Chapter 14: Adolescent Medicine

A 14-year-old male presents to your clinic with his mother for a routine well-child examination. The patient's mother has some questions about puberty. Her son enjoys playing sports and she is concerned that he may be too small to play football. The past medical history is unremarkable.

Question 14.1.1 Which of the following can you tell the mother will likely be the first sign of puberty in this boy?

A) Increase in penile length.

B) Enlargement of the testes.

C) Deepening of the voice.

D) Rapid increase in linear growth.

E) Coarsening of pubic hair.

Answer 14.1.1 The correct answer is "B." Increase in the volume of the testes is the first sign of pubertal development in boys. The age of onset of puberty in the past was 12 years (range 10–14), but recent studies have shown that the mean age of onset is now 1.5 to 2 years earlier than these historical norms. In a study including more than 4,000 healthy boys, the mean age for entering puberty was 10.14 years for Caucasian boys, 10.04 years for Hispanic boys, and 9.14 years for African-American boys. "E" is of special note. While pubic hair appears shortly after the onset of puberty, it is initially long and straight and not in a mature distribution. Coarsening of the pubic hair is a more advanced pubertal stage, occurring approximately 1.5 years after the onset of puberty; an increase in penile length occurs simultaneously. The maximal growth spurt occurs approximately 2 years after the onset of puberty. Changing of the voice is a secondary hormonal effect that is quite variable in nature.

From the mother, you learn that the patient's father began going through puberty during high school, and he did not reach his adult height until he was in college at about age 20. The patient's father is 5′ 10″ tall (∼178 cm). The mother is 5′ 3″ tall (∼160 cm). Physical examination reveals that your patient is Tanner stage I for genitalia and pubic hair. His height and weight continue to track along their previously established curves on the growth chart, both at approximately the fifth percentile. The remainder of the examination is unremarkable.

Question 14.1.2 What is your next step in evaluation of this patient's short stature?

A) Obtain hand radiographs to assess bone age.

B) Draw blood to test for growth hormone and testosterone levels.

C) Obtain an endocrinology consult.

D) Order computed tomography (CT) imaging of the brain to rule out hypothalamic tumors.

E) Order magnetic resonance imaging (MRI) of the brain to rule out hypothalamic tumors.

Answer 14.1.2 The correct answer is "A." In the face of a normal physical examination and appropriate linear growth velocity, the likelihood of an intracranial process is very low. An assessment of bone age can be obtained easily, relatively inexpensively, and would be useful prior to performing other tests.

You decide to obtain a bone age, and the radiologist reports bone age as 12 years and 3 months (remember that our patient is 14 years old).

Question 14.1.3 What is the most likely diagnosis for your patient?

A) Growth hormone deficiency.

B) Sella turcica tumor.

C) Constitutional delay of growth and puberty.

D) Idiopathic testicular atrophy.

E) Testosterone receptor abnormality.

Answer 14.1.3 The correct answer is "C." The bone age of 12 years and 3 months is reassuring. Since there is no fusion of the growth plates, his bones are immature and still have the ability to grow. Had the bone age been 14, it is likely that his adult height would be short; the bones would no longer have the inherent ability to grow. Bone age assessment is an accurate tool for determination of expected growth. Constitutional delay is the most common diagnosis for short stature and it is often associated with a delayed onset of puberty. Constitutional delay is a diagnosis of exclusion; a complete history and physical often rules out other diagnoses. Family history often reveals a parent who was a "late bloomer" but eventually had normal pubertal development. This adolescent's history of normal linear growth velocity (albeit along the fifth percentile) is reassuring for the absence of growth hormone deficiency or intracranial abnormalities. This adolescent's combination of appropriate linear growth velocity, appropriate adjustment for bone age, and paternal history of late pubertal development is classic for a constitutional delay.

When your patient's height is plotted on a growth curve and adjusted for bone age rather than chronological age, the height now plots just below the 50th percentile. Your patient now has a question of his own. His biggest concern is that some of his classmates are starting to get taller, and he is afraid he will be too short to continue competing in sports. Once again, his mother is 5′ 3″ tall (∼160 cm) and his father is 5′ 10″ tall (∼178 cm).

Question 14.1.4 Based on what you know today, what is your best estimate of this patient's adult height?

A) 5′ 3″ ± 2 (160 ± 5 cm).

B) 5′ 5″ ± 2 (165 ± 5 cm).

C) 5′ 7″ ± 2 (170 ± 5 cm).

D) 5′ 9″ ± 2 (175 ± 5 cm).

E) 5′ 11″ ± 2 (180 ± 5 cm).

Answer 14.1.4 The correct answer is "D." You can provide a rough estimate of the patient's adult height using the calculation for mid-parental height (MPH). Remember that the parent of the opposite gender—the mother in this case—must have the height adjusted for this calculation. For boys, add 5 inches to the mother's height (12.5 cm) and then average this corrected maternal height with the paternal height to determine the MPH. For girls, subtract 5 inches from the paternal height (12.5 cm…that is what you subtract, and NOT the paternal height) and then average this corrected paternal height with the maternal height to calculate the MPH. In our patient's case, his mother's corrected height is 68 inches which averaged with his father's height of 70 inches, equates to a MPH of 69 inches. A margin of error of ±2 inches (5 cm) is often given with MPH estimates.

Objectives: Did you learn to…

• Evaluate a patient with growth concerns?

• Identify the clinical presentation of constitutional delay?

• Calculate MPH?

Your next patient is a 16-year-old female cross-country runner who you are seeing in follow-up for right shin pain. She was diagnosed in the local emergency department 1 week ago with "shin splints" and told to limit her activities. In your office, she tells you that the pain has been worsening over the last 3 months, and she has progressively decreased the distance and time of her runs (but, of course she's a runner, so she hasn't quit). She denies fever, swollen joints, or other systemic symptoms. She normally has regular menses but notes that she has irregular menses during cross-country season. The patient's past medical history is significant for a stress fracture in her left foot 18 months ago. Your examination reveals tenderness at the middle one-third of the right tibia. In addition, she has pain on a single-leg hop. You are able to review her x-rays from the emergency department, which do not reveal any fractures or other abnormalities.

Question 14.2.1 What is the most appropriate next step to diagnose your patient's leg pain?

A) Ultrasound of the lower extremity.

B) MRI of the lower extremity.

C) Dual-energy x-ray absorptiometry (DEXA) scan.

D) Thyroid-stimulating hormone (TSH) level.

E) Urine pregnancy test.

Answer 14.2.1 The correct answer is "B." MRI is sensitive and specific for stress fractures and has become the preferred study. The patient's history and examination are concerning for the presence of a tibial stress fracture. Stress fractures often present insidiously and cause gradual progression in symptoms over time until a critical point is reached in terms of sports participation. Half of stress fractures are not visible on plain radiographs. Ultrasound can help in evaluating soft tissue masses, but it does not play a role in evaluating stress fractures. DEXA scan can provide whole-body and site-specific measurement of bone mineral density, which may be related to the pathophysiology of stress fractures, but does not help diagnose a site of injury. Radionuclide bone scans are often less expensive than CT or MRI, and they demonstrate sites of injury based on increased uptake of the radionuclide material. However, bone scans are not specific for stress fractures and are often falsely positive. Of note, plain radiographs may take months to become positive after a stress fracture and, while radiographs may be done, they will not be of use if the result is negative. Given the patient's other complaints, TSH and urine pregnancy test may be warranted but will not assist in the diagnosis of her leg pain.

An MRI is obtained and confirms the presence of a stress fracture in the middle one-third of the right tibia. Because of your patient's history, especially that of multiple stress fractures, you are concerned she may be suffering from the female athlete triad.

Question 14.2.2 What are the components of the female athlete triad?

A) Disordered eating, menstrual dysfunction, altered bone mineral density.

B) Depression, weight loss, sports-related injury.

C) Poor sports performance, low self-esteem, injury.

D) Weight gain, bony injury, mood changes.

E) Fanatical attachment to sports, testosterone abuse, anger management issues.

Answer 14.2.2 The correct answer is "A." The female athlete triad was first identified in the early 1990s and originally characterized as anorexia, amenorrhea, and osteoporosis. As more has been learned about the triad, the realization has been made that the triad likely represents a broader spectrum disorder within each category. Many young women with the triad will exhibit disordered eating behaviors, such as caloric restriction or use of diuretics and diet pills, but would not meet the criteria for anorexia or bulimia nervosa. Menstrual dysfunction may include oligomenorrhea or irregular, intermittent menses, as well as amenorrhea. These young women may also have abnormal bone mineral density, with predisposition to bony injury, without having reached the strict criteria of osteoporosis.

The patient comes back to the office to receive her test results, and you take the opportunity to obtain more history. The patient admits that she is very concerned about her diet during her cross-country season, and she is very careful to choose foods that have very little fat but are often high in protein. She will occasionally "go overboard" and eat a lot, for which she compensates by taking part in extra workouts. She has also used laxatives in the past "to not gain weight when I eat too much."

Question 14.2.3 Which of the following findings is NOT classically found in bulimia nervosa?

A) Loss of dental enamel.

B) Enlarged parotid glands.

C) Metabolic acidosis.

D) Skin changes over the dorsum of the hands.

E) Maintenance of a significantly low body weight.

Answer 14.2.3 The correct answer is "E." Loss of dental enamel, skin changes over the dorsum of the hands, and enlarged parotid glands may be seen as a result of repetitive self-induced vomiting. While self-induced vomiting would cause a metabolic alkalosis through loss of stomach acid, repetitive use of laxatives can cause gastrointestinal losses of bicarbonate, resulting in a metabolic acidosis. Individuals with bulimia nervosa often maintain a normal weight, while anorexia nervosa has strict diagnostic criteria requiring maintenance of significantly low body weight, often less than 85% of the ideal body weight.

Your patient also relates that she began having her periods around age 12. While they were initially irregular, they seemed to become more regular prior to starting high school. However, as she became more involved in high school sports, her periods became more irregular. During her off-season, her menses are "more regular," though she cannot predict when they will occur. She recalls that her last period was about 7 weeks ago.

Question 14.2.4 In evaluating your patient's menstrual dysfunction, what would be your next course of action?

A) Obtain serum LH, follicle-stimulating hormone (FSH), and estradiol levels.

B) Order an abdominal and pelvic ultrasound.

C) Perform a speculum-assisted pelvic examination with Pap smear.

D) Obtain a urine beta-hCG.

E) Prescribe an oral progestin-only pill (progestin challenge).

Answer 14.2.4 The correct answer is "D." The most common cause of secondary amenorrhea in women of childbearing age remains pregnancy. If pregnancy has been excluded, and the history and physical are reassuring, a progestin challenge can be helpful to determine if adequate estrogen is present; the progestin challenge should induce menses if adequate estrogen exists (see Chapter 15 for details on the evaluation of amenorrhea). Imaging studies and hormonal levels may help in excluding other diagnoses or may be warranted based on physical examination. A pelvic examination may be warranted based on history, but is often not necessary in the initial evaluation of menstrual dysfunction. Pap smears are no longer recommended for women under the age of 21, regardless of sexual activity status.

Your patient's pregnancy test is negative and a progestin challenge induced menses, indicating adequate circulating estrogen. A comprehensive plan is developed that includes psychological counseling, dietary modification, physical therapy, consultation with a nutritionist, and frequent follow-up. Over the next several months, the patient recovers from her injury, and returns to running on a modified schedule. However, she now complains of heavy, painful menses and wants to go on the "shot" to stop them.

Question 14.2.5 In your counseling about birth control options, which of the statements below is FALSE?

A) The birth control pill can be used to treat irregular menses of the female athlete triad and will also increase bone deposition.

B) The effect of Depo-Provera (medroxyprogesterone) is to suppress the hypothalamic—pituitary—ovarian axis, creating a low estrogen state akin to peri-menopause.

C) The FDA issued a "Black Box" warning on Depo-Provera that states "prolonged use…may result in loss of bone density that may not be completely reversible after discontinuation of the drug."

D) The risk of future fracture using Depo-Provera is unknown, as bone density is an incomplete measure of bone strength, and remodeling and recovery are significant.

E) Use of a Long Acting Reversible Contraceptive (LARC) should be offered as first line contraceptive choice.

Answer 14.2.5 The correct (and "false") answer is "A." The other statements are all true. Starting a combined estrogen/progesterone contraceptive pill will restart a menstrual cycle but may not increase bone density. As to "E," an American Academy of Pediatrics (AAP) policy statement from September 2014 recommends that a LARC be considered as a first line contraceptive option in adolescents, including intrauterine device (IUD) or subdermal implant. These can provide 3 to 10 years of contraception and are effective and safe forms of birth control. Concerns about an increase in pelvic inflammatory disease (PID) with the IUD have been found to be unwarranted.

In your routine anticipatory guidance, you discover that she avoids most dairy products due to a combination of prior concerns about fat content and lactose intolerance.

Question 14.2.6 What do you recommend for her daily intake of elementary calcium?

A) 900 mg.

B) 1,100 mg.

C) 1,300 mg.

D) 1,700 mg.

E) 2,100 mg.

Answer 14.2.6 The correct answer is "C." While the absolute best intake of calcium for individuals is unknown, studies have shown positive calcium balance for adolescents with an intake of 1,200 to 1,500 mg daily. In its 2010 report, the Institute of Medicine (IOM) set 1,300 mg/day as the "adequate" dietary intake for boys and girls 9 to 18 years of age. This guideline was set to meet the needs of 95% of healthy children, with the upper limit of calcium intake set at 2,500 mg/day.

For most persons, 1,300 mg/day of calcium intake can be accomplished with four servings of dairy products (8 oz of milk = 8 oz of yogurt or cottage cheese = 1 inch cube of cheese) plus a varied diet that includes other calcium-rich foods (e.g., broccoli, collard greens, and turnip greens). It is generally preferable to achieve intake of calcium via diet, including fortified foods, because foods provide multiple nutrients that are important for bone health, such as phosphorus and magnesium. Despite widespread non- and low-fat dairy options and numerous supplements, concern over fat intake has resulted in an average adolescent intake of only 700 to 800 mg/day for girls and about 1,000 mg/day for boys—and yet, we have an obesity epidemic. Ironic but not funny.

Question 14.2.7 On average, what percentage of total body mineral content has a young woman deposited by the time she reaches 12 years of age?

A) 20% to 30%.

B) 40% to 50%.

C) 70% to 75%.

D) 80% to 85%.

E) 95% to 100%.

Answer 14.2.7 The correct answer is "D." Research suggests that by age 12, a young woman has reached approximately 83% of her peak bone mineral content, with 50% deposition happening from the time of "peak height velocity," which is premenarchal through 1 year post-menarche. The ability to absorb calcium from the diet is also enhanced during this period. Rates of deposition begin to decline approximately 2 years post-menarche and no significant gains are seen after the age of 17. These statistics emphasize that osteoporosis, while manifesting in older adults, is truly an issue of adolescent preventive medicine.

Your patient returns from a high-powered sports medicine clinic in Palm Springs (or Laguna Beach…or anywhere more likely to make TV than Iowa). She brings you her DEXA scan results that are consistent with osteopenia. She looks up from her Instagram feed and asks, "So, what are we gonna do about that, Doc?"

Question 14.2.8 You scour the literature and recommend:

A) Alendronate.

B) Calcium and vitamin D.

C) Vigorous weight-bearing exercise.

D) Dehydroepiandrosterone (DHEA).

E) All of the above.

Answer 14.2.8 The correct answer is "B." Alendronate has no proven benefit in adolescent osteopenic females. Recommending exercise is the usual course for older patients with osteopenia, but you need to be careful in the adolescent with weight concerns who may exercise excessively at baseline. DHEA is investigational and has not been shown to increase bone mineral density. Stick with the standard of care: calcium in the daily doses as recommended above and vitamin D 600 IU daily (note that this recommendation is a change in the 2010 IOM guideline).

Objectives: Did you learn to…

• Evaluate leg pain in a runner?

• Identify the "female athlete triad?"

• Recognize the importance of calcium and vitamin D intake and osteoporosis prevention in adolescence?

For adolescent athletes, what is the number one cause of sudden cardiac death (SCD)?

A) Marfan syndrome.

B) Coronary artery disease.

C) Congenital malformation of coronary arteries.

D) Hypertrophic cardiomyopathy.

E) Long QT syndrome.

The correct answer is "D." Hypertrophic cardiomyopathy is an autosomal-dominant trait with highly variable penetrance that results in asymmetric septal wall hypertrophy. This may cause functional aortic outflow tract obstruction, as well as predispose the athlete to arrhythmias. Unfortunately, this condition is often asymptomatic prior to the terminal event and screening tests such as electrocardiographs and echocardiograms have not been proven effective at early detection of this condition. Aberrant coronary arteries are the second leading cause of SCD in young athletes. Marfan syndrome and long QT syndrome are less common.

As part of your group's community outreach, you are participating in a sports physical screening (somehow your partner got to throw out the first pitch at a baseball game, and you got this … we're guessing you must be new). One of the students is noted to be hypertensive with a blood pressure of 143/95 mm Hg. There is no family history of sudden death or early heart attack. He has never experienced any symptoms with exercise. His parents indicated on the form that they did not recall any history of previous heart murmur or high blood pressure. The remainder of the examination is unremarkable except for a I/VI systolic murmur. You ask the athlete to perform a Valsalva maneuver by holding his breath and bearing down while cardiac auscultation is repeated.

Question 14.3.1 Which of the following correctly describes the relationship between murmur intensity and the likely type of murmur?

A) Valsalva maneuver increases flow murmur, decreases outflow tract obstruction murmur.

B) Valsalva maneuver increases both flow murmur and outflow tract obstruction murmur.

C) Valsalva maneuver decreases both flow murmur and outflow tract obstruction murmur.

D) Valsalva maneuver decreases flow murmur, increases outflow tract obstruction murmur.

Answer 14.3.1 The correct answer is "D." The Valsalva maneuver decreases venous return to the heart, resulting in decreased diastolic filling. You would expect this to cause decreased flow through the outflow tract and thus a softer flow murmur. However, the decreased flow exacerbates the functional outflow tract obstruction of hypertrophic cardiomyopathy (there is less volume to push the septum out of the way resulting in a tighter functional stenosis), resulting in a louder murmur. In summary, benign flow murmurs will decrease in intensity with Valsalva maneuver, while the murmur of hypertrophic cardiomyopathy will increase with a Valsalva maneuver.

Reassured by a murmur that disappears with Valsalva maneuver and an otherwise unremarkable examination, you are now faced with an adolescent athlete with an elevated blood pressure confirmed by manual re-testing.

Question 14.3.2 What is the best recommendation for this athlete regarding sports participation and follow-up of his elevated blood pressure?

A) Qualified participation pending serial blood pressure checks over the next 3 weeks.

B) Complete disqualification for 2 months, followed by return if ECG and echocardiogram are normal.

C) Disqualification from competition only for 1 month, but allowed to practice once seen by a nephrologist.

D) Full participation with no required follow-up based on reassuring history and examination.

E) Full participation with blood pressure re-check prior to the next competitive sport season.

Answer 14.3.2 The correct answer is "A." It is important to remember that the diagnosis of hypertension cannot be made at a single screening visit. The screening may be affected by patient anxiety ("white coat hypertension" or standing half naked in front of all of his peers), recent caffeine ingestion, drugs, or a number of other factors (including a common occurrence of scheduling examinations right after practice). Most recommendations include three separate recordings of blood pressure on different occasions after several minutes at rest, sitting comfortably.

Because exercise is beneficial for blood pressure control, continued aerobic activity should be encouraged while the serial blood pressure readings are obtained. Debate exists as to recommendations regarding static exercises, such as weightlifting. While lifting of heavy weights can exacerbate high blood pressure, there is some evidence to suggest that use of light-to-moderate weights with repetition is beneficial. Certainly, the presence of any additional symptoms with exercise, such as headache or lightheadedness, would require more significant limitations in activity.

Objectives: Did you learn to…

• Identify important issues to address at the pre-participation physical examination?

• Evaluate an adolescent athlete with elevated blood pressure?

• Evaluate a cardiac murmur revealed on pre-participation physical examination?

A 15-year-old female presents to your office for a well-adolescent examination. She is a healthy teenager with no complaints—well, she has the usual teenager complaints (her parents are stupid, the teachers don't know anything, etc.). You have incorporated into your routine a screening tool, the Guideline for Adolescent Preventive Services (GAPS) questionnaire, one of many such tools available. The questions cover all areas of adolescent development and are designed so that areas of concern are easily identified.

Question 14.4.1 What are the three leading causes of mortality for adolescents?

A) Leukemia, suicide, accidental drowning.

B) Childhood cancers, perinatally acquired HIV, suicide.

C) Congenital malformations, childhood cancers, suicide.

D) Accidental injury, homicide, suicide.

E) Childhood cancers, SCD, suicide.

Answer 14.4.1 The correct answer is "D." Accidental injury, homicide, and suicide are the three leading causes of death for adolescents and should be addressed during preventive health visits. As a category of accidents, motor vehicle fatality is the leading cause of death to teenagers, representing over one-third of all deaths. A high number of teens report unsafe driving behavior: 41.4% of teens have reported texting or emailing while driving; and while most states have made this illegal, it is still important to discuss with your adolescent patients. Accidental injuries often involve the use of alcohol or other substances in combination with motor vehicle operation or other risk-taking behaviors. Ask about personal use of alcohol and if they are ever passengers of another teenager (or adult) who drives while impaired or intoxicated. The greater the number of teens in the car of a teen driver, the greater the likelihood of an accident. This argues for the law in some states that restrict the number of passengers in a teen driver's car.

You also noticed that your patient checked "yes" for a history of use of alcohol and marijuana.

Question 14.4.2 What is the approximate frequency of lifetime use of these substances among 9th to 12th grade students according to the Centers for Disease Control and Prevention (CDC's) 2013 Youth Risk Behavioral Survey?

A) Alcohol 10% to 20%; marijuana 5% to 10%

B) Alcohol 30% to 40%; marijuana 10% to 20%

C) Alcohol 50% to 60%; marijuana 20% to 30%

D) Alcohol 60% to 70%; marijuana 30% to 40%

E) Alcohol 70% to 80%; marijuana 40% to 50%

Answer 14.4.2 The correct answer is "D." The survey found 66.2% of adolescents reporting use of alcohol at some point in their lives, and 40.7% reporting use of marijuana. In addition, 41.1% have tried cigarettes. Alcohol use has been found to be slightly higher in females at 67.9% compared to 64.4% in males.

After eliciting a positive response to questions about drug use, you ask the patient about depression, and she states that she has been feeling "down" for several months now.

Question 14.4.3 What would your next step be?

A) Call the police and report the illegal use of substances by a minor.

B) Reassure the patient about her confidentiality rights, counsel her to quit using drugs, and see her back annually.

C) Begin the patient on an SSRI and see her back in a month.

D) Negotiate next steps to guarantee the patient's safety and consider counseling referral.

E) Obtain a nonconsented urine drug screen to document recent use of substances.

Answer 14.4.3 The correct answer is "D." Most states' laws, as well as HIPAA, guarantee teenagers confidentiality, to be broken only when there is an issue of imminent danger to self or others or physical/sexual abuse. It is recommended that the patient be involved and consent to who and how the information is shared. Rarely is there a need to involve police, unless there is an issue of abuse requiring a report or concern over safety if the patient is returned to the home environment.

"C" is incorrect. If an SSRI is started, close supervision is required for adolescents. Studies suggest increased suicidality in teenagers treated with SSRIs. There are also increased attempts at suicide but not an increase in successful suicide. The American Academy of Child and Adolescent Psychiatry website has resources outlining patient and parent information about the risks and benefits of pharmacologic treatments. Cognitive behavioral therapy (CBT), along with talk therapy, has been shown to be the best first-line treatment for adolescents with mood disorders. In any case, close follow-up of a depressed adolescent (weekly visits or phone calls) is recommended.

Objectives: Did you learn to…

• Identify and employ useful screening tools for routine adolescent examinations?

• Recognize the importance of screening and treating depression in adolescents?

• Describe common causes of death in adolescents?

• Understand the common lifetime experience use of alcohol, tobacco, and marijuana?

• Describe screening and treatment options for mood disorders and substance abuse?

Your afternoon has a number of patients with sports-related complaints. A 14-year-old wrestler has arrived in the office complaining of a rash on his left shoulder. The rash appears to consist of several small lesions with a vesicular appearance but no purulence and minimal erythema. There is neither tenderness to palpation nor tactile warmth in the affected area.

Question 14.5.1 What would be your best test to confirm your diagnosis of these lesions?

A) Microscopic evaluation with potassium hydroxide (KOH) preparation of the contents of one of the lesions.

B) Gram stain of the contents of one of the lesions.

C) Culture of the contents of one of the lesions.

D) Tzanck smear of the contents of one of the lesions.

Answer 14.5.1 The correct answer is "D." A Tzanck prep will give you immediate information about whether this represents herpes simplex. This is important information when deciding whether or not this patient can return to wrestling. HSV PCR assays are a more sensitive method to confirm HSV infection in clinical specimens obtained from genital ulcers and mucocutaneous sites and should also be obtained. However, these typically take several days to return results.

The lesions have appeared within the past day, and your laboratory testing confirms that the diagnosis is herpes simplex. Your patient does not recall any previous lesions like these. He denies any systemic symptoms.

Question 14.5.2 What would be the best course of treatment for this patient?

A) Cover the involved area to allow return to wrestling.

B) Treat with topical acyclovir and return to wrestling when lesions have crusted over.

C) Treat with oral acyclovir and return to wrestling when lesions have crusted over.

D) Treat with oral steroids to suppress the response and promote quicker return to wrestling.

E) Treat with topical antifungal medication and allow return to wrestling.

Answer 14.5.2 The correct answer is "C." Cutaneous herpes, also referred to in wrestling as herpes gladiatorum, is a highly contagious illness. "B" is incorrect because topical acyclovir is not effective in treating herpes simplex. Most state high school athletic associations have specific rules regarding the treatment of cutaneous disorders in wrestling, including herpes, tinea corporis, and impetigo. With regard to herpes simplex, all lesions must be fully crusted over and the athlete must have had at least 3 days of oral antiviral therapy prior to returning to competition. "D" is incorrect because oral steroids would suppress the athlete's immune response, which would allow for further spread of the lesions.

Your next patient is a 12-year-old male who is here for a sports physical. You review your patient's chart and scan his immunizations. The patient's mother remembers her son receiving his "kindergarten shots;" he has had no immunizations since. His records reveal the following vaccines: 5 doses of diphtheria–tetanus–acellular pertussis (DTaP), 4 doses of injectable polio vaccine (IPV), 4 doses of Haemophilus Influenzae Type B (Hib), 3 doses of hepatitis B; 4 doses of PCV 13, 2 doses of measles–mumps–rubella (MMR), and 2 doses of varicella vaccine.

Question 14.5.3 Which, if any, immunizations would you offer today?

A) None. The patient is up-to-date for all immunizations.

B) Conjugate pneumococcal vaccine.

C) Hepatitis A/B vaccine, conjugate meningococcal vaccine, IPV.

D) Hepatitis A vaccine; Tetanus, diphtheria and pertussis (Tdap); conjugate meningococcal vaccine and start of the HPV series.

E) Human papillomavirus (HPV) vaccine, Tdap, varicella vaccine.

Answer 14.5.3 The correct answer is "D." Universal vaccination for hepatitis B is included in the primary immunization series for infants, so most adolescents have been vaccinated. However, it is still important to make sure this is up-to-date. Since adolescence is a time when experimentation with drugs and sexual activity becomes more prevalent, vaccination for hepatitis B becomes even more relevant. Hepatitis A vaccine is now being required in many states before entry to school and is universally recommended for all children ages 12 months to 2 years. A catch-up vaccination schedule is now recommended for ages 2 to 18 years. For those not up-to-date with their hepatitis B vaccination, a combined hepatitis A/B vaccine exists.

Most children receive their last DTaP prior to entering preschool or kindergarten (age 4–5 years). Beginning in 2005, the CDC recommended giving the tetanus booster with pertussis (TdaP) at entry to middle school/junior high (ages 11–12) in place of the tetanus booster (Td).

For protection against some serotypes of Neisseria meningitidis, the CDC recommends universal vaccination with the conjugate meningococcal vaccine (e.g., Menactra) for teens, including a booster dose between ages 16–18 years.

The CDC recommended HPV vaccination for boys in 2011. Effective March of 2015, the CDC recommends 9-valent HPV, 4-valent HPV, or 2-valent HPV for routine vaccination of females 11 or 12 years of age and females through 26 years of age who have not been vaccinated previously or who have not completed the 3-dose series. Further, the CDC recommends the 9vHPV or 4vHPV for routine vaccination of males 11 or 12 years of age through 21 years of age who have not been vaccinated previously or who have not completed the 3-dose series. This age cut-off may be extended out to 26 years old for men who are immunocompromised or have sex with men and have not been previously vaccinated. "E" is incorrect because he has already had chicken pox.

Question 14.5.4 Which statement does NOT accurately describe how the conjugate meningitis vaccine (Menactra) differs from the older polysaccharide meningitis vaccine (Menomune)?

A) Menactra elicits a T-cell immune response that gives long-term immunity and allows for herd immunity.

B) Menactra protects against all the types of N. meningitidis: A, B, C, Y, W-135.

C) Menomune does not elicit a booster effect, may only be given once, and is recommended only at the onset of high-risk activity, such as living in dorms or being a military recruit.

D) Menactra should be offered at entry to middle school/junior high school (11–12 years) with a booster dose recommended between age 16 and 23 years.

Answer 14.5.4 The correct answer is "B." Unfortunately neither Menomune nor Menactra protect against serogroup Type B. The other choices are correct. N. meningitidis Type B is endemic in North America and up until 2014, no such vaccine was available. In 2014 and 2015, the FDA approved two meningococcal Type B vaccinations (3 dose MenB-FHbp (Trumenba^®) and 2 dose MenB-4c (Bexsero^®). The ACIP in October 2015 provided a grade B recommendation that MenB vaccination may be given in addition to Menactra and other indicated age-based vaccinations (preferably at a different anatomic site) between ages 16 and 23 with preferable dosing at 16 to 18 years to provide peak desired immunologic effect in the group that is at most risk.

Objectives: Did you learn to…

• Identify herpes gladiatorum and describe its treatment?

• Recommend vaccines appropriate for adolescents?

A 15-year-old female returns for her annual well-child check and sports physical. She is well known to your clinic, and over the years she has steadily gained weight. Her parents and a younger sibling are overweight, and now she has become obese by measure of the pediatric BMI percentages. In recent years, you have become more diligent with watching the BMI on her growth curve. She is aware of her weight problem, yet has not voiced any plan for attempting weight loss.

Question 14.6.1 What defines "obesity" in adolescence?

A) A BMI in the 85th to 94th percentile for age-specific measures.

B) A BMI ≥95th percentile for age-specific measures.

C) The child has the appearance of being heavy.

D) The child complains of being fat or overweight.

E) BMI >35 kg/m².

Answer 14.6.1 The correct answer is "B." A BMI at or above the 95th percentile is considered "obese." A BMI in the range of 85th to 94th percentiles is considered "overweight." The use of BMI allows for an objective measure, and although not perfect, can give a picture on the growth curve to patients and parents where they stand relative to age-related norms. Strict BMI numbers (as in "E") are not applicable to children and adolescents. A subjective concern about weight ("D") is important, but does not necessarily always warrant further evaluation.

Question 14.6.2 Her BMI is now at the 97th percentile, having jumped from the 86th percentile last year. What additional work-up is needed?

A) Fasting plasma glucose level.

B) Fasting lipids.

C) Renal function testing with BUN and creatinine.

D) Liver function testing with AST and ALT.

E) All of the above.

Answer 14.6.2 The correct answer is "E." Once a child reaches a BMI at the 85th to 94th percentiles, a lipid panel is recommended to evaluate for hyperlipidemia and screening should be done for early onset type 2 diabetes. When the BMI reaches the 95th percentile, renal function and blood pressure should be monitored and liver function should be checked (looking for signs of fatty liver). Fatty liver disease is possible at an early age and is reversible if weight loss can be achieved. Close attention to family history is essential. If family members are obese or have obesity-related comorbidities, early intervention and evaluation are even more crucial. For females who have started menses, it is important to assess for any changes in menstrual patterns.

Question 14.6.3 Which of the following is NOT a recommended early childhood intervention to prevent and/or treat obesity?

A) Encouraging breast-feeding.

B) Decreasing screen time of electronic devices.

C) Planning fewer family meals.

D) Restricting calories from sweets and fast foods.

E) Improving efforts for exercise and outdoor activity.

Answer 14.6.3 The correct answer is "C." Helping with food preparation, and sitting down as a family for meals, can lead to consumption of more nutritious and lower calorie dense foods. Breast-feeding can lead to protection against obesity even into the teenage years. Formal recommendations suggest limiting TV, tablet, phone, computer use, and video games to less than 2 hours per day. Fast food, sweets, and desserts need to be limited to small servings or few servings per week. Finally, 60 minutes of exercise should be encouraged every day—doing a variety of activities will keep children more engaged and interested.

During the examination of the patient, you notice more acne than the past, some coarse facial hair, and dark skin pigmentation around the base of her neck.

Question 14.6.4 What is another finding you may expect to see with further questions and tests?

A) Normal menses.

B) Low free testosterone level.

C) Low DHEA sulfate (DHEA-S).

D) Hypoglycemia.

E) Abnormal hypothalamic–pituitary axis hormones.

Answer 14.6.4 The correct answer is "E." She is showing signs of possible polycystic ovarian syndrome (PCOS). This can be associated with elevated prolactin, low TSH, and a marked elevation of FSH relative to luteinizing hormone (LH). PCOS can be associated with early menarche, dysmenorrhea, and amenorrhea. A pregnancy test should be done in any case of amenorrhea. PCOS is also associated with elevations of testosterone, DHEA-S, and androstenedione. If there are other significant physical examination findings such as elevated blood pressure, purple striae, and a "buffalo hump," consider screening for Cushing syndrome.

Her obesity is discussed openly during the office visit. As expected, she is ashamed and embarrassed about her weight gain. She admits to not knowing what to do and she asks if anything can be done to quickly lose weight.

Question 14.6.5 Which of these medications would you recommend now as a first-line therapy for weight loss?

A) Topiramate (Topamax).

B) Bupropion (Wellbutrin).

C) Orlistat (Xenical).

D) Sibutramine (Meridia).

E) None of the above.

Answer 14.6.5 The correct answer is "E." No medication is approved for children or adolescents as a first-line therapy. Antidepressants are not helpful if used primarily for weight loss. If there is comorbid depression, which is more common in obese children, a "weight loss" or "weight neutral" antidepressant may be appropriate. Antiepileptic medications have not proven helpful. Sibutramine was pulled off the market in 2010 due to troubling cardiac side effects, but was not approved for use in children anyway. Orlistat is approved for children age 12 and older. Yet, the benefits are limited to an additional 2 to 3 kg of weight loss. Side effects are often intolerable and include loose, oily stools and stool urgency (just mention the phrase "fecal incontinence" to a teenager and see how far you get). Experts agree that orlistat is only appropriate for adolescents with comorbidities caused by obesity.

Objectives: Did you learn to…

• Define "overweight" and "obesity" in an adolescent?

• Identify risk factors associated with obesity in an adolescent?

• Manage an adolescent with a weight problem?

You have watched your patient transform over the years from a rather normal-appearing boy into a very large, muscular, and intense young man. He is now 17 years old, and he has gained almost 45 lb in the last year alone as he prepares for his senior year of football and attempts to attract the attention of college recruiters. Without a doubt he has worked very hard on the field and in the weight room, but you also must raise the question of whether or not he has used some kind of supplement to help him change so drastically.

Question 14.7.1 Which of these substances is NOT prohibited by high school athletic associations or the NCAA?

A) Erythropoietin.

B) Creatine.

C) Androstenedione.

D) Ephedrine.

E) DHEA.

Answer 14.7.1 The correct answer is "B." Creatine is allowed for use as a dietary supplement for athletes. However, the American College of Sports Medicine (ACSM) does not recommend the use of creatine in any athlete less than 18 years old. An estimated 8% of children 14 to 18 years old take creatine routinely. The NCAA does not allow colleges to provide athletes with creatine, but athletes can take it if they choose. All the other listed supplements are prohibited for use as performance-enhancing supplements. Other prohibited substances include anabolic steroids, pseudoephedrine, and blood transfusions.

Your patient does admit to using regular protein shakes and taking creatine. He denies the use of any illegal or prohibited substances and says he would never do anything dangerous. During his examination, his blood pressure is 146/92 mm Hg and his lab results show normal electrolytes, normal TSH, normal urinalysis, BUN 22 mg/dL, and creatinine 1.6 mg/dL (marked elevation for age 17).

Question 14.7.2 What is a possible side effect from the use of creatine?

A) Gastrointestinal discomfort.

B) Edema.

C) Muscle cramps.

D) Acute renal insufficiency.

E) All of the above.

Answer 14.7.2 The correct answer is "E." All are potential adverse effects from creatine use. Most importantly, if used carelessly, creatine can lead to acute renal insufficiency. Creatine is excreted via the kidneys, and if overconsumed in the setting of dehydrating exercise, it can cause renal injury. Seventy-five percent of adolescent athletes who take creatine are either unaware of the proper dose or knowingly take too much. If used, plenty of water is required to help avoid troubling side effects.

Question 14.7.3 All of the following substances can provide potential athletic performance benefits, except:

A) Human growth hormone (HGH).

B) Caffeine.

C) Creatine.

D) Electrolyte replacements.

E) Sodium bicarbonate.

Answer 14.7.3 The correct answer is "A." HGH has no proven benefits for enhancing sports performance. Other substances with no proven benefits include amino acids, beta-hydroxy-beta-methylbutyrate, androstenedione, DHEA, chromium, and iron (when not iron deficient). The other substances can provide short-term or long-term benefits. Caffeine has only a transient effect to help sharpen focus and intensity for brief periods of activity. Creatine can improve strength for those sports that require very short bursts of intense effort. Electrolyte replacement drinks (or tablets) and sodium bicarbonate can help for more prolonged endurance activities where dehydration and resulting electrolyte imbalances are common.

Your patient denies using "steroids," but does know of older guys in the gym where he trains who have routinely used anabolic steroids.

Question 14.7.4 Besides the obvious added muscle girth, what are some other potential benefits of anabolic steroids for athletes?

A) Improved lipid profile.

B) Taller stature.

C) Anxiety relief.

D) Lower blood pressure.

E) None of the above.

Answer 14.7.4 The correct answer is "E." There are no other clear benefits of anabolic steroids if used for athletics only. Potential negative effects include lower HDL, elevated blood pressure, left ventricular hypertrophy, gynecomastia, aggressive or even suicidal behavior, azoospermia, virilization of females, premature physeal closure in adolescents that could lead to shorter stature, and acute myocardial infarction. Approximately 33% of anabolic steroid users are not even athletes and use the substance to help improve physical appearance. Estimates in high school athletes show steroid use to be about 4% in males and about 2% in females. The temptation to use the illegal substance is driven by pressures to be better than peers, to fulfill one's "full potential," to live up to sports idols, and to help acquire college scholarships and/or sports contracts at a young age.

Objectives: Did you learn to…

• Describe the effects of some common performance-enhancing drugs?

A 14-year-old female comes into the office with a chief complaint of headache. She says the headache began after her soccer game yesterday. She recalls striking her head against an opponent when trying to head the soccer ball. During the remainder of the game, she began to feel a headache, and the harder she ran, the more "woozy" she felt. She denied any loss of consciousness, vomiting, visual symptoms, or neck pain. Today, she also has poor concentration and feels excessive fatigue.

Question 14.8.1 Which of the following is NOT a feature of an acute concussion?

A) Caused by an impulsive force transmitted to the brain.

B) Symptoms usually resolve spontaneously.

C) There is a functional disturbance to the body.

D) Neuroimaging always shows abnormalities.

E) Clinical symptoms are highly variable and inconsistent.

Answer 14.8.1 The correct answer is "D." There may be no evident structural brain injury with an acute concussion. Evidence suggests that multiple concussions, or even lessor repetitive head injuries (such as with soccer "heading") can eventually lead to structural tissue damage. The symptoms of concussions have a rapid onset and can vary from short-lived impairment to prolonged post-concussive symptoms. Studies are showing that younger athletes tend to have more severe symptoms and recover more slowly than older, college-aged athletes. This is likely due to the more dynamic brain growth in younger children and adolescents.

Question 14.8.2 Which of the following treatments is key for your patient with a concussion?

A) Early return to aerobic exercise—today if possible.

B) Ibuprofen 800 mg every 8 hours as needed.

C) Avoiding excessive sleep.

D) Aspirin 325 mg daily as needed.

E) Full cognitive rest (put down that smartphone, tablet, and social media!), even missing school if needed.

Answer 14.8.2 The correct answer is "E." The initial and key step in caring for patients with a concussion is full physical and cognitive rest. Very often, a return to the classroom can aggravate or prolong concussive symptoms. Once symptoms are clearly improving at rest, the student-athlete can get back to class and slowly be re-acclimated to physical activity. Sleep can provide a means of allowing the brain to rest and heal. No medications have proven helpful in alleviating the effects of a concussion. NSAIDs, aspirin, or acetaminophen may help with headache or pain.

Question 14.8.3 In which case of head injury would neuroimaging be appropriate?

A) Ongoing mild headache for several days.

B) Poor memory of the recent game and the events of the injury.

C) Any new seizure activity.

D) Loss of consciousness for less than 30 seconds.

E) Mild irritability, depressed mood, and insomnia.

Answer 14.8.3 The correct answer is "C." Seizure activity after head trauma or concussion requires imaging. Other symptoms that should prompt a head CT include severe headache, focal neurological symptoms, repeated emesis, difficulty arousing, slurred speech, prolonged poor orientation, concurrent neck pain, significant irritability, loss of consciousness for over 30 seconds, and any new neurologic or escalating symptoms. The initial study is normally a head CT, but if presenting after 48 hours from injury, a brain MRI is more suitable. Remember that the vast majority of concussion cases will not require imaging.

Question 14.8.4 Which of the following elements of past medical history may be relevant for this adolescent patient following her concussion?

A) Depression.

B) Generalized anxiety disorder.

C) Attention-deficit hyperactivity disorder (ADHD).

D) Migraine headaches.

E) All of the above.

Answer 14.8.4 The correct answer is "E." All of these conditions could be negatively affected by a concussion. Concussions can cause a temporary mood disorder and certainly aggravate depression and anxiety. Commonly, concussions will cause decreased concentration and inattentiveness. Teens who already have ADHD will likely have worsened symptoms and may need modification of their treatment. The headache of post-concussive syndrome may overlap or intensify an underlying headache diagnosis. Concussion may act as a trigger causing an increase in pre-existing migraines.

Your patient is an accomplished soccer player and feels a lot of pressure to return to action. She wants to play in the next game, and her coach and teammates are asking if she'll be back to practice this afternoon—which explains why your waiting room is so full of teenage girls wearing shin guards.

Question 14.8.5 What is your best advice about her return to practice and play?

A) "Go back to practice today, but take it slow and avoid full speed play."

B) "Try to participate in simple drills and just cheer on your teammates."

C) "Go home and engage in cognitive rest (is "engage in" and "rest" an oxymoron?). May return to activity with graded return to play regimen once symptoms resolve."

D) "Return to full, unrestricted team play as your soccer team needs you!"

E) "Do whatever you want."

Answer 14.8.5 The correct answer is "C." Her return to participation needs to be a graded return to activity. Each step of the recovery may be 24 hours. If she advances her activity to the next level and has recurrence of symptoms, then she needs to go back to the prior recovery step. The first stage of recovery is no activity—complete physical and cognitive rest. The next step is return to full academic activities. Step three is light aerobic activity, followed by sport-specific drills. Next, the player can return to non-contact practice. If still symptom free, then she can return to full speed, contact practice. Finally, she can return to game action. If exertion causes any return of symptoms, then she is not ready and should return to the stage in which she was symptom free. Even with normal neuropsychiatric tests, symptomatic athletes should not play.

The above steps should be followed with the assistance of a health-care provider or a qualified athletic trainer. The athlete cannot be put in the position of making the decision about how fast to return to regular play. After a first concussion, the player needs to be watched for other episodes. Two or more concussions have been shown to lower grade point averages and three or more concussions may cause prolonged symptoms over 3 months in duration.

Objectives: Did you learn to…

• Define concussion and recognize its importance in adolescent athletes?

• Treat a patient with concussion?