Cefixime 400 mg PO in single dose • Ofloxacin 400 mg PO in single dose • Ciprofloxacin 500 mg PO in single dose ADDITIONAL TREAMENT FOR CHLAMYDIA TRACHOMATIS IS TYPICAL

26. SYPHILIS: SITE OF INFECTION • MALE: Penis, Anus, Mouth, Lips • FEMALE: Vulva, Vagina, Cervix, Anus, Mouth, Lips • INFANT: Acquired During Pregnancy, Birth Defects, Death Spread to entire body in male and female including heart and brain!

27. SYPHILIS: SIGNS AND SYMPTOMS • PRIMARY SYPHILIS • Chancre on sex organs • Painless indurated ulcer with smooth border • Incubation = 3 weeks, healing = 6 weeks • SECONDARY SYPHILIS • Fever, rashes, generalized illness • TERTIARY SYPHILIS • Infection of brain, blood vessels

28. SECONDARY SYPHILIS • CONSTITUTIONAL SYMPTOMS • Fever, malaise, adenopathy, musculoskeletal symptoms • SKIN AND MUCOUS MEMBRANE FINDINGS • Rash – begins on trunk • Rash – involves palms and soles • Condylomalata – moist plaques • Alopecia SKIN LESIONS ARE HIGHLY INFECTIOUS!

29. Diagnosis – Syphilis • Serologic – nontreponemal • RPR, VDRL, ART • Serologic – treponemal • FTA-ABS, MHATP,TPHA

30. Treatment – Syphilis • Less than 1 year duration – • Benzathine Penicillin-G 2.4 million units IM • Greater than 1 year duration – • Benzathine Penicillin-G 7.2 million units, 3 divided doses

31. A 16 year old girl has had dysuria and a vaginal discharge for 2 weeks. Findings on pelvic examination include a frothy vaginal discharge and cervical petechiae. Microscopic examination of the discharge reveals flagellated organisms. Results of a urinalyis are normal.Among the following, the BEST treatment for this patient’s problem is: • Azithromycin • Cefixime • Ciprofloxacin • Doxycycline • Metronidazole 5

32. Trichomonas • Males • Generally asymptomatic • Females • Malodorous vaginal discharge • Cervicitis • Vulvitis with labial edema

33. Trichomonas • Diagnosis • Observation of flagellate on saline wet mount • Treatment • Metronidazole 2 gm po x 1 dose

34. Bacterial Vaginosis • Non-gonococcal • Non-chlamydial • Non-trichomonal • Non-candidal Due to Gardnerella vaginalis

35. Bacterial Vaginosis • Symptoms • Vaginal discharge- grey-white, thin , watery • Pruritis and itching may accompany • Worsens with intercourse • Malodorous • Diagnosis • Saline wet prep with “clue” cells • Treatment • Metronidazole 500mg PO bid x 7 days

36. Genital Herpes: Site of Infection • Males: Blisters on Penis, Scrotum, Buttocks • Females: Blisters on Vulva, Vagina, Cervix, Buttocks • Infants: Systemic

37. Genital Herpes: Signs and Symptoms • Primary Infection: Very Painful Painful Urination 1-3 weeks • Repeat Infections: Less Painful 1 Week or less

38. Herpes Simplex - HSV • Skin lesions appear at site within 2-14 days • Grouped papules on erythematous base • Ulceration Erosion • Very painful • Constitutional symptoms

39. Genital Herpes: Treatment • Treat Virus • Treat Symptoms • No sex until 1 week after blisters heal • Treat partner only if infected

40. Treatment:Genital Herpes • Primary • Acyclovir 400 mg oral tid X 7-10 days • Recurrent • Acyclovir 400 mg oral tid X 5 days • Prophylaxis • Acyclovir 400 mg oral bid • Suppressive Therapy • A) ACV 400 mg PO BID • B) ACV 200 mg po 2-5 times/day • Severe disease • ACV 5 -10 mg/kg IV every 8 hours X 5-7 days • No role for topical ACV

41. Human Papilloma Virus • Most common STI • Increasing prevalence among teens • Associated with majority of Pap smear abnormalities • Treatment • Podophyllin • Cryotherapy with liquid nitrogen • Podofilox (home treatment)

42. CASE # 3 Over the past 6 months, Marianne, a 15 year old girl in your practice, has missed 8 days of school because of severe, episodic lower abdominal pain that coincides with menses. Menarche was at age 13 and menses are regular. She states that she is not sexually active. Findings on physical exam are normal.

43. Of the following, the BEST treatment for this girl’s abdominal pain is: • Abdominal exercises • Acetaminophen • Hydrochlorothiazide • Low-salt diet • Naproxen 5

44. Normal Menstruation • Normal menstruation is an indication that the hypothalamic--pituitary--ovarian--uterine axis is intact and responsive.

45. Physiology of Menses • FSH - stimulates the maturation of ovarian follicles - directs the conversion of androgens in the granulosa cells of the ovary to estrogens • LH - stimulates theca cells of the ovary to produce androgens - midcycle LH surge stimulates ovulation

46. Physiology of Menses • Estrogens- stimulate the proliferation of endometrial epithelial and stromal cells. Stimulate glandular formation. • Progesterone- produced by corpus luteum, causes the endometrium to function in a secretory manner, leading to increased blood vessel growth and tortuosity.

47. Normal Menstrual Cycles Follicular Phase Ovulatory Phase Luteal Phase

48. Follicular Phase • Endometrial proliferation under estrogen influence • Endometrial stroma becomes compact • Estrogen triggers midcycle LH surge • Cervical mucus is watery

49. Ovulatory Phase • Following ovulation, corpus luteum produces both Estrogen and Progesterone. • Progesterone exerts suppressive effect on Estrogen resulting in the conversion of the endometrium to a secretory state.

50. Ovulatory Phase • Vaginal secretions and Cervical mucus are copious and clear. • Secretions placed on glass slide will demonstrate “ferning” pattern when allowed to dry. (know this !)