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

Adolescence is a unique time of rapid physical, psychologic, sexual, social, and cognitive growth and development that distinguishes the adolescent and his or her wellness care needs and expectations from those of the child or adult. Although puberty cannot be precisely defined by chronologic age, the procedure unremarkably has its onset and completion during the 2nd and the early on role of the third decade of life, spanning approximately x to 24 years of historic period.

To provide comprehensive health care (astute episodic, continuous, and preventive) for this age grouping requires the physician to have a general working cognition of the onset, sequence, characteristics, and interrelationships of the critical features of pubertal growth and development. Perhaps more than any other menstruation in life, an effective synthesis of each of these components is required for optimal health care resulting in "a land of complete physical, mental, and social well-beingness" (Deliege, 1983) rather than simply the absence of disease. Equally important is for the doctor to accept a desire and aptitude for working with this historic period group.

This chapter focuses on the major elements of the pubertal process that define the unique features of the history, physical examination, laboratory evaluation, health instruction, and preventive medicine in the boyish as compared to the child or the developed.

The Pubertal Procedure

Primary Hormone Changes

The precise trigger for the onset of puberty is not known, but much is known about the procedure. Current information propose that the first chemical testify of puberty is an increment in the product and release of dehydroepiandrosterone (DHEA) and its sulfate (DHEA-Due south) past the adrenals (adrenarche). The initial rise usually occurs between 7 and 9 years of historic period in both the male and female followed past a progressive increase to adult levels.

The next identifiable event begins 1 to 2 years after adrenarche when the hypothalamic-pituitary system begins to showroom 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 effect of these increased levels of GnRH and an credible increment in the pituitary's sensitivity to this peptide, there is an increment in the production and release of luteinizing (LH) and follicle stimulating hormone (FSH). At the onset, the increase in LH and FSH occurs merely during non-REM sleep, only, with fourth dimension progresses to a persistent increment throughout the mean solar day. These changes stimulate the growth and hormone product of the gonads, primarily testosterone, estradiol, dihydrotestosterone, and delta-four-androstenedione. These hormones steadily increase to adult levels over a period of well-nigh 3 years in the male person and 4 years in the female. For those who progress most rapidly (fifth percentile) and the slowest (95th percentile), the years are respectively for the male person well-nigh 1.9 and four.7 years and for the female 1.5 and 9.0 years.

During puberty the 24 hour integrated concentration of circulating growth hormone (GH) increases. Beginning at near x years of historic period, the circulating levels of insulin-like growth factor I (somatomedin C), brainstorm to ascension with a peak at about the fourth dimension of the maximum increment in summit and weight during puberty, that is, the year of peak height velocity (PHV) and pinnacle weight velocity (PWV).

Thyroxine, triiodothyronine, cortisol, glucagon, insulin, and parathyroid hormone practise 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 evolution.

Physical Growth

During puberty all body parts usually increase in size with the exception of the thymus, tonsils, and adenoids, which decrease in size. Commonly, the linear growth of puberty accounts for fifteen to 25% of an individual's adult tiptop, 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 peak growth (i.e., PHV and PWV). During this 36-month span, the tertiary to 97th percentiles for linear growth in males are 15.iv and 28.two cm and in females 14.two and 26.ii cm respectively. For weight, these values are 12.3 and 30.viii kg in males and 10.3 and 26.one kg in females. The PHV and PWV normally occurs about 18 to 24 months earlier in the female than the male person.

The major contributors to the gain in weight are the lean, fat, and os masses. The male and female person increases in these components differ quantitatively and qualitatively. The virtually striking differences are in muscle and fatty. In the pubertal male there is about a 7-fold increment in musculus mass compared to a 3- to five-fold in the female. Meridian musculus growth commonly occurs within 6 to 12 months of the PHV year with the acme increase in strength coming 12 to eighteen months later on PHV. In the pubertal female in that location is a four to 10% increase in the percentage of total body weight as fatty compared to a 5 to vii% decrease in the male.

Os mass increases in parallel with musculus mass, and the epiphyses of the hands, wrist, and long bones progressively fuse during puberty. The hand and wrist epiphyses are usually closed in the female person by age 17 years and in the male person past 19 years. Once this fusion is complete, it is rare for an private to grow more another 3.75 cm in summit.

As observed by Tanner (1962), the typical sequence of events is: lengthening of the legs, followed past 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. Peak growth typically occurs within a 12- to 18-month bridge for all these parameters.

The striking facial changes during puberty are the result of an increase in the length and width of the face, peculiarly the mandible, which usually peaks in growth within half-dozen months of PHV. In addition, the olfactory organ and pharynx abound in length and the hyoid bone moves to a lower position than during childhood.

Secondary Sexual Growth

For the body-witting teenager, the evolution of secondary sexual characteristics is an important and easily observed milestone in the pubertal process. For almost all males (~98%), the first concrete testify of beginning puberty is an enlargement of the testes and for near 80% of females the appearance of palpable breast tissue nether the areola (breast budding). For the remainder, pubic hair is the offset concrete evidence of puberty. There is too a progressive growth of axillary hair in both sexes, and in the male the voice lowers and a bristles begins with the mustache of puberty. At that place is near a vii-fold increment in the size of the male'due south testes, epididymis, and prostate and the female's uterus and ovaries. A substantial increment too 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 person.

The uniformity of the sequence of gonad (M) and pubic hair (PH) development in the male and breast (B) and pubic pilus in the female allows these components to be staged (i.e., clinically quantified). Since the PH and G or B stages exercise not necessarily develop or progress in unison, each should be staged separately for the greatest accuracy. The standard system developed by Tanner et al. in the 1960s with minor modifications is shown in Table 223.1.

Tabular array 223.ane

Staging Criteria for Secondary Sexual Evolution.

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

Table 223.2

Mean Age of Onset and Fourth dimension of Progression betwixt Pubertal Events.

Menarche typically occurs during the rapid deceleration phase of linear growth, that is, 6 to 12 months after PHV, ordinarily between PH stage 3 and 4 and B stage four and v. Menstrual periods are commonly irregular, equally is ovulation for the outset 12 to eighteen months and occasionally upwards to 3 to 4 years. Although minimal data are available, it appears that the male'due south first ejaculation may occur equally early as 12 years and G stage 2 with a median age of about 13 years and M phase iii.

Reproductive capability is nowadays from the perimenarchial period, but top fertility usually occurs afterward the completion of secondary sexual development. Males tin 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 Evolution

As the boyish grows physically, he or she must also mature psychologically, sexually, socially, and cognitively. In this complex process, there is a dynamic interrelation among all these components too as the physical. These nonphysical components also keep 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 betwixt the sexes. Different physical development, they may backslide as well equally progress depending on environmental stresses.

In global terms, the adolescent must: (1) emancipate himself/herself from the family, (2) accept his or her adult torso (body paradigm) and ability to procreate (sexuality), (iii) develop an adult identity (cocky-image), (4) achieve the skills required to role in society and be economically contained, and (5) develop developed patterns of thinking (integrative cognitive function). All are necessary if the person is to be an effective developed and have a fulfilling life.

This process typically has its onset early on in the second decade of life and is normally completed in the early adult years. Some of the critical components in this process are depicted every bit a dynamic continuum in which all are interactive at any given bespeak in time (Table 223.3). Although the stages of development in this arena cannot be assigned to a specific chronologic age, it may exist useful to consider the four stages of evolution as early, centre, late boyhood, and young adult.

Table 223.3

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

Early adolescence is characterized by (ane) initial efforts to institute independence from the family, (2) offset aforementioned-sex activity peer relations, and (3) questioning i's identity separate from the family. Developing independence from the family normally expresses itself as a reluctance or refusal to be a compliant participant in family activities and to ascribe equal or greater importance to aforementioned-sex peer group activities. During this phase the peer group increasingly influences the adolescent'due south perception of acceptable behavior and dress. Typically the adolescent's behavior is egocentric (selfish) and body focused. His or her quest for personal identity usually begins by questioning "Am I normal?" This in role is the footing for the increasing concern most his or her irresolute body (i.due east., secondary sexual development, acne, blemishes, etc.). Ambivalence and insecurity are usually observable hallmarks. The adolescent may at one moment or 24-hour interval shun the family unit and in the next seek its security, or be the best of friends with an individual in the peer group and so of a sudden view him or her as an enemy. Adolescents" fourth dimension orientation is predominantly existential and their thinking physical operational (i.e., the future and abstract thought are hard or impossible to encompass, and logical thinking is usually limited to a single item of information). For example, the employ of transverse or sagittal sections of the man body to explain menstrual and reproductive function typically cannot be finer comprehended. For these adolescents, health is viewed simply as the absence of disease or blemishes.

Centre adolescence is the stage in which the boyish is usually well established in the peer grouping and desires to be more than in conformity with it. Mixed-sex activities begin to increment. The teenager usually spends increasing time away from the family and seeks more independence. This results in more overt challenges to authorisation, rules, and established patterns of behavior. These adolescents consider themselves to exist invulnerable and at times invincible. In this milieu, experimentation with drugs, alcohol, tobacco, clothes, and sexuality brainstorm and usually reach a height. In improver, teenagers go more aggressive in seeking increasing autonomy and demanding privacy. Their time orientation continues to be primarily existential, only their thinking begins to move toward formal operational thought. They begin "thinking about thinking" and may withdraw for hours to practise and so. Philosophically, they tend to exist idealistic and from the standpoint of identity begin to ask "Who am I?" Their concern about body image continues. Ambivalence and rapid fluctuations in mood are common, which can be punctuated by hours to a few days of apparent depression.

Socially, during this stage of evolution adolescents remain primarily egoistic. Although they begin to recognize that those around them think and accept feelings, they believe that all others with whom contact is made are focused on them, that is, they believe that they are existence continually scrutinized by others, the then-called imaginary audience.

In relation to anticipatory health counseling, information technology is important for the physician to recognize that adolescent–parent conflicts besides as hazard-taking behaviors commonly peak (i.eastward., a typical time for family unit and school crises that may be accompanied by concrete signs and symptoms). During this phase, as in early adolescence, the teenager primarily sees himself or herself equally externally controlled (external locus of command) by parents, school, and peer group, but an increasing perception of personal responsibility typically begins to emerge (internal locus of command) late in middle adolescence.

Late boyhood is perhaps all-time characterized every bit the boyish's 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 idea go along to advance every bit the teenager begins to more realistically consider such issues as future pedagogy, vocation, and adult sexual commitment. More consideration is given to the thoughts and feelings of others, including the parents. There is less peer group activity and commitment with most tardily adolescents developing two or iii close friends of whom one is typically of the contrary sexual activity. By this time, teenagers are usually able to extrapolate from their experimentation during early and center adolescence to related experiences in different settings. Their sense of invulnerability and abiding scrutiny past 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, anger, or pleasure. There is less dependence on torso image and a greater accent on sell-prototype as they begin to perceive themselves as both internal and external persons.

This is the time when they showtime begin to perceive clearly that they will be physically moving away from their home and family, and assuming increasing responsibility for varying degrees of economic separation, sexual commitment, work, or additional self-motivated education or training. They begin to experience the dubiety of the future. Consequently, it is the virtually common time for separation anxiety to become manifest in the course of physical signs and symptoms. For about youth, this process occurs smoothly and is usually a time when the parents, despite their own pains of separation, renew their confidence in the capabilities of their offspring.

The young adult to developed stage, for most, primarily takes identify away from the family. Private identity becomes stabilized, and intimate personal and sexual relationships are based on the ability to identify and effort to sympathize the thoughts and feelings of some other. The beginning of a defined role in society begins to sally, and an increasing sense of personal responsibility and worth continues to develop. Constructive and fulfilling independent role in an adult guild signifies the completion of the process.

Information technology is worth emphasizing that the progression along the continuum of psychologic, sexual, social, and cognitive development varies. The onset and rate of progression of each component differs from private to individual and between the sexes. Each major component should exist assessed by the physician caring for an boyish, since optimal patient management may be positively or negatively affected by the adolescent's status regarding his or her development in one or more components. For example, a teenage female may exist in belatedly adolescence regarding her quest for independence, only in early on or middle adolescence regarding her cerebral and identity evolution. Consequently, she may engage in sexual intercourse, merely may be reluctant to seek medical advice about contraception or venereal disease because she feels she is under constant scrutiny by all with whom she comes in contact, has little or no concept of the time to come, and believes "pregnancy can"t happen to me" (invulnerability).

An Approach to the Boyish Patient

As in all medicine, the physician's ability to establish an constructive relationship with the patient is crucial. For an constructive relationship to begin, the medico must like teenagers, be comfortable interacting with them, respect them as individuals, and exist willing to relate to them in a non-judgmental manner without being nondirective. The adolescent needs a health intendance advocate, not a surrogate parent or "buddy." In full general, he or she expects the md to employ understandable adult language and not the latest teen jargon. In the author's opinion, physicians who do not like or cannot cope effectively with adolescents should non include them in their exercise.

The physician must found himself or herself as the teenager'due south personal doc. The beginning point is to establish the limits of confidentiality with the patient besides equally 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 historic period such equally 10 years quondam. Statutes relating to confidentiality for teenagers vary from state to land and should be ascertained by the md. In the writer's opinion, confidentiality should exist relative. One effective argument is, "Our conversations will be between you and me alone unless I consider something to be of danger to you lot or others. In such instances, although I volition not discuss it behind your back, I volition share such information with your parent(s) and I volition ask you to exist present. Regarding your diagnosis and any handling required, you and I will discuss what yous wish to be shared with your parent(s) and whether you, I, or both of us volition talk with them about it." A clear argument in this regard provides the footing for a mutually trusting human relationship between the physician and the boyish likewise as the doc and the parent(s).

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

The Medical History

The generic components of the boyish medical history are the same as for the adult 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 be seen alone (1) to assess his or her perception of the patient'south problem and (2) to obtain data regarding the patient'due south birth, developmental, and past medical and family histories. Thereafter, parents should non exist seen without the patient unless the patient then 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's wellness status if no farther 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 announced to exist a mechanistic interrogation. It is important to remember that what the doctor says tends to be far less important to the adolescent in an initial interview than how information technology is said. An initial focus on "getting to know" the patient with questions near activities, school, interests, or hobbies may exist useful in reducing the patient'southward anxiety, merely the showtime component of formal information gathering should be the reason for the visit (main complaint) and the history surrounding it (history of present illness). The adolescent assumes that the main reason for being at that place is also the md's primary concern and therefore may become suspicious and confused if the doctor focuses showtime on an surface area that has no obvious relationship to the reason given for the visit.

The patient'south level of cerebral development is an important consideration in history taking if optimal information is to be obtained. For example, open-ended or complex direct questions when asked of an adolescent whose thought is primarily physical operational will often generate an "I don"t know" or a "huh?" response. Consequently, in the writer'south experience, for most early on and middle adolescents the most effective and efficient history gathering is achieved by using elementary direct questions occasionally punctuated past a question requesting further elaboration of a yes response if the teenager seems to exist openly talking.

Disquisitional components of the psychosocial history are the patient's function at domicile, 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 equally, "Practice yous take a best 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 just mean that the teenager speaks to some peers in the hallway and that they usually speak in render; thus the information 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 all-time friend'southward name?" or "What are the names of the kids you run around with at schoolhouse?"

Table 223.four

Cardinal Features in Assessing Adolescent Psychosocial Function.

In a patient with a background of beliefs or personality problems in childhood or puberty and/or admits to being periodically depressed for days at a time, a specific question about suicide thoughts or attempts is warranted. If the adolescent admits to thoughts of suicide, and so the degree to which information technology has been considered should be explored. For example, has it just been a passing thought, or has he or she considered how to do it? More than a rare fleeting thought of suicide may correspond a serious problem in the adolescent barren requires careful attention and in some cases a psychiatric referral.

Questions relating to the sexual history should be tailored to the developmental stage and sex of the adolescent. The master areas to appraise are: dating, petting, intercourse, pregnancy prevention, condom apply, satisfaction with current sexual activity, masturbation, venereal illness, and homosexual concerns or action. An advisable initial question for the male is: "Practice you have a girlfriend?" If the answer is no, he is unlikely to be having intercourse. If the answer is yes, then an effective follow-up is: "Practise you engagement?" "How oft practise y'all appointment?" "Do you appointment lonely?" If yep, and so: "Are you sexually involved with your girlfriend?" If yes, then: "Are you having intercourse?" If yes, then: "What are yous doing to prevent her from getting pregnant?" "Do you lot apply a condom?" "Are you satisfied with your relationship and sexual experience?" Similar questions can be used to assess the female patient's sexual history.

The diet history is often deferred or abbreviated when gathering an boyish database. In this age group information technology is an important and at times a crucial component. The adolescent is nutritionally vulnerable considering (1) there is a greater demand for energy (calories), quality protein, minerals, and vitamins during the rapid phase of physical growth; (ii) there 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 business concern or request by the adolescent to gain or lose weight be seriously considered by the doc if inappropriate fad diets that may lead to nether- or overnutrition are to be interrupted or avoided. For case, the dr. should accept seriously the desire of an apparently normal-weight boyish to lose 5 kg, or the athlete who wishes to gain weight. Failure to do so may in the onetime result in a diet that provides inadequate diet or in the latter the use of anabolic steroids. Since eating disorders are increasing in frequency in today's youth, especially females, the patient'south eating habits should be carefully explored for potential signs of anorexia nervosa, bulimia, or overeating.

Some of the key features of a successful boyish interview are summarized in Table 223.five. Finally, it tin can often be revealing to conclude the interview by asking, "Are there any areas of business organisation yous have that nosotros take not discussed?"

Tabular array 223.v

Critical Features of a Successful Boyish Interview and Physical Exam.

The Concrete Exam

The physical examination frequently provokes meaning feet in adolescents. Consequently, it is important to properly prepare the teenager for the examination and to communicate to the patient your findings and an interpretation. The old can be accomplished by reviewing with the adolescent what is to be done during the concrete exam immediately following the interview while he or she is still dressed. For instance, the md tin can state to the male patient, "Adjacent I (use the first person, not the 3rd since the adolescent may be confused and apprehensive about what "we" means) will need to do a physical examination. I am going to examine the surface area that has been a problem for you likewise as your eyes, ears, nose, pharynx, cervix, chest, breasts, tum, arms, legs, penis, and testicles. Once you are in the examination room, the nurse will tell you how to put on the test gown after y'all have removed all your clothes. Before anyone comes dorsum into the room, a knock will be used to assure that you lot are ready. Do y'all accept any questions?"

For the boyish, privacy and autonomy are of import issues. Both females and males are basically modest. Consequently, it is of import to provide an examination gown that covers the body and genital area. During the examination the boyish's feeling of control can be but and effectively enhanced by having him or her uncover the area which needs to exist exposed for examination. Talking with the adolescent during the examination also tends to increment comfort; nevertheless, the chat should be advisable to the expanse being examined (i.eastward., don"t discuss the conditions while examining the breasts or genitals; discuss the area being examined). The key features for the boyish physical test are summarized in Table 223.five and the phase of evolution when selected problems are most probable to occur in Table 223.6.

Table 223.6

Selected Correlations with Sexual Maturation Ratings in Males and Females.

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

Since the adolescent is concerned near body growth, development, and "normality," it is important to identify acne, blemishes, or deformities and ask every bit to the adolescent's business about them. If an expanse appears to be normal and secondary sexual development appropriate for age, it is of import to so inform the adolescent since he or she may non enquire de novo. This simple process oft relieves tension, allays fear, and opens the way for the adolescent to ask questions that would otherwise not be verbalized.

Key components of the adolescent'southward concrete test include an accurate height (without shoes) and weight (preferably in the exam gown); sitting or supine blood pressure level; staging of the genitals in the male person, breasts in the female, 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's tiptop and weight should be recorded on a longitudinal (NCHS) or velocity (Tanner and Whitehouse) growth chart along with all available prior values. This (ane) provides an effective method of assessing the patient's growth charge per unit per year and (ii) establishes his or her usual growth percentile. Pinnacle and weight normally progressives continuously during childhood and puberty until the deceleration nadir after the PH V or PWV year. A distinct plateauing of linear growth or weight gain or an unexplained weight loss (>2 kg) should warning the physician to possible underlying affliction and a demand for close observation and/or farther evaluation. The adolescent'south phase of secondary sexual development should also be advisedly recorded for testes or breasts, and for pubic hair. A distinctly early or delayed onset and/or rapid or wearisome 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 every bit hypothyroidism, inflammatory bowel disease (primarily Crohn's), renal tubular acidosis, etc. Although at that place are no absolute criteria for recognizing abnormal height and weight proceeds and secondary sexual evolution during puberty, the guidelines shown in Table 223.7 take proven to be clinically useful.

Table 223.7

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

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

Laboratory Evaluation

Baseline laboratory data for the adolescent should include: hemoglobin or hematocrit, urinalysis, cholesterol, hemoglobin electrophoresis in blacks, every bit 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 stage of evolution. For example, a hematocrit of 36% is normal for a male or female in stage 1 (prepubertal) compared to 41% in the stage five male and 37% in the female person. Adolescents who use drugs or alcohol should likewise have baseline liver function tests. Since alkaline metal phosphatase (AP) rises in a higher place 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, meridian at the fourth dimension of PH 5 in both males and females, and usually pass up into the normal range by the time an adolescent has reached phase 5. Meridian values may be every bit high as three times the upper normal adult values.

Preventive Health Care

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

Some important bug for anticipatory health intendance counseling are: G2-3 or B2 a significant, usually rapid, growth in top and weight should begin inside a few months during which fourth dimension a degree of temporary physical disequilibrium will occur; G4-5 a major increase in strength will occur and such activities as weight lifting should be deferred until that time; G3-4 nocturnal emissions and masturbation are mutual and are non physically harmful; B2-3 menarche and menses should be reviewed; G3 or B3 discussions of sexuality, venereal 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 adolescent's attention. In add-on, near adolescents are beholden of a cursory overview of what to look during their next phase of growth. For such counseling to be most effective, information technology must be tailored to the individual'due south level of psychologic, sexual, social, and cognitive development.

Conclusion

In summary, puberty is a complex dynamic process nearly which the md must take a general working knowledge if optimum comprehensive care is to exist provided. As a patient, the adolescent can exist frustrating, maddening, unpredictable, fourth dimension-consuming, and frightening. More of import, and more ofttimes, caring for him or her is challenging and rewarding.

References

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Daniel WA Jr. Growth at boyhood: clinical correlates. Semin Adol Med 1985;l:15–23. [PubMed: 3843470]
Deliege A. Indicators of physical, mental and social wellbeing. World Health 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 amongst American males and females. J Adol Health Care 1980;fifty:26–29. [PubMed: 6458588]
Rohn RD. Papilla (nipple) development during female puberty. J Adol Health Care. 1982;2:217–twenty. [PubMed: 7096166]
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Source: https://www.ncbi.nlm.nih.gov/books/NBK708/

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