Part 13. Special Health Problems 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
- adolescence´Â
increased emotionality, hypothetical thinking, empathyÀÇ ½Ã±â
- 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
- ½ÉÇÒ ¶§´Â disturbance of eating
& sleeping
Clinical Manifestation
#
¡ÚFive 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
- incidence´Â femaleÀÌ ¸¹Áö¸¸ ¼º°øÀ²Àº
maleÀÌ ¸¹´Ù
#
method of suicide
; *ingestion of medication
-
*¡ãcommon
-
tricyclic antidepressant
/
*¡ãcommon
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
¡ÚTable
105-2
-
induction of hepatic smooth endoplasmic reticulum by barbiturates or alcohol
¡æ
metabolism Áõ°¡, glucuronidationÀ» ÇÊ¿ä·Î ÇÏ´Â
substanceÀÇ excretionÁõ°¡
ÀÌ·¯ÇÑ
abuse°¡ estrogen-containing oral
contraceptive¸¦ ¸ÔÀ¸¸é pregnancy
µÇ±â ½±´Ù.
¹Ý¸é¿¡ estrogenÀ» »ç¿ëÇϸé
alcohol metabolismÀÌ °¨¼ÒÇÏ¿© alcohol
intoxicationÀÇ À§Ç輺ÀÌ ÀÖ´Ù
- alcohol + metronidazole ; abdominal
pain, vomiting
105.1 Opiate
Pharmacology
#
euphoria & analgesia
#
¡ÚTime for Desired effects
- inhaled ; 30ºÐ
- 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
GI
;
constipation, hepatic enzyme activityÁõ°¡
Infection
;
cerebral microabscess or endocarditis (S.aureus)
Immunologic
;
*IgM ¡è (IV »ç¿ëÀÚ)
;
IgA ¡è (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 PSVT°¡ ÀÖÀ»¶§ physostigmine
salicylate·Î Ä¡·á
105.3 Volatile Substance
Airplane Glue
; *toluene
-
main ingredient
-
excreted rapidly in the urine as hippuric acid
; tolerance & physical
dependence
; ¡ÚToxicity
-
acute
/
relaxation, pleasant hallucination up to 2hr
/ cerebral or
pulmonary edema, myocardial involvement
¡æ »ç¸Á¿øÀÎ
-
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¡æviolent 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 ¡é,
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
- ÀÓ½ÅÁß º¹¿ëÇϸé premature, low birth
weight
- congenital malformation, developmental
disorder
105.6 Cigarette Smoking
- 13% of adolescent
- chronic cough, phlegm preduction,
wheezing
- ÀÓ½ÅÁßÈí¿¬ ; fetal weight Æò±Õ
200g ³·¾ÆÁü
- smoking + oral contraceptive ;
myocardial infarction
- induce hepatic smooth endoplasmic
reticulum
- WBC, Hb, Hct, MCV, plt aggregation ¡è
- Cr, albumin, globulin, uric acid ¡é
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
¡æ excess synthesis of triglyceride
¡æ fatty liver
¡æ necrosis ¡æ
inflammatory process ¡æ fibrosis
2nd
pathway
¡¤microsomal
system of the liver
¡æ
cofactor is reduced nicotinamide-adenin dinucleotide phosphate
¡æ
decreased metabolism of drug
2) Clinical manifestation
- CNS depressant, euphoria, grogginess,
talkativeness, impaired short term
memory, pain threshold¡è,
vasodilation, hypothermia, respiratory depression,
diuretic effect
- withdrawal synd ; 8½Ã°£ ÈĺÎÅÍ ½ÃÀÛÇÏ¿©
48½Ã°£À» ³ÑÁö ¾ÊÀ½, 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
- alcoholismÀÌ ¾ø´Â °æ¿ì
liver°¡ 400mg/dlÀ»
zero·Î °¨¼Ò½Ã۴µ¥ 20½Ã°£ °É¸°´Ù
- blood level 400ÀÌ»óÀÏ ¶§
dialysis°í·Á
- Tx of alcohol withdrawal ;
chlordiazepoxide(librium)
105.8 Anabolic Steroid
;
for enhanced athletic performance
;
¡ÚToxicity
- 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%´Â 13¼¼ ÀÌÀü
- low socioeconomic level
;
*bulimia is more common than AN
Diagnosis
#
¡ÚDSM-IV Criteria Of AN
1) intense fear of becoming
obese(weight loss°¡ ÁøÇàµÇ¾îµµ °¨¼ÒÇÏÁö ¾ÊÀ½)
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
#
¡ÚCharacteristics of AN
; excessive physical
activity, denial of hunger, preoccupation with food preperation, bizarre eating
behavior, studiousness, academic success
#
¡ÚDSM-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 ¡é, somatomedin C¡é
; *TSH normal, T3¡é, reverse T3¡è
;
peripheral edema ; inappropriate secretion of ADH
;
BUN¡è, ESR¡é
; *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
-
ÀÌÀ¯
/
protein intake is relatively good
/
low estrogen & elevated cortisol
;
bone density may be abnormally low (estrogen¡é, Ca¡é,
cortisol¡è)
;
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
¡æ
prevent the surge of LH
¡æ
inhibit ovulation
#
¡ÚComplication
; *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)
; *3°³¿ù ¸¶´Ù
Åõ¿©
#
long acting progestational agent
; *lovonorgestrel(Norplant), implanted subcutaneously
; *potency remains for 5yr
Postcoital Contraception
- 72½Ã°£À̳»
#
*Norgestrel(Ovral)
; two pills initially after
coitus and two additional pill 12hr later
Intrauterine Device
;
97-99%
#
¡ÚComplication
; ectopic pregnancy,
increased menstrual bleeding, increased dysmenorrhea, infection¡è,
septic abortion & death¡è
Chapter 110. Sexually Transmitted Disorder
#
adolescents
; *¡ãhighest 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 ¡æ
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, 42°¡ ÁÖ·Î °¨¿°À» ÀÏÀ¸Å²´Ù
;
Treatment
- *trichloroacetic acid 85%
/
three times each week
/
*¡ãbest
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 ; 3°³¿ùÀÌ»ó
mens ¾øÀ½
- menarche normally ; 10-16¼¼
- menarche normally ; 10-16¼¼
#
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¡è, LH¡è ; 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
#
¡ÚPrimary Amenorrhea + Advanced Pubertal Development
; *imperforate hymen
-
*¡ãcommon
-
*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¡è)
;
Sertoli-Leydig cell or lipoid cell tumor
#
secondary amenorrhea
; pregnancy
; *drugs - phenothiazines, opiates
111.2 Menometrorrhagia
;
excessive menstrual bleeding
Dysfunctional Uterine Bleeding
; *¡ãoften
; 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 excessiveÀ϶§
°í·ÁÇØ¾ß ÇÑ´Ù.
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 cycle¶§ ½ÃÀÛ
mens½ÃÀÛÇÏ¸é¼ »ç¶óÁü
- 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
; *¡ãcommon breast disorder
of adolescents
; *´ëºÎºÐ benign cyst or
fibroadenoma
; mass°¡ Áö¼ÓµÇ°Å³ª
°è¼ÓÁõ°¡Çϸé 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¡è
; amenorrhea-galactorrhea synd
Chapter 113. Skin Problem
- acne ; tetracyclin or cis-retinoic acid
(Ä¡·áÀü¿¡ Àӽſ©ºÎ È®ÀÎ)
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 sediment¿¡¼
polymorphonuclear leukocyte°¡ º¸ÀÌ¸é ´ÙÀ½°ú °°Àº °¡´É¼º
ÀÌ ÀÖ´Ù
; cervicitis,
vaginitis, urethritis, asymptomatic infection of the urinary tract
- ÃʰæÈÄ IDA°¡ Àß¿À¹Ç·Î
hematocrit¸¦ ¸Å³â °Ë»çÇÑ´Ù
- 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 ÀÌ»ó
; hypertension
two standard
deviation ÀÌÇÏÀ϶§ anorexia nervosa & addison ds¸¦ ÀǽÉÇØ¾ßÇÑ
´Ù
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