Part 13. Special Health Problems During Adolescence

PART XIII. Special health problem during adolescence

PART XIII. Special Health Problem During Adolescence

Chapter 102. Epidemiology Of Adolescent Disease

; *violence(accident, homicide, suicide)

- *70% of all adolescent death

- neoplasm(7%) ; testicular tumor & tumor of bone or lymphatics

- infectious ds and disease of congenital nature(7%)

; Health-destructive behavior

; Eating disorder ; anorexia nervosa, bulimia

; automobile & motorcycle accident

- *63% involve passengers in cars

- alcohol is factor underlying most vehicular fatalities

- *male predominant

- occur between 8:00pm and 4:00am

; sports injury & accidental drwoning

Chapter 103. Depression

- adolescence는 increased emotionality, hypothetical thinking, empathy의 시기

- mood swing

- at least 3 consecutive hours for three periods or more each week

Diagnosis

- Symptom of depression ; falling school grade, increase in school absentecism or truancy,

use of alcohol or drug, accident proneness, pervasive boredom

- 심할 때는 disturbance of eating & sleeping

Clinical Manifestation

# ★Five Forms

1) normal depressive mood swings

2) acute depressive reaction ; after death or sepatation from a loved one,

equivalent of a healthy grief response

3) neurotic depressive disorder ; feeling of hopelessness & helplessness, of

self-incrimination

4) masked depression

; variant of neurotic depressive disorder

; denial & somatization

; *acting out behavior

- running away from home, school truancy, multiple accidents, substance abuse

; headache, abd. pain, physical complaints

; psychiatric management

5) Psychotic depressive disorder ; impaired reality testing thought distortion,

delusion of guilt

CHAPTER 104. Suicide

- 3rd leading cause of death among 15 to 19 yr old

- incidence는 female이 많지만 성공율은 male이 많다

# method of suicide

; *ingestion of medication

- *▲common

- tricyclic antidepressant

/ *▲common agents

- an attempt by a teenager with a family history of suicide is particularly significant

# Impulsive Adolescents

; *less serious commiting suicides

Chapter 105. Substance Abuse

Epidemiology

- decrease in the use of marijuana, amphetamine, methaqualone, lysergic acid

diethylamide(LSD), barbituate, tranquilizer, PCP, heroin

- inhalant ; stable at 4% since 1980

- the use of cocaine doubled between 1975 & 1979

- alcohol use ; 93% of high school senior

69% within the previous month

5.5% daily use

# smoking

; 29% in 1977, 12% by 1991

; *female more regular smoke than male

Etiology

- the desire to explore the limits of emotionality

the need to try on new adult role

the wish to expand one's consciousness

availability of drug

desire to escape an unpleasnat or stressful experiance

peer pressure

Pathogenesis

- 1/3 of adolescent female who use heroin have secondary amenorrhea

- endogenous opiates block the release of gonadotropin-releasing hormone

- amphetamine interfere with stage 4 sleep

Table 105-1

★Table 105-2

- induction of hepatic smooth endoplasmic reticulum by barbiturates or alcohol

→ metabolism 증가, glucuronidation을 필요로 하는 substance의 excretion증가

이러한 abuse가 estrogen-containing oral contraceptive를 먹으면 pregnancy

되기 쉽다. 반면에 estrogen을 사용하면 alcohol metabolism이 감소하여 alcohol

intoxication의 위험성이 있다

- alcohol + metronidazole ; abdominal pain, vomiting

105.1 Opiate

Pharmacology

# euphoria & analgesia

# ★Time for Desired effects

- inhaled ; 30분

- subcutaneous ; within minite

- IV ; immediate effect

# constipation , miosis

Clinical manifestation

Neuromuscular

- euphoria, diminution in pain, lowering of body temperature, trasverse myelitis

of the thoracic segment, rarely G-B synd, toxic amblyopia

Cardiovascular

; vasodilation

Respiratory

; respiratory depression (alveolar underventilation)

Dermatologic

; track(hypertrophic linear scar), fat necrosis, lipodystrophy

Genitourinary

; loss of libido, urinary retension

; constipation, hepatic enzyme activity증가

Infection

; cerebral microabscess or endocarditis (S.aureus)

Immunologic

; *IgM ↑ (IV 사용자)

; IgA ↑ (inhale the drug)

Withdrawal

;

- earliest sign ; yawning, lacrimation

- mydriasis, insomnia, goose fresh, cramping of the voluntary musculature,

hyperactive bowel sound & diarrhea, tachycardia, systolic hypertension, grand

mal seizure

- Tx ; short course of diazepam, methadone

Overdose Synd

- stupor, coma, seizure, miotic pupil, respiratory depression, cyanosis, pulmonary

edema

- opiate antagonist ; naloxone

105.2 Hallucinogen

- LSD, PCP, certain mushroom, jimsonweed

Phencyclidine

- arylcyclohexalamine

1) Clinical manifestation

- euphoria, nystagmus, ataxia, emotional lability

- within 2-3 min after smoking 1-5mg

- with dose of 5-15mg ; toxic psychosis, disorientation, hyperventilation, abuse

language

15mg ; comatose within 30-60min, alternating period of wakefulness, dystonic

posturing, muscular rigidity, myoclonic jerk, hypotension, generalized

seizure, cardiac arrythmia(plasma concentration, 40-200 g/dl)

2) Treatment ;

- diazepam(10-20mg orally, 10mg IM every 4hr)

- ammonium chloride ; 500mg every 6hr

- maintain urinary PH 5.5-6

Mushrooms

; both cholinergic & anticholinergic effect, euphoria, hallucination

Jumsonweed

- devil's weed, locoweed, stinkweed

- alkaloid(hyoscyamine + atropine, scopolamine)

- dose-related CNS & other anticholinergic effect

- restlessness, disorientation, desired hallucination

- dry mouth, dry hot skin, fever, mydriasis, cycloplegia, urinary retention, sinus

tachycardia, delirium, visual or auditory hallucination

- hypertension, convulsion, severe hallucination PSVT가 있을때 physostigmine

salicylate로 치료

105.3 Volatile Substance

Airplane Glue

; *toluene

- main ingredient

- excreted rapidly in the urine as hippuric acid

; tolerance & physical dependence

; ★Toxicity

- acute

/ relaxation, pleasant hallucination up to 2hr

/ cerebral or pulmonary edema, myocardial involvement

→ 사망원인

- chronic

/ *pulmonary hypertension, restrictive lung defect, reduced diffusion capacity, peripheral neuropathy, acute rhabdomyolysis, hematuria, tubular acidosis, cerebral and cerebellar atropy

Gasoline Sniffing

- ataxia, nausea, loss of consciousness, euphoria→violent excitement & coma

- chronic exposure ; irreversible encephalopathy, bone marrow aplasia

Volatile Nitrites

(amyl nitrite, butyl nitrite)

- headache, syncope, lightheadness, hypotension, cutaneous flushing,

vasoconstriction, tachycardia, inverted T wave, depressed ST segment,

methemoglobinemia, increased bronchial irritation, increased intraoccular

pressure

105.4 Marijuana

- resin of the cannabis sativa plants

- tetrahydrocannabinol(THC)fraction of the resin ; hallucinogenic properties,

absorbed rapidly by the nasal or oral route

Clinical Manifestation

- impairment of short term memory, poor performance of task requiring divided

attention, loss of critical judgment distortion of time perception, visual

hallucination, decreased temperature, tachycardia, tachypnea, systolic & diastolic

hypertension, reduction in bronchospasm, fall in intraocular pressure

# *dose-related suppression of plasma testosterone level & spermatogenesis

; minmum of 4day/wk for 6mo

- glucose tolerance ↓, antiemetic effect, appetite stimulation

105.5 Cocaine

- most expensive

Pharmacology

- rapidly absorbed from the nasal mucosa, detoxified by the liver, excreted in the

urine

- half life ; slight more than 1hr

Clinical manifestation

- euphoria, increased motor activity, decreased fatigability, paranoid ideation

- tachycardia, hypertension, hyperthermia

- tolerance, psychologic dependence

- 임신중 복용하면 premature, low birth weight

- congenital malformation, developmental disorder

105.6 Cigarette Smoking

- 13% of adolescent

- chronic cough, phlegm preduction, wheezing

- 임신중흡연 ; fetal weight 평균 200g 낮아짐

- smoking + oral contraceptive ; myocardial infarction

- induce hepatic smooth endoplasmic reticulum

- WBC, Hb, Hct, MCV, plt aggregation ↑

- Cr, albumin, globulin, uric acid ↓

105.7 Alcohol

- legal definition of intoxication ; blood ethanol level - 100mg/dl(0,08%, 0.1%)

1) pharmachology & pathophysiology

- rapidly absorbed from the stomach

- two pathway

primary pathway

·removal of two hydrogen atom to form acetaldehyde

·removed hydrogen atom supply energy

→ excess synthesis of triglyceride

→ fatty liver

→ necrosis → inflammatory process → fibrosis

2nd pathway

·microsomal system of the liver

→ cofactor is reduced nicotinamide-adenin dinucleotide phosphate

→ decreased metabolism of drug

2) Clinical manifestation

- CNS depressant, euphoria, grogginess, talkativeness, impaired short term

memory, pain threshold↑, vasodilation, hypothermia, respiratory depression,

diuretic effect

- withdrawal synd ; 8시간 후부터 시작하여 48시간을 넘지 않음, anxiety, tremor,

insomnia, irritability

3) Diagnosis

- >200 mg/dl ; risk of death

- >500 mg/dl(median lethal dose) ; fatal outcome

4) Tx

- usual mechanism of death ; respiratory depression

- alcoholism이 없는 경우 liver가 400mg/dl을 zero로 감소시키는데 20시간 걸린다

- blood level 400이상일 때 dialysis고려

- Tx of alcohol withdrawal ; chlordiazepoxide(librium)

105.8 Anabolic Steroid

; for enhanced athletic performance

; ★Toxicity

- liver abnormalities

/ hepatocarcinoma, peliosis hepatis, cholestasis

- endocrine

/ male-gynecomastia, testicular atropy

/ female-hirsutism, baldness, deepening of voice, breast atrophy, clitoral enlargement, acne

- cardiovascular

/ *increased LDL, decreased HDL

- fluid retention

- growth retardation

Chapter 106 Sleep Disorder

# maturational changen in adolescents

; *increase in daytime sleepiness & decrease in sleep latency

; *between SMR3 nd SMR4

- Narcolepsy often first become symptomatic during adolescence

attack of REM sleep during wakefulness with excessive day time sleepiness

hypnagogic hallucination

cataplexy, the sudden inhibition of tone of a muscle group

sleep paralysis

- insomnia ; 10-20% of adolescent, cause may be depression or the delayed sleep

phase syndrome

Chapter 107. Anorexia Nervosa & Bulimia

Epidermiology

- 1/100 female 16-18yr old

- one peak 14.5 & the other at 18yr

- 25%는 13세 이전

- low socioeconomic level

; *bulimia is more common than AN

Diagnosis

# ★DSM-IV Criteria Of AN

1) intense fear of becoming obese(weight loss가 진행되어도 감소하지 않음)

2) disturbance in the way in which one's body weight, size, or shape is experienced

3) refusal to maintain body weight

4) in females, absence of at least three consecutive menstrual cycle

# ★Characteristics of AN

; excessive physical activity, denial of hunger, preoccupation with food preperation, bizarre eating behavior, studiousness, academic success

# ★DSM-IV Defining Bulimia

1) recurrent episode of binge eating

2) during the eating binges, a fear of not being able to stop eating

3) regularly self-induced vomiting, use of laxatives, rigorous diets

4) two binge eating episode per week for at least 3mo

5) self-evauation is unduly influenced by body weight & shape

Eiology & Psychodynamics

- AN ; excessive dependency, developmental immaturity, isolation, onset -

puberty, defense against emerging sexuality, problem in identity

development disorder of mood accompanied by manic or depressive

symptomatology

Clinical Manifestation

; death rate in AN : 10%

- caused by severe electrolyte disturbance, cardiac arrythmia, congestive heart failure in recovery phase

; *bradycardia, postural hypotension

; *hypothermia

; hypothalamic-pituitary-adrenal axis dysfunction

- increased secretion of cortisol, loss of diurnal variation in tis secretion, failure of dexamethasone to suppress it

; GH secretion ↓, somatomedin C↓

; *TSH normal, T3↓, reverse T3↑

; peripheral edema ; inappropriate secretion of ADH

; BUN↑, ESR↓

; *bone marrow hypoplasia

- common in AN

- *leukopenia, anemia, thrombocytopenia

; constipation

; electrolyte imbalance

- due to vomiting, water loading, abuse of diuretics or laxative (potassium depletion, hypochloremic alkalosis)

; *remarkably resistant to infection

- 이유

/ protein intake is relatively good

/ low estrogen & elevated cortisol

; bone density may be abnormally low (estrogen↓, Ca↓, cortisol↑)

; skin ; dry, lanugo hair

; hair loss

Treatment

; current use combine psychotherapy

Chapter 108 Pregnancy

Chapter 109 Contraception

Barrier Method

Condom

; acceptance of this method is low in this age group

Diaphragm

- preventing access of sperm to the cervix

- placing spermicidal jelly in a position to be effect

- effective in only 85%

Cervical Cap

Spermicide

; *nonoxynol-9

; contact vaginitis - rare side effect

Combination Methods

- condom by the male, spermicidal foam by the female, failure rate-2%

- toxic shock synd has been reported in user of the sponge

Hormonal Methods

- estrogen-progestin combination

→ prevent the surge of LH

→ inhibit ovulation

# ★Complication

; *thrombophlebitis, hepatic adenoma, myocardial infarction, carbohydrate intolerance

; post pill amenorrhea

; *higher levels of HDL

# contraindication

; hepatocellular da, migrane headache, DM, hypercoagulobility

# *pregnancy rate - 0.8% per yr

# injectable pregestin

; *medroxyprogesterone(Depo-Provera)

; *3개월 마다 투여

# long acting progestational agent

; *lovonorgestrel(Norplant), implanted subcutaneously

; *potency remains for 5yr

Postcoital Contraception

- 72시간이내

# *Norgestrel(Ovral)

; two pills initially after coitus and two additional pill 12hr later

Intrauterine Device

; 97-99%

# ★Complication

; ectopic pregnancy, increased menstrual bleeding, increased dysmenorrhea, infection↑, septic abortion & death↑

Chapter 110. Sexually Transmitted Disorder

# adolescents

; *▲highest rate of STD of any age group

Gonorrhea

- via the urethral, cervical, anal, pharyngeal, conjunctival route

- extension along mucosal plane, hematogenous dissemination

; drug of choice

- *ceftriaxone

Syphilis

; VDRL

- most sensitive, least specific

- false posivite results

/ IV abusers

/ liver disease

/ collagen-vascular disease

/ IM

- second stage ; condyloma latum, lesion on the palm & sole

Chlamydia

- most cases of urethritis, previously called nongonococcal

; Treatment

- *cefoxitin 2g iv twice a day for 10days

- *doxycyclin

/ *specific for chlamydia

/ 100mg iv twice for 10 days

Chancroid

- vesicopustule → painful, purulent, sharply delineated, ulcer without induration

- ceftriaxone

Herpes Progenitalis

- sharp pain radiating from the perineum along the course of affected nerve root

- acyclovir

Human Papilloma Virus

- genital wart(condyloma acuminata)

- subclinical infection

- the potential for oncogenic progression

- type 6, 11, 42가 주로 감염을 일으킨다

; Treatment

- *trichloroacetic acid 85%

/ three times each week

/ *▲best chemical treatment

- *liquid nitrogen & podophyllin

- topical 5-fluorouracil, bleomycin, interferon, carbon dioxide laser

Trichomonas

- frothy vaginal discharge

- metronidazole

Hemophilus(Gardnerella) Vaginitis

; *foul-smelling vaginal discharge

--> *fishy odor

; 10% KOH added

--> *clue cell (epithelial cells ringed with the rod-shaped organisms)

; Tx ; metronidazole

Chapter 111. Menstrual Problem

111.1 Amenorrhea

- primary ; menarche has never occured

- secondary ; 3개월이상 mens 없음

- menarche normally ; 10-16세

# Menarche

; SMR2 - 10%

; SMR3 - 20%

; *SMR4 - 60%

; SMR5 - 10%

- functional & anatomic integrity

the hypothalamus

anterior pituitary

ovary

uterus

Etiology

# Primary

; chromosomal or congenital abnormality (gonadal dysgenesis, triple-X syndrome, isochromosomal abnormality, testicular feminization synd, hermaphroditism)

- FSH↑, LH↑ ; primary gonadal failure

; chronic illness (primary or secondary amenorrhea)

- malnutrision, tissue hypoxia, DM, inflammatory bowelds, dystic fibrosis, cyanotic CHD

; CNS tumor

- craniopharyngioma

; hyperthyroidism

- cf)hypothyroidism - precocious puberty, menometrorrhagia

; anorexia nervosa

# ★Primary Amenorrhea + Advanced Pubertal Development

; *imperforate hymen

- *▲common

- *recurrent abdominal pain, midline abdominal mass, hematocolpos

- agenesis of the cervix or uterus in association with sacral agenesis

# amenorrhea + virilization

; adrenal or ovarian ds, abuse of anabolic steroid

# ovarian cause of virilization

; polycystic ovary synd(FSH-normal, LH↑)

; Sertoli-Leydig cell or lipoid cell tumor

# secondary amenorrhea

; pregnancy

; *drugs - phenothiazines, opiates

111.2 Menometrorrhagia

; excessive menstrual bleeding

Dysfunctional Uterine Bleeding

; *▲often

; secondary to the anovulatory cycle that normally occur in the 1st yr after menache

; Treatment

- *25mg norethynodrel(Enovid) po

/ *rapid effect within 2hr

congenital coagulopathy

; Von Willebrand ds

- *adolescent whose first menstrual period is excessive일때 고려해야 한다.

Aspirin

; disruptio of Platelet adhesiveness

Thrombocytopenia

Exogenous Hormones

; improper use of oral contraceptives

Thyroid Disorder

; *hypothyroidism

; rarely hyperthyroidism

Other Cause

; adrenal dysfunction, DM, estrogen-secreting ovarian tumor

; adenocarcinoma of vagina

- scant bleeding

; trauma, infection, pregnancy

111.3 Dysmenorrhea

- Secondary dysfunction

·underlying structural abnormality of the cervix or uterus, foreign body,

endometriosis, endometritis

- PGF2 & E2 ; stimulate the myometrium to contract producing pain

anproxen-sodium - destroying the PG

111.4 Premenstrual Synd

- second half of the menstrual cycle때 시작 mens시작하면서 사라짐

- breast fullness, tenderness, bloating, fatigue, headache, increase apetite,

irritability, mood swing, depression, inability to concentrate, fearfulness, violent

tendency

- Tx ; use of a gonadotropin-releasing hormone agonist

Chapter 112. Breast

# Mass

; *▲common breast disorder of adolescents

; *대부분 benign cyst or fibroadenoma

; mass가 지속되거나 계속증가하면 surgical consultation

; biopsy series

- 71% ; fibroadenima

- 11% ; abscess

- 2% ; cystosarcoma phyllodes

- multiple small lump, fibrocystic ds

- nipple discharge ; local stimulation use of medication, pregnant, pituitary or

brease neoplasm or infection

- serum prolactin level↑ ; amenorrhea-galactorrhea synd

Chapter 113. Skin Problem

- acne ; tetracyclin or cis-retinoic acid (치료전에 임신여부 확인)

Chapter 114. Orthopedic Problem

# more common disease in adelescents

; *slipped capital femoral epiphysis, Osgood-Schlatter ds., idiopathic scoliosis, chostochondritis of the sternoclavicular junction(Tietze synd)

# more common neoplasm in adolescents

; osteogenic sarcoma

# more common infection of bone & joints

; *complication of disseminated gonococcemia, sickle cell anemia

; *rubella, IM arthralgia

Chapter 115. Delivery Of Health Care To Adolescents

115.1 Legal Issue

115.2 Screening

- screening tests should be performed only if they are cost effective

Laboratory Test

; screening urinalysis & culture

- *indicated for female

- urinary sediment에서 polymorphonuclear leukocyte가 보이면 다음과 같은 가능성

이 있다

; cervicitis, vaginitis, urethritis, asymptomatic infection of the urinary tract

- 초경후 IDA가 잘오므로 hematocrit를 매년 검사한다

- estrogen supress erythropoietin

androgen have the opposite effect

; SMR 1 - male average Hct ; 39%

SMR 5 - male average Hct ; 43%

- tuberculosis testing on an annual basis

- sexually active adolescent

; screening for sexually transmitted ds., pap smear

2. Audiometry ; highly amplified music of the kind enjoyed by many adolescents

3. Vision testing ; the pubertal growth spurt may involve the optic globe,

resulting in its elongation and myopia in genetically

predisposed individuals

4. Blood pressure determination

; two standard deviation 이상 ; hypertension

two standard deviation 이하일때 anorexia nervosa & addison ds를 의심해야한

다

5. Scoliosis

- mild curvature of the spine ; 5% of male, 10-14% of female

- scoliosis is typically manifested during the peak of the hight velocity curve

(12yr in females & 14yr in males)

6. Breast exam

7. Scrotum exam

- peak incidence of germ cell tumor ; late adolescence & early adulthood

8. psychosocial