Transcript B4 (updated 2016)

Common Medical Problems
during Adolescence
11
Learning objectives
To describe the range of common medical
problems that young people present with in
clinical practice including skin problems,
musculoskeletal conditions and fatigue.
To describe the adolescent-specific aspects
of these conditions
To demonstrate the skills in assessment,
diagnosis and management of the
conditions highlighted.
2
Outline
Intro
Dermatology
Fatigue and Sleep
MSK
3
Multiple health
complaints
@ 15 years
www.hbsc.org
(2013/2014 survey)
4
Multiple Health Complaints
www.hbsc.org.uk, England 2014 survey
5
When to Worry
Co-occurrence of multiple symptoms
Chronicity > 3 months
 School attendance
Isolation
Recent family, school, psychological
problems
6
Presentations of Adolescents
to primary care
16-24 year olds (Australia)
1. Respiratory 13.8%
2. MSK - back pain 11.1%
3. Skin – acne 10.4%
13-15 year olds (UK)
1. Respiratory conditions 35.1%
2. Skin (acne and eczema) 28.9%
3. Musculoskeletal conditions (including trauma,
sports injuries, and joint problems) 22.1%
7
Common Somatic Symptoms
Passport symptoms
Hidden agendas
Windows of opportunity
8
Acne
Types of lesions
Non-inflammatory
Mild acne
– Comedones
• Closed (whiteheads)
• Open (blackheads)
Inflammatory
Moderate acne
– Papules
– Pustules
Severe Acne
– Nodules
– Cysts
– Scars
9
Acne
85% of adolescents have acne to some degree
Due to  androgen-induced sebum production
 Abnormal keratinisation leading to ductal obstruction
+ Proliferation of propionibacterium acnes
 Inflammation!
Important psychosocial consequences
–
Impact on self-esteem and body image of the developing
adolescent
–
May affect social interactions
10
Psychosocial judgements and
perceptions of adolescents with
acne vulgaris:
A blinded, controlled comparison
of adult and peer evaluations
Ritvo E et al,
Biopsychosocial Medicine 2011
11
Q. Which of the following
are the effect of having acne?
Not shown in the graph above; None of these = 14%, Other = 4%.
12
Acne Management
Explore perceptions regarding impact on
self-image and social relationships
Address myths and misconceptions
Eg the central discloration of blackheads is not
dirt but oxidised melanin
Emphasise “it takes time”
Self-management skills including adherence
13
Topical Therapy
–
–
–
–
–
Benzyl Peroxide 2.5-10%
Bacteriocidal, mild comedolytic, anti-inflammatory
Night use
Gels better than alcohol
Often worse before gets better
ADR: peeling and irritation; contact dermatitis;
bleaching of towels and clothing
Antibiotics
– Tetracycline, erythromycin, clindamycin
14
Topical Therapy
–
–
–
–
–
Retinoids (vitamin A derivatives)
Decreases folllicular plugging
Alternate nights initially
Cream less irritating than gel
Avoid sun exposure (sunblock)
NB Contraception advice
15
Systemic Therapy
–
Antibiotics
(avoid combination with topical antibiotic therapy as
resistance)
Minocycline, Doxycycline, Tetracycline, Erythromycin
–
–
–
–
Isoretinoin
Specialist supervision
For nodulocystic acne
Teratogenic
Significant toxicity
–
–
Hormonal
Oral contraceptive pill
Antiandrogens Eg in Polycystic Ovary syndrome
–
16
Acne @ 2013!
Dawson AL, Dellavalle RP. Acne vulgaris
BMJ. 2013 May 8;346:f2634.
Eichenfield LF, Krakowski AC, Piggott C et
al; American Acne and Rosacea Society.
Evidence-based recommendations for the
diagnosis and treatment of pediatric acne.
Pediatrics. 2013 May;131 Suppl 3:S163-86.
17
Pityriasis Rosea
herald patch 2-6cm, 2-21 days before the rash (DDx
eczema)
maculopapular rash
Oval, sl. scaly lesions 1-2cms
Rash follows Langer's lines (cleavage lines; Xmas tree
pattern)
Not painful or itchy.
Trunk and extremities
Lasts 1-2 months then fades
No treatment
18
Tinea Versicolor
hypopigmented or
hyperpigmented macules
or patches
upper trunk and arms:
occasionally on the face
and neck.
Pityrosporum orbiculare.
usually asymptomatic
Predisposing factors:
Humidity, hyperhidrosis,
heredity, diabetes mellitus
and corticosteroids
Diagnosis: observation of
hyphae and spores
(spaghetti and meatballs)
on potassium hydroxide
wet mount.
Wood's light - shows
yellow/brown fluorescence
Rx: topical antifungals ,
daily for 2 weeks
19
Acanthosis Nigricans
gray-brown thickening of the skin.
symmetrical, velvety, papulomatous plaques, with
increased skinfold markings.
base of the neck, axilla, groin, and antecubital fossa.
Associations
obesity
insulin resistance
Malignancy (adults)
Management
Screen for diabetes
Encourage weight loss
20
Erythema nodosum
Wide Differential
Includes
– Infections – viral,
strep, TB
– Drugs inc Oral
contraceptive pill,
codeine
– Systemic disease inc
Inflammatory bowel
disease, SLE,
sarcoidosis
21
SLE
–
–
–
–
–
–
–
Photosensitive malar rash
of SLE
Many “classic teenage
complaints” eg
Fatigue
Anorexia
Raynauds
Mouth ulcers
MSK pain
Headaches
Moodiness!
22
Raynauds
Classical
– White  blue  red
– Discomfort on re-warming
Triggers – cold, anxiety
Differential diagnosis
– Underlying Connective tissue disease
(unlikely if ANA negative and normal nail fold
capillaries)
23
Nail Fold Capillaries in SLE
24
Raynauds
Gloves and socks!
Moisturisers and emollients
Avoidance of triggers, smoking
Advice for PE teachers at school
Trial of Calcium blockers eg Nifedipine slow
release
25
Outline
Intro
Dermatology
Fatigue and Sleep
MSK
26
Young People, Sleep and Fatigue
http://www.sleepscotland.org/sound-sleep/
27
Adolescent Sleep
Important as
A cause and the result of health problems
2 independent but related processes
i. A daily circadian rhythm
ii. The sleep-wake pressure (homeostatic)
system, (sleep “urge”)
28
Adolescent sleep
“he won’t get out of bed in the morning!”
The Pubertal phase delay
– Pubertal slowing of the circadian timing
system
– Sleep pressure system changes during
puberty - easier to stay awake longer in
later puberty
– Found in adolescents of other species so
has an evolutionary purpose (?!)
During puberty, variation in alertness across
the day (young children have less variation)
29
Too sleepy OR too tired?
Sleepiness
=  tendency to fall asleep
Fatigue
= abnormal exhaustion after normal activities
30
www.hbsc.org (England, 2014)
31
Limited Awareness
Documentation in Case-Notes of Adolescents with JIA in
10 UK centres
8%
Improved to 29% post implementation of a Transition
programme (p<0.001)
Robertson L et al, 2006
32
Key Sleep Diagnoses
(i) Delayed Sleep Phase syndrome (DSPS)
Most common sleep disorder
Up to 7% of adolescents
Difficulty falling asleep (2-4am then wake late)
Disrupted circadian rhythm
NB different from YP who choose to stay up late
but fall asleep very quickly!
(ii) Obstructive Sleep Apnoea
33
Other Sleep Disorders
Night terrors
Sleep walking (pre-pubertal)
Sleep-onset anxiety
Restless legs syndrome
Narcolepsy
34
Antecedents of Adult Health
Adolescent sleep disturbances predicted
adult sleep disturbances
If problems at 16
– A third still had problems at 23 years
– 10% at 42 years
Dregan A & Armstrong D 2010
35
Sleep History
Sleep
Habitual bedtime and rise time
Sleep duration
Sleepiness
Difficulties falling asleep (sleep-onset latency)
No of night wakings
No of daytime naps
Subjective opinion
Fatigue
Other sleep problems
Beliefs
36
Sleepy HEADSS!
Home: Bed room environment
Education: Schoolday vs weekend (sleep irregularities)
School achievement
Activities:Cell phone/computer use;competing demands
Drug use include caffeine/energy drinks
Safety – Injuries, Driving
Suicide – mood; anxiety
37
Sleeping BEARS! (Jones JA & Dalzell V, 2005)
B
Bedtime problems
Do you have any problems falling asleep at
bedtime
E
Excessive daytime
sleepiness
Do you feel sleepy a lot during the day? In
school? While driving
A
Awakenings during the
night
Do you wake up a lot at night?
R
Regularity and duration
of sleep
What time do you usually go to bed on
school nights? Weekends? How much sleep
do you usually get?
S
Sleep disordered
breathing
Does your teenager snore loudly at night?
(ask family members)
How often do you nap after school and for how long?
How much exercise do you get and what is the time of day?
How much coffee, tea and cola do you drink each day?
How often do you drink alcohol?
38
Sleep Promotion!!
“Crash in Bed – Instead”; “ Sleep Smart”
Positive benefits of Sleep Education
Programmes
James SL, 1998; Rossi CM 2002; Cortesi F, 2004
Young Person’s Perspective!
87% - good/excellent
90% - felt it useful
Cortesi F et al, 2004
39
The Energy Debt during Adolescence
Physiological
demands
of growth
Social and
educational
demands
40
Fatigue: Definitions
Important to distinguish
Physical fatigue,
– physiological
– refreshing
AND
Psychological fatigue
– “I don’t like doing anything”
“I’m tired” may mean “I’m depressed”.
41
Epidemiology of Fatigue
Incidence
Fatigue
30.3%
Point
Prevalence
34.1%
Chronic Fatigue
1.1%
0.4%
Chronic fatigue
syndrome
0.5%
0.1%
Rimes KA et al, 2007
42
Chronic Fatigue Syndrome
Persistent debilitating severe fatigue for ≥ 6m (? 3m in
adolescents)
Plus
CFS related Symptoms
Un-refreshing sleep
MSK: Muscle and/or joint pain
Headaches
ENT: Sore throat, Tender cervical/axillary lymph
nodes
Neuropsych: Concentration, Memory problems
Which cannot be explained by another medical or
psychiatric illness
43
Differential Diagnosis
Infections
Medications and substance misuse
Anaemia
POTS – postural orthostatic tachycardia syndrome
(may be 20 to CFS)
Endocrine
Chronic disease eg SLE
Neurological
Psychological inc depression, eating disorders,
refusal syndromes
44
Assessment
TIME++++
Acknowledge distress and disability
“Symptoms are REAL”
Thorough history
Thorough examination
(inc MSK, neuro, lying and standing HR
and BP)
Assessment of psychological well-being,
family functioning, social and educational
development
45
Baseline Investigations
FBC
Acute phase response markers (ESR, CRP)
Basic biochemistry
Thyroid function
Muscle enzymes (CK,AST, LDH)
Immunoglobulins
Autoantibodies (ANA, coeliac)
? Re Addisons
? EBV and Lyme disease
46
Factors suggesting an organic cause
Increase fatigue over the day
Reduce with rest
Associated physical
symptoms eg weight loss,
fever, etc
47
Management
Invest time in giving the diagnosis
Acknowledge the reality of the symptoms
Enable ownership of the management
programme by the YP as well as
engagement of the family
Multidisciplinary approaches
Focus on functional improvement and
symptom control
48
Think of a young person with chronic fatigue
and imagine what aspects of their lives they would
use to create their fatigue/energy spider…
Energy/
Fatigue
49
Management
Energy Spider!
Goal setting with YP with regular review
Activity Diary
Activity management
Graded Activities and Exercise programme
Graded re-integration programme
Sleep hygiene
Dietary
Rx depression and mood disorders
CBT
Simple analgesia and non-pharmacological pain relief
? Role of SSRI, melatonin
Management of relapse
Family support
Regular review (GP/paed team)
50
Prognosis of CFS
? More favourable than CFS in adults
52% complete/nearly complete recovery
48% NO improvement
High health care use
Low school and work attendance
Unfavourable outcome:
Older age, pain, poor mental health/self esteem/general health
perception
Van Geelen SM 2010
51
Outline
Intro
Dermatology
Fatigue and Sleep
MSK
52
Presentations of Adolescents
to primary care
16-24 year olds (Australia)
1. Respiratory 13.8%
2. MSK - back pain 11.1%
3. Skin – acne 10.4%
13-15 year olds (UK)
1. Respiratory conditions 35.1%
2. Skin (acne and eczema) 28.9%
3. Musculoskeletal conditions (including trauma,
sports injuries, and joint problems) 22.1%
53
MSK problems during adolescence
Back
Knee
Hip
54
Back Pain
By mid to late adolescence,
>50% YP will have at ≥ 1
episode of back pain
Thoracic or lumbar
Majority nonspecific
 disc herniation vs adults (6%
of total)
55
Aetiology
Nonspecific – majority!
Mechanical: hypermobility, Scheuermann’s.
spondylolysis, idiopathic scoliosis
Idiopathic pain syndromes
Inflammatory: Enthesitis related JIA (ERA) ,
Juvenile Psoriatic arthritis
Metabolic: osteoporosis
Vascular: sickle cell, AVM, spinal infarct
Infectious : osteomyelitis, disciitis, epidural
abscess
Tumour: benign, malignant, spinal cord
Referred pain from hip, abdomen, pelvis, thorax
56
The Hypermobile Back
Asymptomatic!
Hyperlordosis
Spondylolysis
Spondylolisthesis
Disc prolapse
57
12 year old girl
Complaining of thoracic pain after
school
Mother complaining of her terrible posture
and blames her spending
too much time at the computer
On examination:
Mild fixed thoracic kyphosis and scoliosis
Pain worse on forward flexion
58
Scheuermann’s
Early adolescence
M=F
T7-T10
Progression during growth spurt
Thoracic back pain
- worse on forward flexion
Lumbar Scheuermans > painful; < common
Kyphosis -  on forward flexion
1/3 have a mild/moderate scoliosis
Management: Physiotherapy
Rarely bracing and surgery
Improvement when growth completed
59
Scheuermann’s Xray criteria
Narrowed IV disc space
Irregular superior and
inferior vertebral endplates
Schmorls nodes –
protrusion of disc material
into adjacent vertebral body
Anterior wedging of ≥ 1
vertebrae ≥ 50
60
15 year old male tennis player
just entering growth spurt
Insidious onset low back pain
Worse on exercise and
prolonged standing
Examination
Pain worse on hyperextension
Limited forward flexion and SLR
Focal tenderness L5/S1
61
The Sporty Back
–
–
–
–
Repetitive flexion,
extension or rotation
Increased risk of back
pain due to:
Spondylolysis
Spondylolisthesis
Hyperlordotic back
pain
Herniated disc
62
Spondylolysis
Insidious onset
Mild to moderate lumbar
back pain worse on
hyperextension
Relieved by rest
Defect in pars
interarticularis of L4 or L5
Esp sports involving
repeated hyperextension
eg gymnastics, dancing,
football
+/- family history
Oblique xrays, MRI, CT
63
Management of Spondylolysis
Conservative usually
Analgesia
Activity modification
Exercises to strengthen abdominal and paraspinal
muscles
Cessation of sports for 3 months
During growth
Monitor for development of spondylolisthesis (if
bilateral)
64
Risk of Spondylolisthesis
50-60% spondylolysis
25% have disc degeneration
(? Discogenic pain)
65
Knee Pain
14 year old elite athlete
c/o diffuse unilateral knee
pain
Examination Findings
–Reduced ROM
–Mild effusion
66
Knee pain
Trauma
Osgood Schlatters
Anterior knee pain syndrome
(chrondromalacia patella)
Sinding Larssen Johanssen
syndrome
Referred from hip
(Slipped Capital Femoral epiphyses
SCFE)
Osteochronditis Dissecans
67
Osgood Schlatters
Swelling, pain, tenderness at anterior tibial
tubercle
Difficulty running, jumping, stairs
Athletic teenage boys at growth spurt
25% bilateral
Partial avulsion fracture at apophyseal ossification
centre 20 heterotropic bone formation (lump)
Self-limiting 12-24 months until closure of
apophyses
Management: rest, shock absorbing insoles,
physio
68
Intervertebral Expansion (cms)
Schober’s Test: Normal Values
10
8
Boys
6
Girls
4
2
0
10 yr
11 yr
12 yr
13 yr
14 yr
15 yr
Age
http://www.youtube.com/watch?v=B9RaFB5BwrQ
69
References
Carskadon M. Sleep in Adolescents: The Perfect storm. Pediatric Clinics of North America
2011;58:637-647
Dawson AL, Dellavalle RP. Acne vulgaris. B Med Journal 2013 [Epub ahead of print]
Findlay SM. The tired teen: A review of the assessment and management of the adolescent with
sleepiness and fatigue. Paediatr Child Health 2008;13:37-42.
Houghton KM. Review for the generalist: evaluation of low back pain in children and adolescents.
Pediatr Rheumatol Online J. 2010 Nov 22;8:28.
van Geelen SM, Bakker RJ, Kuis W, van de Putte EM. Adolescent chronic fatigue syndrome: a followup study. Arch Pediatr Adolesc Med. 2010 Sep;164(9):810-4.
Other Websites
www.restproject.org.uk The Resources for Effective Sleep Treatment Project
http://www.sleepscotland.org
http://www.sleepforscience.org
MSK examination resources
http://www.pmmonline.org/about-pmm
http://www.arthritisresearchuk.org/health-professionals-and-students/video-resources/pgals/pgalssummary.aspx
70