Figure 67-6 Sequence of pubertal events in the average American male. Testicular volume less than 4 mL using an orchidometer (Prader Beads) represents prepubertal stage. (From Brookman RR, Rauh JL, Morrison JA, et al: The Princeton maturation study, 1976, unpublished data for adolescents in Cincinnati, Ohio. Reprinted from Assessment of Pubertal Development, Columbus, Ohio, 1986, Ross Laboratories.)
Stage 2 There is sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, primarily at the base of the penis.
Stage 3 The hair is considerably darker, coarser, and more curled. The hair spreads sparsely over the junction of the pubes.
Stage 4 The hair, now adult in type, covers a smaller area than in the adult and does not extend onto the thighs.
Stage 5 The hair is adult in quantity and type, with extension onto the thighs.
Figure 67-5 Typical progression of male pubertal development. A, Pubertal development in the size of male genitalia. B, Pubertal development of male pubic hair. Note that in stage 1 there is no pubic hair. (Courtesy of J.M. Tanner, MD, Institute of Child Health, Department of Growth and Development, University of London, London, England.) voice, facial hair, and acne indicate the early stages of puberty. See Chapter 174 for discussion of disorders of puberty.
Changes Associated with Physical Maturation
Tanner stages mark biologic maturation that can be related to specific laboratory value changes and certain physical conditions. The higher hematocrit values in adolescent boys than in adolescent girls are the result of greater androgenic stimulation of the bone marrow and not loss through menstruation. Alkaline phosphatase levels in boys and girls increase during puberty because of rapid bone turnover, especially during the growth spurt. Worsening of mild scoliosis is common in adolescents during their growth spurt.
SEE TABLE 67-3 AND CHAPTERS 7 AND 9.
When interviewing an adolescent, use a nonjudgmental approach and find some common ground to get the adolescent talking about himself or herself. The HEADDSS (home, education, alcohol, drugs, diet, sex, suicide/depression) mnemonic addresses important risk-taking elements of the history (see Table 67-5). Adolescents who experiment in one area of risk-taking often have contemplated or tried multiple other risk-taking behaviors. When all of the risk-taking information has been gathered, the physician should choose one or two health care issues to discuss, making it clear that the information is confidential and that he or she is there to help the adolescent in a partnership way. Although the focus in adolescent care is on psychosocial issues, a general examination also needs to be performed (Table 68-1). Pediatric issues, such as immunization (see Chapter 94) and health screening, should be included (see Table 9-5).
Rapid changes in physical appearance and behavior are the major characteristics of early adolescence, leading to a great dealof self-consciousness and need for privacy. The history focuseson the early adolescent’s physical and psychosocial health.
Autonomy and a global sense of identity are the major characteristics of middle adolescence. The history focuses on
Explain to your patient what you are going to do. Explain how you are going to do it. Ask whether your adolescent wants his or her parent in the room.* Be sensitive to the adolescent’s needs. Always use a sheet or blanket to provide privacy. Let the adolescent remain dressed and work around the clothing. Ask some questions as you go through the physical to keep the adolescent at ease. Give reassurance that elements of the physical are normal for this age.
Examination can be used to offer reassurance about normalcy.†
Assess the following:
Skeletal: scoliosis, Osgood-Schlatter disease, slipped capital