THG12-001
A mother brings her 11 years old daughter for a routine check up to the pediatrician since she is worried about her breast size and has some queries.
a. What is the first sign of puberty in girls and age of occurrence?
b. What is the order of development of secondary sexual characters and when does menarche appear?
c. What is the earliest sign of puberty in boys and at what age it starts?
d. When does penile growth start?
Answer
- a. Development of breast buds—thelarche and it starts between 8 and 13 years.
- b. Thelarche → pubarche → menarche; menarche begins within 3 years of thelarche anywhere between 9 and 15 years of age.
- c. Testicular enlargement which starts at 9 years.
- d. Around 12 years during sexual maturity rating (SMR) stage 3.
THG12-002
A 14-year-old girl is brought to the outpatient department by her parents with complaints of poor diet such as skipping meals and extreme avoidance of fatty food, that she is extremely concerned about gaining weight even though she is of normal weight.
a. What is this girl suffering from and what are the types?
b. Describe the various forms of clinical presentations that can occur with this condition.
c. What is HEEADSSS?
d. Name any two scales used for assessment of this condition.
e. What are the indications for referral to a mental health professional?
Answer
- a. This girl has a negative body image. Body image is defined as internal representation of one’s external appearance, it can be positive or negative.
- b. Concerns about growth and pubertal changes, eating disorders, excessive exercise, menstrual irregularities, parental conflicts, intake of drugs or supplements, medical emergencies such as electrolyte disturbances and hypotension.
- c. HEEADSSS is a form of psychosocial history taking for adolescent concerns. It stands for:
- H: Home
- E: Education
- E: Eating habits
- A: Activities
- D: Depression
- S: Substance use
- S: Sexuality
- S: Safety
- d. Figure rating scale (schematic drawings), Body Shape Questionnaire (BSQ), Adolescent Body Image Satisfaction Scale (ABISS), and Eating Attitudes Test (EAT).
- e. EAT score >20, poor response to multiple counseling sessions, severe substance use disorder, severe depression, suicidal ideation, and behavior.
THG12-003
A 16-year-old boy has been brought with complaints of increase in breast tissue size on both sides for past 6 months.
a. Define gynecomastia and its types.
b. Name any two drugs that cause gynecomastia.
c. What are the key points to be elicited in the history?
d. What are the laboratory tests needed?
e. What medicines can be tried and what is the indication for surgery?
Answer
- a. Gynecomastia is symmetrical proliferation of breast tissue in males. Its types are as follows:
- True: presence of glandular breast tissue
- Pseudo: accumulation of fat in breast in overweight males
- Physiological pubertal: unilateral or bilateral, transient tenderness and spontaneous regression within a few months
- Pathological: genetic forms, male hypogonadism, and exogenous causes
- b. Drugs—ACE inhibitors, spironolactone, isoniazid, anabolic steroids, ketoconazole, cimetidine, flutamide, and oral contraceptive pills (OCPs).
- c. Family history of male relatives with gynecomastia, history of liver or renal diseases, intake of medications or drug abuse, and exposure to herbal and cosmetic products that may contain phytoestrogens.
- d. Thyroid function tests, liver and kidney function tests, testosterone, estradiol, human chorionic gonadotropin (hCG), prolactin, and luteinizing hormone (LH) levels.
- e.
- Medical: raloxifene (60 mg/day) or tamoxifen (10–20 mg/day) for 3 months.
- Surgical: Tanner stage 3–5 with failure of regression in 18–24 months who have completed or near completed puberty.
THG12-004
A 16-year-old girl comes to the outpatient department (OPD) with complaints of menstrual irregularities and hirsutism for past 6 months.
a. What is the condition and the criteria for diagnosis?
b. At what age should the diagnosis be made?
c. What is the differential diagnosis for this condition?
d. What are the long-term complications?
e. What are the management measures?
Answer
- a. Adolescent PCOS if both irregular periods and features of hyperandrogenism are present and Rotterdam criteria (2 out of 3 present):
- Oligoovulation / anovulation
- Polycystic ovaries on ultrasonography (USG) (>12 follicles in 1 ovary or ovarian volume >10 mm³)
- Clinical and/or biochemical hyperandrogenism
- b. Adolescent PCOS is diagnosed 2 years after menarche.
- c. Diseases such as hyperprolactinemia, thyroid disorders, adult-onset 21-hydroxylase deficiency, Cushing syndrome, and androgen-secreting tumors of ovary and adrenal should be ruled out.
- d. Long-term complications include fertility issues, features of metabolic syndrome such as insulin resistance, glucose intolerance, obesity, dyslipidemia, and endometrial cancer.
- e. Lifestyle modifications through diet and weight loss, metformin, combination OCPs (estrogen and progestin), antiandrogens such as spironolactone, cyproterone acetate, finasteride, and flutamide, and specific therapies for acne and hair removal.
THG12-005
A 15-year-old boy comes to the OPD with complaints of sleep disturbance for past 6 months.
a. What are the common sleep disorders in adolescents?
b. What are the external factors that can interfere with adolescent sleep?
c. How to assess sleep disorders in an adolescent?
d. What is the BEARS sleep screening tool?
e. What are the treatment measures for sleep disorders in adolescents?
Answer
- a. Delayed sleep-wake phase disorder (DSWPD), obstructive sleep apnea (OSA), psychophysiological insomnia, narcolepsy, restless legs syndrome, sleep walking (somnambulism), and excessive daytime sleepiness.
- b. Early school hours, academic pressure, caffeine intake, anxiety, depression, chronic adenoid hypertrophy, asthma, obesity, and increased screen time.
- c. Detailed history taking including sleep pattern, routine around sleep time, dietary practices and other symptoms, sleep and media history via HEEADSSS psychosocial history taking, examination and evaluation of chronic medical disorders like asthma, obesity, OSA, and hypertension.
- d. BEARS is a screening tool to evaluate any potential sleep problem in children aged 2–18 years:
- B: Bedtime problems
- E: Excessive daytime sleepiness
- A: Awakenings during the night
- R: Regularity and duration of sleep
- S: Sleep-disordered breathing
- e. Advising sleep hygiene and screen time guidelines, iron supplements for restless legs syndrome, treatment of ear, nose, and throat (ENT) causes for OSA, appropriate treatment for specific sleep disorders, treatment of comorbidities, and psychotherapy for psychiatric issues.
THG12-006
A mother brings her 15 years old daughter for evaluation with complaints that she has not attained menarche still and she does not also have secondary sexual characters.
a. What kind of amenorrhea does this girl have? Differentiate between primary and secondary amenorrhea.
b. What key points should be elicited in the history?
c. What are the important examination findings to be looked for?
d. What are the various causes for primary amenorrhea?
e. How will you evaluate an adolescent for primary amenorrhea?
Answer
- a. This girl has primary amenorrhea.
- Primary amenorrhea: absence of menstruation by the age of 15 years.
- Secondary amenorrhea: absence of menstruation for 3 months consecutively in those with previously normal menstruation or for >6 months in those with irregular menstruation.
- b. Key history points:
- Dietary intake
- Any ongoing symptoms such as fever, headache, and vision disturbances
- Chronic gastrointestinal or respiratory complaints
- Galactorrhea, changes in nails or hair or body hair
- Family history of menarcheal age and drug intake
- History pertaining to PCOS and sexual history
- History suggestive of thyroid dysfunction
- c. Plotting of growth charts, assessing SMR, BMI, blood pressure (BP), lymphadenopathy, thyroid palpation, anosmia, skin and hair changes, abdominal examination, and genital examination.
- d. Syndromes like Turner syndrome, Kallmann syndrome, Mayer–Rokitansky–Küster–Hauser syndrome, gonadal dysgenesis, imperforate hymen, functional or idiopathic hypothalamic or pituitary causes, constitutional delay, ovarian causes like primary ovarian insufficiency, PCOS, systemic diseases like Langerhans cell histiocytosis (LCH), craniopharyngioma, sellar masses, and adrenal hormone deficiencies.
- e. Evaluation of primary amenorrhea starts with ruling out pregnancy, measurement of LH, follicle-stimulating hormone (FSH), estradiol, thyroid-stimulating hormone (TSH), prolactin, pelvic ultrasound, and genetic analysis.
THG12-007
A 14-year-old girl presented to emergency room (ER) with complaints of breathing difficulty and palpitations for the past 30 minutes. On examination, her vitals showed heart rate (HR)— 140 beats/minute and respiratory rate (RR)—26 breaths/minute. Examination of cardiovascular system (CVS) and respiratory system (RS) were normal, electrocardiogram (ECG) was normal, she was observed for an hour and her symptoms abated. On probing she revealed that her examinations are nearing.
a. What condition does this girl have?
b. What are the types of anxiety disorders?
c. What differential diagnosis will you consider?
d. What is the management?
Answer
- a. Panic disorder
- b. Anxiety disorders are divided into:
- Generalized anxiety disorder
- Phobias
- Panic disorder
- Social anxiety disorder
- Obsessive compulsive disorder
- Post-traumatic stress disorder
- Separation anxiety disorder
- Situational anxiety
- c. Arrhythmias, substance use and withdrawal, hyperthyroidism, pheochromocytoma, anaphylaxis, autoimmune encephalitis, and delusional disorder.
- d. Anxiolytic agents, selective serotonin reuptake inhibitors (SSRIs), and atypical antidepressants.
THG12-008
A 16-year-old girl presents with complaints of heavy menstrual bleeding that have been ongoing for 10 days, she has been having similar cycles for the past 6 months. She attained menarche 2 years ago. She also complaints of lethargy but is hemodynamically stable.
a. What is abnormal uterine bleeding and its types?
b. What are the causes?
c. What are the laboratory tests that should be done?
d. How will you manage based on the severity of bleeding?
Answer
- a. Abnormal uterine bleeding is menstrual bleeding that is abnormal in volume, duration, frequency, and regularity. It can be either intermenstrual bleeding or heavy menstrual bleeding which is the most common form.
- b. Causes—endocrine causes like PCOS, thyroid disorders, hyperprolactinemia; bleeding disorders like von Willebrand disease, clotting factor deficiencies; infections like cervicitis, sexually transmitted infection (STI); uterine pathologies like polyp, adenomyosis, malignancy, ectopic pregnancy; medications like anticoagulants; and traumatic causes.
- c. Complete blood counts, coagulation profile, urine pregnancy test, screening for sexually transmitted disease (STD), liver and renal function tests, TSH, testosterone levels, prolactin, adrenal function tests, and pelvic ultrasound.
- d. Treatment based on severity of bleeding:
- Mild (Hb >10 g/dL): oral iron with nonsteroidal anti-inflammatory drugs (NSAIDs) with progestin or OCPs OD for 21 days.
- Moderate (Hb 8–10 g/dL): oral iron with OCPs BD till bleeding stops and then OD for 21 days.
- Severe (Hb <8 g/dL): blood transfusion with conjugated estrogen or OCPs.
THG12-009
A 16-year-old girl comes to the OPD with complaints of foul smelling grayish white vaginal discharge for the past 1 month.
a. Along with regular history taking what key component of history should be included here?
b. What is the diagnosis for this girl and the causative organisms?
c. What should be looked for in the microscopic examination of specimen?
d. What is OSOM BV BLUE test?
e. What is the treatment?
Answer
- a. A thorough sexual history is important for identifying adolescents who need screening for STDs even though bacterial vaginosis can be present in sexually inactive teens.
- b. Bacterial vaginosis that can be caused by Gardnerella vaginalis, Trichomonas vaginalis, Ureaplasma, or Mycoplasma.
- c. Microscopy of specimen slide shows Clue cells or motile or dead T. vaginalis that indicate bacterial vaginosis.
- d. It is a test that detects high vaginal fluid sialidase activity which is an enzyme produced by the causative organisms.
- e. Metronidazole or tinidazole 2 g oral in a single dose (or) metronidazole 500 mg BD for 7 days.
THG12-010
A 17-year-old adolescent boy is brought by his parents with complaints that he tries to intentionally self-harm.
a. What are a pediatrician’s goals in managing an adolescent with suicidal tendency?
b. What should be the first step?
c. How do you examine such adolescent?
d. What are the warning signs of suicide in an adolescent?
e. What is the risk categorization and management plan for an adolescent with suicidal behavior?
Answer
- a. Pediatrician’s role—screening, risk evaluation and stratification, brief intervention by immediate counseling and reassurance, safety planning, referral, follow-up, and prevention.
- b. Proper documentation of case assessment and management by doing the HEEADSSS screening, establishing rapport, active listening, being nonjudgmental and showing empathy, asking open-ended questions to assess risk of suicide.
- c. Clinical examination—general appearance (behavior, dressing, and facial expression) with vital signs, hesitation cuts and injuries, attitude, mental status examination, features of child and substance abuse, and features of any systemic diseases.
- d. Warning signs are identified by the mnemonic IS PATH WARM:
- I: Ideations of suicide
- S: Substance use
- P: Purposelessness
- A: Anxiety
- T: Trapped
- H: Hopelessness
- W: Withdrawal
- A: Anger
- R: Recklessness
- M: Mood changes
- e. Risk categorization and management:
- Low risk: has only thoughts of death, no planning or behavior; evaluate for psychiatric disorders, refer to psychiatrist.
- Moderate risk: has idea of suicide but with limited intent and no proper plan; evaluate for psychiatric disorders, refer to psychiatrist.
- High risk: has suicidal plan and has tried to rehearse it; if severe psychiatric symptoms or access to means or poor support then hospitalize, needs continuous monitoring and urgent psychiatry consultation.
THG12-011
A 14-year-old girl comes to the OPD with complaints of multiple acne lesions on her face that are pustular in nature.
a. What is the pathology and causative organism of acne?
b. What are the types of lesions in acne?
c. What is the primary treatment for acne vulgaris?
d. What topical medications can be used?
e. What oral antibiotics can be used?
Answer
- a. Increased sebum production from sebaceous glands, excessive keratinization leading to blocked follicular lumen, and proliferation of Cutibacterium acnes in the follicle leading to inflammation.
- b. Open or closed comedones, papules, pustules, and nodulocystic lesions.
- c. Topical retinoid should be the primary treatment.
- d. Topical retinoids such as tretinoin, adapalene, or tazarotene, and topical antimicrobials like benzoyl peroxide, clindamycin, erythromycin, and other agents like salicylic acid.
- e. Doxycycline, minocycline, and erythromycin.
THG12-012
Q12.12
a. What are the adolescent health programs in India?
b. Expand RKSK program and when was it launched?
c. What are the components of RKSK?
d. What are the key drivers of the program?
e. What services does it focus on?
Answer
- a. Adolescent health programs in India:
- Adolescent Friendly Health Clinics (AFHCs)
- Weekly Iron and Folic Acid Supplementation (WIFS)
- Rashtriya Kishor Swasthya Karyakram (RKSK)
- Menstrual Hygiene Scheme (MHS)
- Peer education program
- b. Rashtriya Kishor Swasthya Karyakram—an adolescent reach program for males and females, especially in marginalized and underserved groups, launched on January 7, 2014.
- c. Components include sexual and reproductive health, nutrition, injuries, violence, noncommunicable diseases, mental health, and substance abuse.
- d. Key drivers include community-based interventions through outreach by counselors, facility-based counseling, social and behavior change communication, and strengthening of AFHCs.
- e. It focuses on reorganizing the public health system to include preventive, promotive, curative, routine checkups, and counseling services to adolescent boys and girls (both married and unmarried).
THG12-013
A 13-year-old boy is brought to the OPD with complaints of inadequate sleep in the night, snoring, and feeling sleepy throughout the day. His weight is 72 kg and height is 154 cm.
a. Calculate body mass index (BMI) for this child, what is the complete diagnosis?
b. What key features of examination will you assess?
c. What parameters are used to assess the metabolic risk in obese adolescents and how will you measure them?
d. Elaborate causes of non-nutritional obesity.
e. What investigations should be done for nutritional obesity and what main lifestyle and diet advice will you give?
Answer
- a. BMI = Weight (kg) / Height² (m²) = 72 / (1.54)² = 30.3 kg/m²; Diagnosis: Obesity with OSA syndrome.
- b. Measurement of height, weight, waist circumference, BP, SMR assessment, and head-to-foot examination for clues for comorbidities.
- c. Parameters for metabolic risk:
- Waist circumference: measured in the standing position at the midpoint between the lowest rib and the iliac crest in the mid-axillary line at the end of expiration with a nonelastic tape. Waist circumference >90th centile indicates metabolic risk.
- Blood pressure: measured after 5 minutes of rest in sitting position at heart level; elevated BP must be confirmed on subsequent visits.
- d. Causes of non-nutritional obesity:
- Endocrine: hypothyroidism, Cushing’s disease, and growth hormone (GH) deficiency
- Genetic syndromes: Prader–Willi, Bardet–Biedl, and Alström syndromes
- Drug-induced: steroid therapy, antiepileptics, and psychotropic drugs
- Monogenic: leptin deficiency and leptin receptor defects
- Central causes: hypothalamic tumors, cranial radiation, and meningitis
- e.
- Investigations: lipid profile, fasting blood sugar, oral glucose tolerance test, and USG abdomen (to look for fatty liver/NAFLD).
- Lifestyle and diet advice:
- Eating portion-controlled food that is home cooked
- Do not skip breakfast
- Restrict to timely three meals and one or two healthy snacks
- Avoid junk food and sugary beverages
- Follow the traffic light method for eating
- At least 30–60 minutes of moderate-to-vigorous physical activity daily
- Restrict recreational screen time to <1–2 hours/day
- Ensure 8–10 hours of continuous sleep per night