Welcome to The 2002 Summer School - Unil

Welcome to The 2002 Summer School - Unil

Common Medical Problems during Adolescence Updated July 2016 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 wont 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 Persons 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 dont like doing anything Im tired may mean Im depressed.

41 Epidemiology of Fatigue Incidence Point Prevalence Fatigue 30.3% 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, Scheuermanns. 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 Scheuermanns 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 Scheuermanns 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)

Schobers 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 follow-up 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/pgals-su mmary.aspx 70

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