when assessing a 13-year-old adolescent, what is an expected finding?

Boyhood is a unique time of rapid physical, psychologic, sexual, social, and cognitive growth and development that distinguishes the boyish and his or her health care needs and expectations from those of the child or adult. Although puberty cannot exist precisely defined by chronologic age, the process usually has its onset and completion during the second and the early part of the third decade of life, spanning approximately ten to 24 years of historic period.

To provide comprehensive health care (acute episodic, continuous, and preventive) for this age group requires the md to have a general working noesis of the onset, sequence, characteristics, and interrelationships of the disquisitional features of pubertal growth and development. Perhaps more whatever other period in life, an effective synthesis of each of these components is required for optimal health intendance resulting in "a state of complete physical, mental, and social well-being" (Deliege, 1983) rather than only the absence of disease. Equally important is for the physician to have a desire and aptitude for working with this age grouping.

This chapter focuses on the major elements of the pubertal procedure that ascertain the unique features of the history, physical test, laboratory evaluation, health instruction, and preventive medicine in the adolescent as compared to the kid or the adult.

The Pubertal Process

Primary Hormone Changes

The precise trigger for the onset of puberty is not known, but much is known about the process. Current data suggest that the first chemical bear witness of puberty is an increase in the production and release of dehydroepiandrosterone (DHEA) and its sulfate (DHEA-S) past the adrenals (adrenarche). The initial ascension commonly occurs between 7 and ix years of age in both the male person and female followed by a progressive increment to adult levels.

The side by side identifiable event begins ane to ii years after adrenarche when the hypothalamic-pituitary system begins to exhibit a diminished sensitivity to the prepubertal levels of the gonadal steroids, primarily estradiol and testosterone. This results in an increased production and release of gonadotropin releasing hormone (GnRH) by the hypothalamus. As a result of these increased levels of GnRH and an apparent increase in the pituitary's sensitivity to this peptide, there is an increase in the production and release of luteinizing (LH) and follicle stimulating hormone (FSH). At the onset, the increase in LH and FSH occurs just during not-REM sleep, only, with fourth dimension progresses to a persistent increase throughout the day. These changes stimulate the growth and hormone production of the gonads, primarily testosterone, estradiol, dihydrotestosterone, and delta-four-androstenedione. These hormones steadily increase to adult levels over a flow of near iii years in the male and 4 years in the female. For those who progress most rapidly (5th percentile) and the slowest (95th percentile), the years are respectively for the male most ane.9 and four.7 years and for the female person 1.5 and 9.0 years.

During puberty the 24 hour integrated concentration of circulating growth hormone (GH) increases. Beginning at about 10 years of age, the circulating levels of insulin-like growth factor I (somatomedin C), begin to rising with a peak at virtually the fourth dimension of the maximum increase in top and weight during puberty, that is, the year of peak height velocity (PHV) and superlative weight velocity (PWV).

Thyroxine, triiodothyronine, cortisol, glucagon, insulin, and parathyroid hormone do not increase significantly, but normal levels of these hormones are an important part of the internal milieu since they serve permissive and/or facilitative roles for the primary hormones of puberty to produce normal growth and development.

Physical Growth

During puberty all trunk parts normally increase in size with the exception of the thymus, tonsils, and adenoids, which decrease in size. Normally, the linear growth of puberty accounts for 15 to 25% of an private's developed height, while the growth in weight accounts for close to 50% of an "ideal" developed body weight.

The majority of this height and weight increase occurs during a 36-month period that includes the year of top growth (i.e., PHV and PWV). During this 36-calendar month span, the 3rd to 97th percentiles for linear growth in males are 15.4 and 28.2 cm and in females xiv.ii and 26.2 cm respectively. For weight, these values are 12.3 and 30.8 kg in males and 10.3 and 26.one kg in females. The PHV and PWV unremarkably occurs about 18 to 24 months earlier in the female than the male.

The major contributors to the proceeds in weight are the lean, fat, and bone masses. The male and female increases in these components differ quantitatively and qualitatively. The most striking differences are in muscle and fat. In the pubertal male person there is about a 7-fold increment in muscle mass compared to a 3- to 5-fold in the female person. Superlative musculus growth unremarkably occurs within 6 to 12 months of the PHV yr with the superlative increment in forcefulness coming 12 to 18 months after PHV. In the pubertal female in that location is a 4 to 10% increase in the percentage of full torso weight as fatty compared to a 5 to 7% decrease in the male.

Bone mass increases in parallel with muscle mass, and the epiphyses of the hands, wrist, and long basic progressively fuse during puberty. The hand and wrist epiphyses are usually closed in the female person by age 17 years and in the male by nineteen years. Once this fusion is consummate, information technology is rare for an individual to grow more than than some other 3.75 cm in height.

Every bit observed by Tanner (1962), the typical sequence of events is: lengthening of the legs, followed by a widening of the breast and hips, then a broadening of the shoulders (males > females), followed by a lengthening of the trunk and the anterior posterior width of the thorax. Superlative growth typically occurs within a 12- to 18-month span for all these parameters.

The striking facial changes during puberty are the outcome of an increment in the length and width of the face, peculiarly the mandible, which ordinarily peaks in growth within half-dozen months of PHV. In add-on, the olfactory organ and pharynx grow in length and the hyoid bone moves to a lower position than during childhood.

Secondary Sexual Growth

For the body-conscious teenager, the evolution of secondary sexual characteristics is an of import and easily observed milestone in the pubertal procedure. For almost all males (~98%), the first physical bear witness of beginning puberty is an enlargement of the testes and for virtually fourscore% of females the appearance of palpable breast tissue nether the areola (breast budding). For the residue, pubic hair is the first physical bear witness of puberty. There is also a progressive growth of axillary hair in both sexes, and in the male person the phonation lowers and a beard begins with the mustache of puberty. In that location is virtually a 7-fold increase in the size of the male'due south testes, epididymis, and prostate and the female's uterus and ovaries. A substantial increase as well occurs in the size of the areola and penis in the male and the areola, breasts, labia, clitoris, vagina, and fallopian tubes in the female.

The uniformity of the sequence of gonad (G) and pubic hair (PH) development in the male and chest (B) and pubic hair in the female allows these components to be staged (i.eastward., clinically quantified). Since the PH and G or B stages do not necessarily develop or progress in unison, each should be staged separately for the greatest accurateness. The standard system adult by Tanner et al. in the 1960s with minor modifications is shown in Table 223.i.

Table 223.1

Staging Criteria for Secondary Sexual Development.

The onset and progression of these changes vary between the sexes and within the same sex. The mean age of onset and standard divergence plus the 5th and 95th percentiles for the intervals between stages are shown in Tabular array 223.2. An appreciation of these normal variations is crucial to appropriate and toll-effective evaluation and counseling of adolescents, particularly those who present with overt or covert concerns about their secondary sexual development.

Table 223.2

Mean Age of Onset and Time of Progression between Pubertal Events.

Menarche typically occurs during the rapid deceleration phase of linear growth, that is, half-dozen to 12 months after PHV, unremarkably betwixt PH phase iii and 4 and B phase iv and v. Menstrual periods are commonly irregular, as is ovulation for the first 12 to 18 months and occasionally upwardly to 3 to four years. Although minimal information are available, it appears that the male'due south showtime ejaculation may occur as early on as 12 years and G stage 2 with a median age of nigh 13 years and G stage 3.

Reproductive adequacy is present from the perimenarchial catamenia, only peak fertility ordinarily occurs after the completion of secondary sexual development. Males tin can impregnate a woman in one case ejaculation has begun, but routinely sufficient sperm in the ejaculate probably does non occur until near the completion of secondary sexual development.

Psychologic—Sexual—Social—Cognitive Development

Every bit the adolescent grows physically, he or she must also mature psychologically, sexually, socially, and cognitively. In this circuitous process, there is a dynamic interrelation amongst all these components likewise as the concrete. These nonphysical components too proceed along a continuum of development during puberty. They rarely proceed in unison and complete harmony. The onset and progression varies from individual to individual, and between the sexes. Unlike physical development, they may backslide besides as progress depending on ecology stresses.

In global terms, the adolescent must: (ane) emancipate himself/herself from the family, (2) have his or her adult torso (body image) and ability to procreate (sexuality), (3) develop an adult identity (cocky-prototype), (4) accomplish the skills required to function in society and be economically contained, and (5) develop adult patterns of thinking (integrative cognitive part). All are necessary if the person is to exist an effective adult and take a fulfilling life.

This procedure typically has its onset early in the second decade of life and is usually completed in the early adult years. Some of the critical components in this process are depicted as a dynamic continuum in which all are interactive at whatsoever given betoken in time (Table 223.3). Although the stages of development in this arena cannot be assigned to a specific chronologic age, it may be useful to consider the 4 stages of development as early on, middle, tardily adolescence, and young developed.

Table 223.3

Continuum of Adolescent Psychologic, Social, Sexual, and Cognitive Development.

Early adolescence is characterized by (one) initial efforts to establish independence from the family, (2) beginning same-sexual practice peer relations, and (3) questioning 1'due south identity separate from the family. Developing independence from the family normally expresses itself as a reluctance or refusal to exist a compliant participant in family activities and to ascribe equal or greater importance to aforementioned-sex activity peer group activities. During this phase the peer group increasingly influences the adolescent's perception of acceptable beliefs and wearing apparel. Typically the adolescent'southward behavior is egocentric (selfish) and torso focused. His or her quest for personal identity unremarkably begins past questioning "Am I normal?" This in function is the basis for the increasing business organization about his or her changing body (i.due east., secondary sexual development, acne, blemishes, etc.). Ambivalence and insecurity are commonly observable hallmarks. The adolescent may at one moment or day shun the family unit and in the next seek its security, or be the best of friends with an private in the peer grouping and then suddenly view him or her as an enemy. Adolescents" time orientation is predominantly existential and their thinking concrete operational (i.east., the future and abstract idea are hard or incommunicable to comprehend, and logical thinking is ordinarily limited to a single detail of data). For example, the use of transverse or sagittal sections of the human body to explain menstrual and reproductive role typically cannot be effectively comprehended. For these adolescents, wellness is viewed simply as the absence of illness or blemishes.

Middle adolescence is the stage in which the adolescent is usually well established in the peer group and desires to be more than in conformity with it. Mixed-sex activities begin to increase. The teenager usually spends increasing fourth dimension abroad from the family and seeks more independence. This results in more overt challenges to authorization, rules, and established patterns of beliefs. These adolescents consider themselves to exist invulnerable and at times invincible. In this milieu, experimentation with drugs, alcohol, tobacco, dress, and sexuality brainstorm and unremarkably reach a peak. In addition, teenagers become more aggressive in seeking increasing autonomy and enervating privacy. Their time orientation continues to exist primarily existential, only their thinking begins to motion toward formal operational idea. They begin "thinking almost thinking" and may withdraw for hours to do and then. Philosophically, they tend to be idealistic and from the standpoint of identity begin to ask "Who am I?" Their business organisation almost body paradigm continues. Ambivalence and rapid fluctuations in mood are common, which tin be punctuated by hours to a few days of credible depression.

Socially, during this phase of development adolescents remain primarily egocentric. Although they brainstorm to recognize that those effectually them think and take feelings, they believe that all others with whom contact is made are focused on them, that is, they believe that they are being continually scrutinized by others, the so-chosen imaginary audience.

In relation to anticipatory health counseling, information technology is important for the physician to recognize that boyish–parent conflicts as well as risk-taking behaviors commonly superlative (i.e., a typical fourth dimension for family and schoolhouse crises that may be accompanied past physical signs and symptoms). During this stage, every bit in early on adolescence, the teenager primarily sees himself or herself as externally controlled (external locus of control) by parents, schoolhouse, and peer group, but an increasing perception of personal responsibility typically begins to emerge (internal locus of control) tardily in center adolescence.

Late adolescence is maybe best characterized as the adolescent'south beginning response to the question "Who am I in relation to those around me and to the future?" Personal independence from the family unit and formal operational thought continue to advance equally the teenager begins to more realistically consider such issues as future education, vocation, and adult sexual commitment. More consideration is given to the thoughts and feelings of others, including the parents. In that location is less peer group activity and delivery with nearly tardily adolescents developing two or three close friends of whom one is typically of the opposite sex. By this time, teenagers are unremarkably able to extrapolate from their experimentation during early and middle adolescence to related experiences in unlike settings. Their sense of invulnerability and constant scrutiny by others begins to assume more realistic proportions. An internal locus of control continues to develop as they realize their ability to provoke others to happiness, sadness, acrimony, or pleasure. At that place is less dependence on body image and a greater emphasis on sell-prototype as they begin to perceive themselves as both internal and external persons.

This is the time when they first begin to perceive conspicuously that they volition exist physically moving away from their abode and family, and bold increasing responsibility for varying degrees of economic separation, sexual commitment, work, or additional cocky-motivated pedagogy or training. They begin to experience the uncertainty of the hereafter. Consequently, it is the most common time for separation anxiety to become manifest in the form of physical signs and symptoms. For nearly youth, this process occurs smoothly and is commonly a time when the parents, despite their ain pains of separation, renew their conviction in the capabilities of their offspring.

The immature developed to adult phase, for most, primarily takes place away from the family. Private identity becomes stabilized, and intimate personal and sexual relationships are based on the ability to identify and attempt to understand the thoughts and feelings of another. The kickoff of a defined role in order begins to emerge, and an increasing sense of personal responsibleness and worth continues to develop. Effective and fulfilling independent function in an adult club signifies the completion of the process.

It is worth emphasizing that the progression forth the continuum of psychologic, sexual, social, and cognitive development varies. The onset and charge per unit of progression of each component differs from individual to individual and betwixt the sexes. Each major component should exist assessed by the doc caring for an adolescent, since optimal patient management may be positively or negatively afflicted by the adolescent'south status regarding his or her development in one or more components. For example, a teenage female may be in belatedly boyhood regarding her quest for independence, but in early or middle adolescence regarding her cognitive and identity development. Consequently, she may engage in sexual intercourse, but may be reluctant to seek medical communication about contraception or venereal disease because she feels she is nether constant scrutiny by all with whom she comes in contact, has little or no concept of the futurity, and believes "pregnancy can"t happen to me" (invulnerability).

An Approach to the Boyish Patient

As in all medicine, the medico's power to constitute an effective relationship with the patient is crucial. For an effective relationship to brainstorm, the physician must like teenagers, exist comfortable interacting with them, respect them as individuals, and be willing to relate to them in a non-judgmental fashion without being nondirective. The adolescent needs a wellness intendance advocate, not a surrogate parent or "buddy." In general, he or she expects the md to apply understandable adult linguistic communication and not the latest teen jargon. In the author'south stance, physicians who do non like or cannot cope effectively with adolescents should not include them in their do.

The physician must establish himself or herself as the teenager's personal physician. The beginning point is to establish the limits of confidentiality with the patient as well as his or her parent(s) or guardian either before or at the time of the initial visit, or for those previously seen as children at a defined age such equally ten years onetime. Statutes relating to confidentiality for teenagers vary from state to state and should be ascertained by the physician. In the author's opinion, confidentiality should be relative. One constructive argument is, "Our conversations volition be between you and me lonely unless I consider something to exist of danger to you or others. In such instances, although I volition not discuss it behind your back, I will share such information with your parent(s) and I will ask you to be present. Regarding your diagnosis and any treatment required, y'all and I volition hash out what you lot wish to be shared with your parent(s) and whether you, I, or both of us will talk with them nigh it." A clear statement in this regard provides the basis for a mutually trusting relationship betwixt the physician and the adolescent equally well equally the doc and the parent(s).

An obvious corollary to confidentiality is that the patient must be seen alone during all or part of the history and physical test. In the author'south view, the patient should be seen solitary for the history and nongenital parts of the physical exam unless the patient prefers to have someone else in omnipresence. For the genital portion of the examination, it is appropriate to let the patient to decide whether he or she wishes a parent, friend, or chaperone to exist present or to have total privacy. Finally, the physician's relationship with the adolescent should be growth promoting wherein the patient is expected to gradually assume increasing responsibility for his or her ain health intendance needs.

The Medical History

The generic components of the boyish medical history are the same every bit for the developed with specific attention to the immunization, nutrition, sexual, and social histories.

The sequencing of the interview is important. A parent who accompanies the patient should exist seen alone (1) to assess his or her perception of the patient'southward problem and (two) to obtain data regarding the patient'south nascency, developmental, and by medical and family histories. Thereafter, parents should non be seen without the patient unless the patient and so desires. Next, the patient is seen solitary for the remaining history and physical examination. Finally, the patient and the parent(s) are seen together to discuss the plans for further evaluation or therapy when required or to review the patient'south health status if no further evaluation or therapy is needed.

The history should be taken in a quiet private room. The format should be open, caring, nonjudgmental, friendly, and not appear to be a mechanistic interrogation. It is important to remember that what the dr. says tends to be far less important to the adolescent in an initial interview than how it is said. An initial focus on "getting to know" the patient with questions most activities, school, interests, or hobbies may be useful in reducing the patient'due south anxiety, but the beginning component of formal information gathering should be the reason for the visit (chief complaint) and the history surrounding it (history of present illness). The adolescent assumes that the main reason for being in that location is too the doc's primary business organisation and therefore may become suspicious and dislocated if the physician focuses get-go on an area that has no obvious relationship to the reason given for the visit.

The patient's level of cerebral evolution is an important consideration in history taking if optimal data is to exist obtained. For example, open up-ended or complex straight questions when asked of an boyish whose idea is primarily concrete operational will often generate an "I don"t know" or a "huh?" response. Consequently, in the writer'south feel, for most early and middle adolescents the most effective and efficient history gathering is achieved by using simple direct questions occasionally punctuated past a question requesting farther elaboration of a yes response if the teenager seems to be openly talking.

Critical components of the psychosocial history are the patient's role at dwelling house, at schoolhouse, and with peers. Selected useful questions to explore these areas are detailed in Table 223.4. In general, it is wise to avoid generic-type questions, such as, "Do you have a all-time friend or friends at school?" Such a question is almost invariably given a yes answer, thus potentially masking an underlying problem. A yes response may only hateful that the teenager speaks to some peers in the hallway and that they unremarkably speak in return; thus the data desired (Does the teenager have a peer group to run around with or a best friend to talk to?) is not provided. More revealing and pertinent questions are: "What is your best friend's name?" or "What are the names of the kids you run effectually with at schoolhouse?"

Tabular array 223.four

Key Features in Assessing Boyish Psychosocial Function.

In a patient with a background of behavior or personality problems in babyhood or puberty and/or admits to existence periodically depressed for days at a time, a specific question almost suicide thoughts or attempts is warranted. If the adolescent admits to thoughts of suicide, then the degree to which it has been considered should be explored. For case, has it just been a passing thought, or has he or she considered how to do information technology? More a rare fleeting idea of suicide may stand for a serious trouble in the adolescent barren requires conscientious attending and in some cases a psychiatric referral.

Questions relating to the sexual history should be tailored to the developmental stage and sexual activity of the adolescent. The primary areas to assess are: dating, petting, intercourse, pregnancy prevention, condom utilise, satisfaction with current sexual activity, masturbation, venereal disease, and homosexual concerns or activity. An appropriate initial question for the male person is: "Do y'all accept a girlfriend?" If the answer is no, he is unlikely to be having intercourse. If the answer is yes, and then an effective follow-upward is: "Do you lot date?" "How oft do you date?" "Practise you date lone?" If yes, then: "Are you sexually involved with your girlfriend?" If aye, then: "Are you having intercourse?" If yep, and so: "What are you doing to prevent her from getting pregnant?" "Do yous use a condom?" "Are y'all satisfied with your relationship and sexual feel?" Like questions can be used to appraise the female patient's sexual history.

The nutrition history is often deferred or abbreviated when gathering an adolescent database. In this age grouping it is an of import and at times a crucial component. The boyish is nutritionally vulnerable because (1) there is a greater need for free energy (calories), quality protein, minerals, and vitamins during the rapid phase of physical growth; (two) at that place is almost invariably a change in eating habits and lifestyle (irregular meals, snacking, "junk" food eating, and dieting) during puberty; and (3) there may be additional nutrient demands for the adolescent who participates in sports, is pregnant, etc. Furthermore, it is important that any concern or request by the adolescent to gain or lose weight be seriously considered past the md if inappropriate fad diets that may lead to under- or overnutrition are to be interrupted or avoided. For example, the medico should take seriously the want of an apparently normal-weight adolescent to lose v kg, or the athlete who wishes to gain weight. Failure to practise so may in the former result in a diet that provides inadequate nutrition or in the latter the use of anabolic steroids. Since eating disorders are increasing in frequency in today'due south youth, especially females, the patient's eating habits should exist carefully explored for potential signs of anorexia nervosa, bulimia, or overeating.

Some of the key features of a successful adolescent interview are summarized in Table 223.5. Finally, it can frequently exist revealing to conclude the interview past request, "Are there whatever areas of concern you lot have that nosotros take not discussed?"

Table 223.5

Disquisitional Features of a Successful Adolescent Interview and Physical Examination.

The Concrete Examination

The physical examination oft provokes significant feet in adolescents. Consequently, information technology is important to properly prepare the teenager for the examination and to communicate to the patient your findings and an interpretation. The sometime tin exist accomplished by reviewing with the boyish what is to exist done during the concrete test immediately following the interview while he or she is still dressed. For example, the doctor tin can state to the male patient, "Next I (utilise the start person, not the 3rd since the adolescent may be confused and apprehensive about what "we" means) will demand to do a physical examination. I am going to examine the area that has been a problem for you lot as well as your optics, ears, nose, pharynx, cervix, chest, breasts, stomach, arms, legs, penis, and testicles. In one case yous are in the examination room, the nurse volition tell y'all how to put on the examination gown after you have removed all your clothes. Before anyone comes back into the room, a knock volition be used to assure that you are fix. Do yous have whatsoever questions?"

For the adolescent, privacy and autonomy are important issues. Both females and males are basically pocket-size. Consequently, it is of import to provide an examination gown that covers the trunk and genital area. During the examination the boyish'south feeling of command can be merely and effectively enhanced by having him or her uncover the surface area which needs to be exposed for examination. Talking with the adolescent during the examination likewise tends to increase condolement; nevertheless, the conversation should be appropriate to the area being examined (i.e., don"t discuss the conditions while examining the breasts or genitals; hash out the area beingness examined). The cardinal features for the adolescent physical exam are summarized in Table 223.5 and the stage of development when selected problems are most probable to occur in Table 223.six.

Table 223.6

Selected Correlations with Sexual Maturation Ratings in Males and Females.

In the concrete exam, equally in the interview, the outset component examined should be the area suggested by the reason for the visit, even though it may differ from the physician's usual sequence for a complete physical examination.

Since the boyish is concerned well-nigh body growth, development, and "normality," it is important to identify acne, blemishes, or deformities and inquire as to the adolescent's business concern almost them. If an area appears to be normal and secondary sexual evolution advisable for age, it is important to and so inform the boyish since he or she may non ask de novo. This uncomplicated process frequently relieves tension, allays fear, and opens the style for the boyish to ask questions that would otherwise not be verbalized.

Central components of the adolescent'southward physical exam include an accurate acme (without shoes) and weight (preferably in the examination gown); sitting or supine blood force per unit area; staging of the genitals in the male, breasts in the female person, and pubic hair in both; breasts in the male for possible gynecomastia; back for scoliosis (particularly females) and dorsal kyphosis; skin for acne, hyperkeratosis, hyperhidrosis, and in females hirsutism; teeth for obvious dental pathology; visual activity; and hearing.

The patient'due south height and weight should be recorded on a longitudinal (NCHS) or velocity (Tanner and Whitehouse) growth nautical chart along with all available prior values. This (1) provides an effective method of assessing the patient'southward growth rate per year and (2) establishes his or her usual growth percentile. Pinnacle and weight unremarkably progressives continuously during childhood and puberty until the deceleration nadir later the PH Five or PWV year. A distinct plateauing of linear growth or weight proceeds or an unexplained weight loss (>two kg) should warning the dr. to possible underlying disease and a need for close observation and/or further evaluation. The adolescent'south stage of secondary sexual development should also be carefully recorded for testes or breasts, and for pubic hair. A distinctly early or delayed onset and/or rapid or slow progression may exist the result of hypothalamic, pituitary or gonad disease, abnormal genetic composition (Turner or Kleinfelter syndrome, etc.), or an underlying, often occult, organic affliction such as hypothyroidism, inflammatory bowel disease (primarily Crohn's), renal tubular acidosis, etc. Although there are no absolute criteria for recognizing aberrant height and weight gain and secondary sexual development during puberty, the guidelines shown in Table 223.7 take proven to be clinically useful.

Tabular array 223.seven

Guidelines for Identifying Abnormal Growth in Peak, Weight, and Secondary Sexual Development in Adolescents.

A rectal examination in males is required only when at that place is a suspicion of prostate or bowel disease, unexplained anemia, or homosexual activity. In the latter instance, a rectal culture for gonorrhea should be obtained. A female pelvic exam is required when at that place is a suspicion of disease, abnormal secondary sexual development, pregnancy, the patient'south female parent received DES during her pregnancy, contraception is requested, or the patient is sexually active. If an examination is performed, a baseline pap smear and culture for gonorrhea should be obtained.

Laboratory Evaluation

Baseline laboratory data for the adolescent should include: hemoglobin or hematocrit, urinalysis, cholesterol, hemoglobin electrophoresis in blacks, as well as a rubella titer in females. Since hemoglobin/hematocrit values increment progressively in males during secondary sexual development and minimally so in females, information technology is important to translate the values according to their phase of evolution. For example, a hematocrit of 36% is normal for a male person or female in stage 1 (prepubertal) compared to 41% in the phase 5 male person and 37% in the female. Adolescents who use drugs or alcohol should also have baseline liver part tests. Since alkaline phosphatase (AP) rises above normal adult values during puberty, it too must be interpreted in conjunction with the stage of development. AP levels begin to ascension with the onset of puberty, peak at the fourth dimension of PH V in both males and females, and usually decline into the normal range past the fourth dimension an adolescent has reached stage 5. Peak values may exist every bit high as iii times the upper normal developed values.

Preventive Wellness Care

The best therapy for disease is prevention or early treatment. Consequently, anticipatory health intendance counseling and early detection should exist routine when providing comprehensive health care for the adolescent. Tabular array 223.6 identifies some of the disquisitional areas for attention based on the boyish's stage of development.

Some important bug for anticipatory health care counseling are: G2-3 or B2 a significant, usually rapid, growth in height and weight should begin within a few months during which fourth dimension a caste of temporary physical disequilibrium volition occur; G4-five a major increment in force will occur and such activities equally weight lifting should exist deferred until that time; G3-4 nocturnal emissions and masturbation are common and are not physically harmful; B2-3 menarche and flow should be reviewed; G3 or B3 discussions of sexuality, crabs disease, and prevention of pregnancy should be offered; and at the advisable stages the major symptoms and/or signs of potential medical concerns can be brought to the boyish's attention. In improver, well-nigh adolescents are appreciative of a brief overview of what to look during their next phase of growth. For such counseling to be most effective, it must be tailored to the individual'southward level of psychologic, sexual, social, and cognitive development.

Conclusion

In summary, puberty is a complex dynamic process well-nigh which the medico must accept a general working cognition if optimum comprehensive care is to be provided. As a patient, the boyish can be frustrating, maddening, unpredictable, time-consuming, and frightening. More important, and more frequently, caring for him or her is challenging and rewarding.

References

Barnes, HV. Recognizing normal and abnormal growth and evolution during puberty. In: Mass AJ, ed. Pediatric update. New York: Elsevier, 1979;103–29.
Barnes HV. Disorders of boyish growth and development. In: Stein JH, ed, Internal medicine. 2nd ed. Boston: Fiddling, Brown, 1987.
Blum RW, Stark T. Cerebral development in boyhood. Semin Adol Med. 1985;one:25–32. [PubMed: 3843471]
Breipe RE, McAnarney ER. Psychosocial aspects of boyish medicine. Semin Adol Med. 1985;1:33–45. [PubMed: 3843472]
Daniel WA Jr. Growth at adolescence: clinical correlates. Semin Adol Med 1985;fifty:xv–23. [PubMed: 3843470]
Deliege A. Indicators of physical, mental and social wellbeing. World Wellness Organization Stat Q. 1983;36:346–93. [PubMed: 6678087]
Goldstein S, Saenger P. The physiology of puberty. In: Moss AJ, ed. Pediatric update. New York: Elsevier, 1984;63–93.
Lee PA. Normal ages of pubertal events among American males and females. J Adol Health Care 1980;l:26–29. [PubMed: 6458588]
Rohn RD. Papilla (nipple) evolution during female puberty. J Adol Health Care. 1982;ii:217–twenty. [PubMed: 7096166]
Tanner JM. Growth at boyhood. second ed. Oxford: Blackwell Scientific, 1962.
Tanner JM. Issues and advances in adolescent growth and development. J Adol Health Intendance. 1987;8:470–78. [PubMed: 3121548]

Source: https://www.ncbi.nlm.nih.gov/books/NBK708/

Posted by: amadorhagerre1998.blogspot.com