# Clinical Cases: Adolescent Medicine

## Case 1: Adolescent Depression with Suicidal Ideation

### Patient Demographics
- **Age:** 15-year-old female
- **Sex:** Female

### Chief Complaint
"I'm here for my sports physical."

### History of Present Illness
A 15-year-old girl presents for a preparticipation sports physical for the upcoming soccer season. Her mother is in the waiting room. When interviewed alone, the patient appears withdrawn and makes limited eye contact. During the HEADSS assessment, she discloses that she has been feeling "sad and empty" for the past 3 months. She has difficulty falling asleep, often lying awake until 2 AM thinking about "everything that's wrong." She has lost interest in soccer and hanging out with friends. Her grades have dropped from As and Bs to Cs and Ds. She admits to thinking "everyone would be better off without me" and has thought about taking pills from her mother's medicine cabinet. She denies a specific plan or intent to act. She denies substance use. Her parents divorced 6 months ago, and she feels caught in the middle.

### HEADSS Assessment Summary
- **Home:** Parents divorced 6 months ago; lives with mother; feels caught in the middle of parental conflict
- **Education:** Junior in high school; grades dropped significantly this semester
- **Eating:** Decreased appetite, lost 8 lbs over 2 months
- **Activities:** Withdrew from friends; stopped attending soccer practice
- **Drugs:** Denies tobacco, alcohol, or drug use
- **Sexuality:** Has a boyfriend of 4 months; sexually active with condoms; denies abuse or coercion
- **Suicide/Safety:** Passive suicidal ideation (thoughts that others would be better off without her); has thought about method (pills) but denies current intent or plan

### PHQ-A (Patient Health Questionnaire - Adolescent)
- Score: 18/27 (moderately severe depression)
- Positive for nearly every day: feeling down, sleep problems, fatigue, worthlessness, concentration difficulty
- Reports some thoughts of self-harm

### Physical Examination
- **Vital Signs:** HR 72 bpm, BP 110/68 mmHg, Weight: 52 kg (down from 56 kg 4 months ago)
- **General:** Appears tired, poor eye contact, slow to respond to questions, flat affect
- **Skin:** No evidence of self-harm (cutting); intact without lesions
- **Cardiovascular:** Normal
- **Otherwise:** Normal examination appropriate for sports clearance

### Diagnosis
**Major depressive disorder, moderate to severe, with suicidal ideation**

### Clinical Reasoning
This adolescent meets DSM-5 criteria for major depressive disorder with depressed mood and multiple additional symptoms (sleep disturbance, loss of interest, decreased energy, worthlessness, poor concentration, weight loss) present for more than 2 weeks, causing significant functional impairment (grades, social withdrawal). The suicidal ideation with thoughts of method but without current intent places her at moderate risk requiring careful safety planning. Precipitating stressor (parental divorce) is identified but does not diminish the severity of the disorder. The presentation at a "sports physical" is typical - adolescents often do not self-identify depression and may only disclose when specifically asked during confidential screening.

### Management
1. **Risk assessment:** No imminent risk given lack of plan/intent, but requires safety planning
2. **Safety planning:**
   - Identify warning signs and coping strategies
   - List trusted adults she can contact
   - Remove access to lethal means (discuss medication lockbox with parent)
   - Provide crisis line information (988 Suicide and Crisis Lifeline)
3. **Parental involvement:** With patient's agreement, involve mother in safety planning; emphasize means restriction
4. **Psychotherapy referral:** Cognitive behavioral therapy (CBT) or interpersonal therapy - first-line treatment
5. **Medication consideration:** Given severity, discuss starting fluoxetine (FDA-approved for adolescent depression) 10 mg daily
6. **Black box warning counseling:** Discuss increased monitoring for suicidal ideation with SSRI initiation
7. **Close follow-up:** See in 1 week; more frequent contact during first month of medication
8. **Sports clearance:** Defer pending mental health stability

### Clinical Image
![PHQ-A screening questionnaire](case_01_image.jpg)

**Image Description:** Sample Patient Health Questionnaire for Adolescents (PHQ-A) used for depression screening, demonstrating the scoring system and key questions about mood, sleep, and suicidal thoughts.

**Source:** Wikimedia Commons - Mental Health Screening
**URL:** https://commons.wikimedia.org/wiki/File:Depression_screening.svg
**License:** CC BY-SA 4.0

---

## Case 2: Anorexia Nervosa

### Patient Demographics
- **Age:** 16-year-old female
- **Sex:** Female

### Chief Complaint
"Her coach is worried about her weight loss."

### History of Present Illness
A 16-year-old cross-country runner is brought in by her mother after her coach expressed concern about significant weight loss over the past 4 months. The patient states she has been trying to "eat healthy" to improve her running performance. She has eliminated most carbohydrates, fats, and snacks from her diet, eating mostly salads and fruit. She exercises 2-3 hours daily in addition to team practice. She denies vomiting, laxative use, or binge eating. She reports feeling "fine" and insists she is "not that thin." Her last menstrual period was 4 months ago. She was previously having regular monthly periods. She feels cold frequently and has noticed increased hair on her arms.

### History
- **Weight history:** Current 47 kg; weight 6 months ago was 58 kg (19% weight loss)
- **Menstrual history:** Menarche age 12; regular periods until 4 months ago; now amenorrheic
- **Exercise:** Running 8-10 miles daily; added extra workouts without coach's knowledge
- **Purging behaviors:** Denies vomiting, laxatives, diuretics
- **Body image:** Feels stomach is "still fat"; wants to lose 5 more pounds

### Physical Examination
- **Vital Signs:** Temperature 35.8C (hypothermic), HR 48 bpm (bradycardic), BP 88/54 mmHg (orthostatic drop of 20 mmHg on standing), RR 14/min
- **Height:** 165 cm
- **Weight:** 47 kg
- **BMI:** 17.3 kg/m2 (severely underweight; <5th percentile)
- **General:** Thin, ill-appearing adolescent in mild distress from cold
- **Skin:** Dry skin, lanugo hair on arms and back, yellowish tinge to palms (carotenemia)
- **Cardiovascular:** Bradycardic, regular rhythm, no murmurs
- **Abdomen:** Scaphoid, normoactive bowel sounds
- **Extremities:** Cold, mottled, delayed capillary refill
- **Neuropsych:** Denies depressed mood; anxious about being weighed

### Laboratory Findings
- **CBC:** WBC 3,200/uL (low), Hemoglobin 11.2 g/dL
- **Electrolytes:** Na 138, K 3.2 mEq/L (low), HCO3 28
- **BUN/Cr:** 22/0.9 (elevated BUN suggesting dehydration)
- **Glucose:** 62 mg/dL (low)
- **ECG:** Sinus bradycardia, HR 46 bpm, QTc 480 ms (prolonged)
- **LH, FSH:** Low (hypothalamic suppression)

### Diagnosis
**Anorexia nervosa, restricting type**

### Clinical Reasoning
This patient meets DSM-5 criteria for anorexia nervosa: (1) restriction of energy intake leading to significantly low body weight (BMI 17.3, <5th percentile, with 19% weight loss), (2) intense fear of gaining weight despite being underweight, (3) disturbance in body image (feels "stomach is still fat"). The subtype is restricting (no binge-purge behaviors). She has multiple medical complications of starvation: hypothermia, severe bradycardia, orthostatic hypotension, prolonged QTc (risk for arrhythmia), hypoglycemia, and amenorrhea. These findings indicate severe disease requiring hospitalization.

### Management
1. **Hospital admission:** Required due to:
   - HR <50 bpm
   - Orthostatic hypotension
   - Prolonged QTc
   - Hypoglycemia
   - Severe malnutrition
2. **Cardiac monitoring:** Telemetry for arrhythmia risk
3. **Nutritional rehabilitation:** Start low (1,200-1,400 kcal/day) and advance slowly to prevent refeeding syndrome
4. **Refeeding syndrome prevention:**
   - Monitor phosphorus, potassium, magnesium twice daily during initial refeeding
   - Supplement phosphorus prophylactically
   - Slow rate of caloric increase
5. **Multidisciplinary team:** Medical, psychiatry, nutrition, family therapy
6. **Psychotherapy:** Family-based treatment (Maudsley approach) has strongest evidence for adolescent anorexia
7. **Remove from sports:** Until medically and psychologically stable
8. **Weight restoration goal:** Establish target weight with return of menses

### Clinical Image
![Adolescent with anorexia showing physical signs](case_02_image.jpg)

**Image Description:** Clinical photograph demonstrating lanugo hair on the back of a patient with anorexia nervosa, a physical sign of the body's attempt to maintain temperature in the setting of severe malnutrition.

**Source:** DermNet NZ
**URL:** https://dermnetnz.org/topics/lanugo
**License:** CC BY-NC-ND 3.0 NZ

---

## Case 3: Substance Use Disorder

### Patient Demographics
- **Age:** 17-year-old male
- **Sex:** Male

### Chief Complaint
"I'm here because my parents found weed in my room."

### History of Present Illness
A 17-year-old male is brought in by his parents after they discovered marijuana and a vaping device in his room. He is initially defensive but opens up when interviewed alone. He reports using marijuana "almost every day" for the past year, usually smoking after school and before bed to "relax and deal with stress." He started vaping nicotine at age 14 and now goes through about one pod per day. He admits to drinking alcohol on weekends at parties, typically 5-6 drinks per occasion. He has tried Xanax twice that he obtained from friends "just to see what it was like." He missed several days of school last semester and his grades have dropped. He was caught driving under the influence of marijuana 2 months ago but charges were dismissed after completing a diversion program.

### CRAFFT Screening
| Question | Response |
|----------|----------|
| C: Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs? | Yes |
| R: Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? | Yes |
| A: Do you ever use alcohol or drugs while you are by yourself, or ALONE? | Yes |
| F: Do you ever FORGET things you did while using alcohol or drugs? | Yes |
| F: Do your FAMILY or friends ever tell you that you should cut down on your drinking or drug use? | Yes |
| T: Have you ever gotten into TROUBLE while using alcohol or drugs? | Yes |

**Score: 6/6 (high risk)**

### Physical Examination
- **Vital Signs:** HR 88 bpm, BP 118/74 mmHg, RR 16/min
- **General:** Casually dressed, mild marijuana odor on clothes
- **Eyes:** Mild conjunctival injection
- **Lungs:** Clear to auscultation
- **Otherwise:** Normal examination

### Diagnosis
**Cannabis use disorder, moderate; Nicotine use disorder, moderate; Alcohol use disorder, mild**

### Clinical Reasoning
The CRAFFT score of 6/6 indicates high-risk substance use requiring intervention. This patient meets criteria for cannabis use disorder with daily use, use despite legal consequences (DUI), tolerance, and interference with school. Nicotine dependence is evident from daily vaping. The pattern of weekend binge drinking (5-6 drinks) meets criteria for alcohol use disorder. Risk factors include early onset of use (nicotine at 14), polysubstance use, and legal involvement. Protective factors include engaged parents who brought him for evaluation. The brief intervention should assess readiness for change and enhance motivation.

### Management
1. **Brief intervention (motivational interviewing):**
   - Explore his perspective on his use ("What do you like about using?")
   - Provide feedback on risks in a non-judgmental way
   - Assess readiness to change (precontemplation, contemplation, preparation)
   - Explore discrepancy between goals and current behavior
   - Support autonomy in decision-making
2. **Referral to adolescent substance abuse treatment:** Outpatient counseling for cannabis and alcohol use
3. **Nicotine cessation:** Offer nicotine replacement therapy or discuss varenicline for older adolescents
4. **Mental health screening:** Screen for underlying depression and anxiety (common comorbidities)
5. **Harm reduction:** If not ready to quit, discuss reducing use, never driving impaired, carrying naloxone if ever around opioids
6. **Parental involvement:** With patient's agreement, engage parents as supports
7. **Follow-up:** Frequent visits to monitor progress and reinforce motivation

### Clinical Image
![CRAFFT screening questionnaire](case_03_image.jpg)

**Image Description:** The CRAFFT substance use screening tool designed for adolescents, showing the mnemonic questions used to identify high-risk alcohol and drug use in young patients.

**Source:** Wikimedia Commons - Substance Use Screening
**URL:** https://commons.wikimedia.org/wiki/File:Substance_screening.svg
**License:** CC BY-SA 4.0