2025 – PAGE 68 – ADOLESCENT MEDICINE

CHROMOSOMAL ABNORMALITIES

Microcephaly and dysmorphic features should suggest a chromosomal abnormality.

INADEQUATE CALORIC INTAKE or MALABSORPTIVE DISORDERS

For a patient with inadequate caloric intake or a malabsorptive disorder, look for an initial decline in the weight curve, THEN a deceleration of the height or length. So if you see that HC and HT are spared while WT falls off, consider CALORIC INSUFFICIENCY.

PEARL: If you see a quick drop in weight without significant drop in height yet (low WT for HT), there is a severe underlying disorder. Consider a workup for GI (Celiac, malabsorption), Renal or Metabolic disorders.

SPARING OF HEAD CIRCUMFERENCE

If there is sparing of head circumference while the weight and height are falling on the curves, it’s usually due to an ENDOCRINE problem. Sometimes, this can also be seen with GENETIC SHORT STATURE and CONSTITUTIONAL DELAY.

SMALL HEAD DISORDERS

• ­PRIMARY CRANIOSYNOSTOSIS: Abnormal suture lines, normal brain on imaging
• ­PRIMARY MICROCEPHALY: Brain is genetically abnormal
• ­SECONDARY MICROCEPHALY: Normal sutures, abnormal brain on imaging because of some type of disease process or environmental exposure.

AMENORRHEA

AMENORRHEA PEARLS

• ­Always rule out pregnancy, anatomic obstructions, and malformations. Remember, menarche is usually during SMR 3 or 4.
• ­PREGNANCY is a frequent answer.
• ­LH results in Progesterone production.
• ­FSH results in Estrogen production. Estrogen is responsible for breast development!

MNEMONIC: Use the THREE letters of FSH and THREE syllables of es-tro-gen to remember that FSH is responsible for estrogen production.

AMENORRHEA WORKUP

Always start an amenorrhea workup with an HCG; if that is negative, then move on to further testing:

• ­PROGESTERONE CHALLENGE
  • If POSITIVE (patient bled within 2 weeks of administration), that means there is plenty of ESTROGEN, but progesterone was missing. Why? Obtain an LH level:
    • High LH level = PCOS
    • Low LH level? → Get PRL (prolactin) and TSH levels. Keep in mind that elevated PRL can be the primary disorder or due to hypOthyroidism. If only the PRL level is high, then the diagnosis is likely a PROLACTINOMA.
  • If NEGATIVE, there is NOT enough ESTROGEN. So obtain an FSH level:
    • HIGH FSH: Consider OVARIAN FAILURE (TURNER’S SYNDROME, an autoimmune disease, chemo­therapy, premature menopause). It is doubtful that it is increased due to excess release from the pituitary.
    • Low FSH: Means there’s a CENTRAL problem = Mass? Prolactinoma? Craniopharyngioma? HypOthyroid?