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Paediatrics Royal College > Adole/Gyne/Psych > Flashcards

Adole/Gyne/Psych Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

What is the average age of first intercourse in Canada?

A

16.5

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2
Q

What is the age of consent for sexual activity in Canada?

A

16 years Close age exception: 1. 14-15 years can consent to someone up to 5 years older 2. 12-13 years can consent to someone up to 2 years older 3. Must NOT be in a position of authority

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3
Q

Which of the following is not a contraindication to OCP:

  1. Migraine with focal neuro signs 2. Unexplained VB 3. Mirgaine with aura 4. Smoking 5. DVT
A

smoking!

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4
Q

What are the failure rates of contraception methods: 1. Chance 2. Condoms 3. Combined OCP 4. Depo-Provera

A
  1. Chance- 85% 2. Condoms-12% 3. Combined OCP-8% 4. Depo-Provera-0.4%
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5
Q

What are the drug interactions with OCPs?

A
  1. AED: phenytoin, carbamazepine, barbituates (decrease efficacy) NOT VPA 2. Anti retroviral therapy 3. Rifampin NO interaction with antibiotics
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6
Q

What are the contraindications for OCPs?

A
  1. Possible pregnancy 2. Unexplained bleeding 3. Classic or complicated migraine 4. History of thrombosis 5. Uncontrolled HTN
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7
Q

What are the benefits of the OCP?

A

Reduction in: Blood loss, anemia PMS, dysmenorrhea acne, hirsutism Endometrial, ovarian cancers Ovarian cysts PID Benign breast disease

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8
Q

What are the main side effects of Depo?

A
  1. Irregular bleeding for 3-12 months 2. Weight gain 4-15 lbs 3. Reduced bone density 4. Increased risk of postpartum depression
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9
Q

What is the timing for emergency contraception?

A
  1. Preferable within 72 hours but can be given up to 120 hours
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10
Q

What are the methods of emergency contraception?

A
  1. Plan B (0.75 levonorgestrol x 2, separated or at the same time), SE: nausea, vomiting 2. Yuzpe
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11
Q

What are the contraindications for emergency contraception

A
  1. Anaphylaxis to the product 2. Pregnancy
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12
Q

What are the most common symptoms of a Chlamydia infection?

A
  1. None in 60-80% 2. Dysuria, vaginal d/c, abdominal pain, vaginalspotting
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13
Q

What is the treatment of Chlamydia?

A

Azithromycin 1 gm x 1 dose PO

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14
Q

What is the presentation of gonorrhea?

A

Less common than chlamydia None in 75-90% Discharge, dysuria, abdo pain Rarely systemic symptoms

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15
Q

What is the treatment of gonorrhea?

A
  1. Ceftriaxone 250mg IM x1 PLUS azithromycin 1 gram PO 2. Cefixime 800 mg PO x azithromycin 1 gram PO
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16
Q

What is the most common STI?

A

HPV 75-85% of sexually active people will acquire by age 50

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17
Q

What are the diagnostic critiera for PID?

A
  1. Lower abdominal pain PLUS either 2. Adnexal tenderness, uterine tenderness or cervical motion tenderness Supportive: Fever > 38.3, discharge, WBC on microscopy, elevated ESR/CRP, positive testing for G/C
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18
Q

What is the treatment for PID?

A

Outpatient: Ceftriaxone 250 IM x 1 then doxcycline 100 po BID x 14 days Inpatient: Cefoxitin 2 g IV Q6H PLUS doxycycline

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19
Q

When should you hospital with PID?

A
  1. Concerns about adherence 2. Pregnancy 3. Failure to respond to oral treatment 4. Severe illness, vomiting 5. Tubo-ovarian abscess 6. HIV infection
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20
Q

What is normal breast development in teens?

A

Thelarche at 8-14 years Precedes andrenarche by 6 months precedes menarche by 2 years Assymetry common, larger on side of dominant hand

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21
Q

What is an approach to mastalgia?

A

Usually benign, improves with time May get better or worse with OCP usually cyclical, worsening prior to menses R/o mass or infection Rx: supportive, NSAIDS prn

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22
Q

What are the common types of breast masses?

A

-Less than 1% are malignant -Fibroadenoma- solitary, painless, mobile, no change with menstrual cycle -Fibrocystic disease- cystic masses, tenderness, worse prior to menses

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23
Q

What is the only province with a formal age of consent?

A

Quebec 14 years

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24
Q

What are the statistics around teen suicide?

A
  1. Second leading cause of death 2. 41% of depressed youth have suicidal ideation 3. 35-50% will make an attempt
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25
Q

Which teens are at high of suicide?

A

-Males -Access to firearms -Past suicide attempt -Exposure/Family History -Bullies/being bullied -Substance abuse -Bipolar disorder -Intent/plan/means -Sexual minority

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26
Q

What is the definition of abuse?

A

-Adverse consequences related to use (missing school, unplanned sex, conflict with parents, negative health)

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27
Q

What are common risk behaviours in teens?

A

-Defiance of family rules -Truancy -Sexual experimentation -Smoking -Not using seat belt, helmets -shoplifting, bullying SUbstance use

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28
Q

How can we improve adherence in teens?

A
  1. Regime: simplify, once daily dosing, long acting meds, minimize side effects 2. Patient-physician relationship (most important) 3. Reminders 4. Rewards 5. Counselling
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29
Q

What is ARFID?

A

Avoidant/restrictive food intake disorder -Eating disturbance associated with failure to meet nutritional needs AND 1 of: 1. Weight loss or growth failure 2. Nutritional deficiency 3. Dependence on enteral feeds 4. Marked interference with functioning -NO EVIDENCE OF BODY IMAGE ISSUES -No medical illness

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30
Q

What are the significant changes in the DSM 5 to anorexia nervosa?

A
  1. “Refusal” has been removed 2. No specific weight criteria 3. Amenorrhea not necessary
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31
Q

What are the DSM 5 criteria for anorexia nervosa?

A

A/ Restriction of energy intake relative to requirements leading to significantly low body weight

B/ Intense fear of gaining weight or becoming fat, even though at significantly low weight

C/ Disturbance in the way in which body weight or shape is experienced

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32
Q

What are the DSM 5 criteria for bulimina nervosa?

A

A/ Recurrent episodes of binge eating

B/Recurrent inappropriate compensatory behaviour to prevent weight gain

C/ Binge eating and compensation occur at least once/week and for 3 months D/Self-image is unduly influence by body shape and weight E/Not during episodes of AN

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33
Q

What are the cardiovascular complications of eating disorders?

A

-Sinus bradycardia -Decreased voltages -Prolonged QTc -Ventricular arrhythmias -Orthostatic hypotension

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34
Q

What are the GI complications of eating disorders?

A

-Delayed gastric emptying -constipation -Elevated LFTs -SMA syndrome -acute pancreatitis

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35
Q

What are the complications of vomiting?

A

Complications of vomiting: -Parotid swelling and increased amylase -Gastric rupture -Mallory-weiss -erosion of dental emanel

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36
Q

What is the impact of ED on puberty and growth?

A

-Absence of pubertal development and failure of growth -Amenorrhea -Dramatic alternation in GH axis: growth failure possible -Osteoporosis

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37
Q

What are the indications for hospitalization in ED?

A
  • Wt<75-85
  • Arrest growth and development
  • Dehydration, electrolyte abN
  • Cardiac arrhythmias, HR <50day, HR <45 night, hypotension, hypothermia, orthostatic changes
  • Acute food refusal, uncontrolled binge/purge, acute psychiatric emergencies, comorbid
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38
Q

What percentage of teens have painful periods?

A

60% (14% miss school)

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39
Q

What is the differential diagnosis for dysmenorrhea?

A
  1. Primary 2. Secondary (endometrimosis, obstruction, other system)
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40
Q

What is the treatment of dysmenorrhea?

A
  1. NSAIDS 2. Hormonal
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41
Q

What is the most common pediatric mental health disorder?

A

Anxiety disorders

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42
Q

What are the three most common anxiety disorders?

A
  1. Separation anxiety 2. GAD 3. Social phobia
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43
Q

What are the characteristics of separation anxiety?

A
  • Developmentally inappropriate, >4 weeks
  • Most common in: girls, single parent families, families with panic history
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44
Q

What are the characteristics of generalized anxiety disorder?

A

-More days than not, >6 months -Somatic presentations are common: headaches, abdominal pain, insomnia, fatigue -causes functional impairment

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45
Q

What are the characteristics of social phobia?

A

-Social avoidance due to fear of humiliation of embarrassment -Most chronic, at risk for alcholism -Response to SSRIs

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46
Q

What is the most common co-morbidity of childhood anxiety disorders?

A
  1. Depression 2. Dysthymia
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47
Q

What is the strongest evidence for combination therapies in anxiety disorders?

A

SSRI + CBT

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48
Q

What are the side effects of SSRIs?

A

-GI, anxiety, agitation, weight gain, HA, sexual dysfunction

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49
Q

What are the adverse effects of SSRIs?

A

-Severe akathsia -Serotonin syndrome -Suicidal thoughts -Switch to mania/hypomania

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50
Q

What is the most common compulsion in childhood?

A

Repeated checking

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51
Q

What are the three most common comorbidities in OCD?

A

-ADHD, Mood D/o, tic disorders

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52
Q

What are the two therapies for OCD?

A
  1. CBT 2. SSRI
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53
Q

What is one presentation of PTSD that is NOT common in children as compared to adults?

A

Flashbacks

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54
Q

What is the mechanism of SSRIS?

A

-Inhibit serotonin transport to block reuptake -Metabolized by liver, CYTp450

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55
Q

What is the presentation of serotonin syndrome?

A

Fever, shivering, severe diarrhea, muscle rigidity, confusion, dilated pupils, seizures

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56
Q

What is the treatment of childhood bipolar disorder?

A

Mood stabilizers- carbamazepine, lithium

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57
Q

Which is more severe: ODD or CD?

A

CD, high rate of development of anti-social personality disorder

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58
Q

Are psychotic symptoms common <5 years of age

A

No Stress, anxiety, transient, benign

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59
Q

What are the three phases of the menstrual cycle?

A
  1. Follicular: proliferative endometrium 2. Ovulation: peak of estradiol one day before leading to LH surge and release of egg 36 hours later 3. Luteal: secretory, if no fertilization loss of progres and estradiol production therefore endometrial sloughing
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60
Q

What is the average length of a menstrual cycle?

A

21-45 days Menses last 3-7 days

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61
Q

What is the number one cause of heavy menstrual bleeding in adolescents?

A

Anovulation Post Menarche: 2years: 55-82%, 4 years 20%

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62
Q

How can do tell if a cycle is ovulatory or not?

A

Ovulatory cycles will have PMS symptoms because they have estrogen

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63
Q

What are the possible causes of hypothalamic amenorrhea (anovulation)?

A
  1. Eating disorder 2. Female althlete triad 3. Stress
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64
Q

What is the treatment of hypothalamic amenorrhea (anovulation)?

A
  1. Increase energy availability 2. Treat low BMD: increase energy availability, resumption of menses 3. Supplement Ca and Vit D
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65
Q

What is the definition of heavy menstrual bleeding?

A

Bleeding lasting morethan 7 days or resulting in the loss of more than 80mL of blood

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66
Q

What percentage of women with HMB have a bleeding disorder? Which is the most common?

A

10-47% Von Willebrand

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67
Q

What are some of the potential treatment options for HMB?

A
  1. Iron supplmentation 2. Contraception 3. OCP, Mirena 4. Antifibrinolytic medications (TXA) 5. GnRH antagonist
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68
Q

When do you need to order an u/s in patients with dysmenorrhea?

A

Dysmenorrhea with anovulatory cycles

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69
Q

Why are prepubertal girls susceptible to VV?

A

-Lack of estrogenization -Proximity of the vagina to anus -Lack of protective hair and labialfat pads -Poor hygiene

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70
Q

What is lichen sclerosis?

A

-Chronic disease of itching, irritation, soreness,bleeding, dysuria -White, atrophic, parchment-like skin -Associated with vitiligo, thyroid siease

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71
Q

What is the treatment of labial adhesion?

A
  1. Expectant- spontaneous separation at puberty 2. Topical estrogen 3. Rarely surgery
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72
Q

What is McCune-Albright syndrome?

A

Triad of: 1. Precious puberty 2. Cafe au lait spots 3. Fibrous dysplasia of bone

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73
Q

What is the best method of evaluation for ovarian cyst in prepubertal girls?

A

ultrasound

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74
Q

What are two emergencies of ovarian masses in adolescents?

A
  1. Tubo-ovarian abscesses 2. Ectopic pregnancy
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75
Q

Is a solid ovarian mass worrisome?

A

YES: malignant until proven overwise Usually germ cell

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76
Q

What are the contraindications for IUDs?

A
  1. Pregnancy 2. PID 3. Undiagnosed VB 4. Malignant tumors of the GU tract 5. Anatomical abnormalities of the uterus 6. Active cervicitis 7. Wilson’s disease
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77
Q

What are the definitions of amenorrhea?

A

Primary: Lack of menses by 15 or more than 3 years after development of seocndary sexual characteristics Secondary: 3 months without a period

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78
Q

What is the most common cause of hypergonadotrophic hypogonadism?

A

Gonadal dysgensis from Turners

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79
Q

Amenorrhea + anosmia=?

A

Kallman

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80
Q

What is the diagnostic critiera for PCOS?

A
  1. Anovulatory menses 2. Hyperandrogenism 3. Polycystic ovaries on US
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81
Q

What does PCOS put patients at risk for?

A

Insulin resistance therefore metabolic syndrome and DM2

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82
Q

What investigations would you do in suspected PCOS?

A
  1. Preg test 2. LH, FSH 3. DHEAS, Free test 4. US 5. TSF/FT4
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83
Q

What are the most common causes of infectious vaginitis?

A
  1. Candidiasis (cottage cheese, edema) 2. BV (foul smelling, gray-white) 3. Trichomoniasis (frothy, green-yellow, purulent)
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84
Q

What is reiter syndrome?

A

-Reactive arthritis associated with chlamydia and enteric infections -Presents with urogential, arthritis, ocular, mucocutaneous symptoms

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85
Q

What percentage of adolescent traumas involve alcohol?

A

-30-40%

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86
Q

Short term effects of weed?

A

-cough, asthma exacerbation, decreased PFTs, tachycardia, hypertension, vasodilation

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87
Q

Long term effects of weed?

A

Decreased sperm count, decreased immune function Memory and learning deficits,distorted sensory and time perception, depression, sexual dysfunction

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88
Q

What is the CRAFT score?

A

Car, Relax, Alone, Forget, Friends, Trouble 2+ 85% sensitivity and specificity

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89
Q

What is refeeding syndrome?

A

-Complication from refeeeding in ED

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90
Q

What lab abnormalities occur with refeeding syndrome?

A

Low PO4, MG, K

91
Q

What are the serious complications of refeeding syndrome?

A

Rhabdomyolysis Decreased cardiac contractility Cardiomyopathy Edema Hemolysis ATN

92
Q

What is the female athlete triad?

A
  1. Eating disorder 2. Hypothalamic amenorrhea 3. Osteoporosis
93
Q

What are the nuisance side effects of OCPs?

A
  1. Breast tenderness 2. BTB 3. Nausea 4. Headache
94
Q

What are the main medical complications of ED?

A
  1. Low WBC 2. ESR normal 3. HypoK hypoCL metablic alkalosis from vomiting. Laxative- acidosis, low Mg 4. HypoGl 5.Bradycardia, prolonged QTc 6. Renal function normal or high
95
Q

What are the addition physical signs you can see with bulimia?

A

Salivary gland enlargement, hypovolemia, knuckle calluses, dental erosion

96
Q

What is refeeding syndrome?

A

Low phosphate leading to cardiac abnormalities, rhabdo fluid and electrolyte shifts, seizrues, delirium Drop in Po4, Mg, K Can have Wernerkes encephalopathy from thiamine deficiency.

97
Q

What percentage of adolescent moms will have another pregnancy?

A

>1/3 within 2 years

98
Q

What is the most common disorder of reproductive hormone dysfunction?

A

PCOS

99
Q

What are the clinical hallmarks of PCOS?

A

Menstrual abnormalities HYperandrogenism Absent ovulation

100
Q

What are the risk factors for PCOS?

A

-Premature adenarche, risk factors for insulin resistance, FHX of DM2

101
Q

What is Fitz-Hugh Curtis Syndrome?

A

Infection of the liver capsule and peritoneal surgaces of the anterior RUQ with minmial stromal liver involvement Violin string adension

102
Q

What are the main ethical principles?

A

-Non-maleficence: do no harm -Beneficence: do good -Autonomy: right to information and self determination -Veracity: full and honest disclosure -Confidentiality

103
Q

What are the principles of informed consent?

A

-Adequate information -Voluntariness -Capacity to understand

104
Q

What is assent?

A

1 of the informed consent principles is not met Child and physician

105
Q

When can you breech confidentiality?

A
  1. Duty to warn:risk to others 2. Risk to self: suicide 3. Child abuse 4. Coroner 5. Reportable infections: HIV, TB
106
Q

What are physical signs of eating disorders

A

-Sinus bradycardia -Hypothermia -Orthostatic vital changes -Dull, thinning hair -Dry skin, lanugo -Cacheixa -Acrocyanosis -Extremity edema

107
Q

What are the good prognosticators of anorexia?

A

Early age at onset

108
Q

What are the bad prognosticators of anorexia?

A

Late age at onset, purging behaviour, more significant weight loss, family dysfunction, comorbid mental illness, longer duration of illess

109
Q

What is the mechanism of osteopenia in eating disorders?

A

Decreased LH and FSH result in anovulation and low levels of estrogen Estrogen is necessary to incorporate calcium into bone

110
Q

What is the PRIMARY feature of refeeding syndrome?

A

Hypo PO4

111
Q

What are the two key features to determine the management of menorhaggia?

A

Hemoglobin Orthostatic hypotension

112
Q

What is the mean age for the presentation of ovarian torsion?

A

14.5 years

113
Q

What is Kallman syndrome?

A

-Defect in GnRH with gonadotropin deficiency and hypogonadism -Maldevelopment of the olfactory lobes also occurs with anosmia -Cleft palate, congenital deafness, kidney malformation and color blindness can co-occur -Small phalus and testes -Delayed bone age

114
Q

What is the most common cause of primary gonadal failure in boys?

A

Klinefelter syndrome (1/1000 males) Gynecomastia and small firm testes XXY

115
Q

What are the long term sequelae of PID?

A

-Tubo-ovarian abscess -Recurrent PID -Chronic abdominal pain -Ectopic pregnancy -Infertility

116
Q

Are the current recommendations for spermicide?

A

NO

117
Q

What are the possible serious side effects of OCP?

A

Thrombosis!

118
Q

A 16 year old girl presented with a unilateral painless breast mass. Most likely diagnosis:

  1. Fibroadenoma
  2. Adneocarinoma
  3. Fibrocystic changes
  4. Metastatic tumor
  5. Lipoma
A

Fibroadenoma

Then fibrocystic then metastatic

119
Q

What are the serious adverse effects of SSRIs?

A
  1. Mania
  2. Aggression
  3. Suicide attempt
  4. SIADH
  5. Serotonin
  6. QTc
120
Q

Which SSRI has the hghest risk of withdrawal symptoms?

A

Paroxetine

121
Q

The management of aggression in children involves all of these except:

  1. Parent management training preventative counselling, CBT
  2. Risperidone which increased aggression
  3. Antipsychotic meds
  4. Psychostimulants whih improve ADHD symptoms
A
  1. Risperidone decreases aggression
122
Q

What are the differences between serotonin syndrome and NMS?

A

-Increased CK, WBC and low serum iron

123
Q

How to differeniate between serotonin syndrome and NMS?

A

Shivering, hyperreflexia, myoclonus, and ataxia in SS less than NMS

Nausea, vomiting, and diarrhea are also a common part of the prodrome in serotonin syndrome

Rigidity and hyperthermia, when present in SS, are less severe than in patients with NMS

124
Q

What is the most frequent cause of school absence in teenage girls?

A

Dysmenorrhea

125
Q

When does parental conflict peak in adolescence?

A

Middle

126
Q

Which of the following in an absolute CI to the OCP?

  1. Family histroy of stroke
  2. DM
  3. HTN
  4. Migraine
  5. Liver disease
A

Liver disease

127
Q

What tanner stage does menarche occur?

A

tanner IV

128
Q

When can a teen treated for chlamydia resume sexual activity?

A

7 days after treatment

129
Q

What is the recurrence risk for depression?

A

40%

130
Q

Options for inpatient management of PID?

A
  1. Cefoxitin + Doxy
  2. Clinda + Gent
131
Q

Options for outpatient management of PID?

A
  1. Ceftriaxone x 1 then doxy 14 day
  2. Cefoxitin then doxy 14 day
132
Q

Management of gonorrhea?

A
  1. Ceftriaxone + Azithromycin
  2. Cefoxitine + Azithromycin
  3. Cefotaxime + Azithromycin
133
Q

What are the first line agents for the treatment of chlamdyia?

A
  1. Azithromycin
  2. Doxycycline

Levofloxacin (NOT CIPRO)

134
Q

What are the risk factors for MRSA?

A
  1. Overcrowding
  2. Frequenct skin to skin contact
  3. Participation in activities with abraded or compromsied skin
  4. Sharing of personal items
  5. Limited access to health care
135
Q

DSM 5 AN Diagnostic criteria

A
  1. Restriction of energy intake relative to requirements, leading to a significantly low body weight
  2. Intense fear of gaining weight or of becoming fat or persistent behavior that interferes with weight gain
  3. Disturbances of perception of body shape and size,
136
Q

Good and bad AN prognostic indicators?

A

Good: Early age at onset (< 14 years), supportive family, shorter duration of illness

Bad: Late age at onset, purging behavior, more significant weight loss, family dysfunction, comorbid mental illness, longer duration of illness

137
Q

Rrhagias?

A

Menorrhagia: large quantity of bleeding

Metrorrhagia: irregular interval bleeding

Menometrorrhagia: heavy and irregular bleeding

138
Q

Meds for dysmenorrhea?

A

NSAIDS

OCP

139
Q

Ectopic pregnancy?

A

Amenorrhea with unilateral abdominal or pelvic pain, irregular vaginal bleeding, and a positive pregnancy test

140
Q

Genital ulcers

A
141
Q

What drugs are associated with gynecomastia?

A

CHEST

Calcium-channel blockers: verapamil, nifedipine

Hormonal medications: anabolic steroids, oral contraceptives

Experimental/illicit drugs: marijuana, heroin, amphetamines, methadone

pSychoactive drugs: diazepam, methyldopa, phenytoin, tricyclic antidepressants

Testosterone antagonists: spironolactone, flutamide, cimetidine, ketoconazole

142
Q

What is binge eating disorder?

A

Recurrent episodes of binge eating (large amounts of food in a short period of time accompanied by a feeling of loss of control)

These episodes must be accompanied by at least 3 of the following:

eating much more rapidly than normal

eating until feeling uncomfortably full

eating large amounts when not feeling physically hungry

eating alone because of embarrassment

feeling disgusted with oneself, depressed, or guilty afterward

Marked distress regarding binge eating is present.

Behavior must occur at least once a week for 3 months.

With binge eating disorder, there is no compensatory purging.

143
Q

Which SSRI is associated with the highest incidence of withdrawal if stopped abruptly?
-least withdrawal?

A

Most withdrawal: paroxetine
-least withdrawal: fluoxetine

144
Q

What group of medications should be avoided in patients with bipolar disorder?

A

Selective serotonin reuptake inhibitors - increase the frequency of manic episodes

145
Q

What are helpful tips for talking to kids about separation from parents (from divorce, physical distance, etc.)?

A
  1. Explain to the child why the separation has happened.
  2. Be concrete about what is happening.
  3. Try to keep the child in their own home (ie. bringing someone in to help take care of them)
  4. If they have to move back and forth from mom’s to dad’s, allow them to bring transition object so that it’s a piece of their home.
  5. Allow them to see the other parent.
  6. Do NOT live together just for the kids because it’s very confusing for the child and builds false hope.
146
Q

How do the following groups view death?

  • preschoolers
  • school age children
  • how can you explain death to child?
A
  1. Preschoolers: do not view death as permanent, often think it’s their fault
    - need to reassure them that it’s nothing that they did
  2. School age children: usually have good understanding but only teenagers will have full understanding of permanence of death

***do NOT compare it to sleep or else they’ll be terrified of sleeping

  • explain that death represents cessation of all body functions and that the person will not be returning
  • do not hide the event
  • do not give false or misleading info
147
Q

What are 3 indications for use of risperidone?

A
  1. Schizophrenia
  2. Bipolar disorder
  3. Irritability in autism
  4. Tic disorder (2nd line)
148
Q

How do antipsychotics work?

A

Block dopamine receptors

149
Q

Which syndrome is associated with childhood psychosis?

A

Digeorge syndrome

150
Q

What are common comorbid conditions are associated with ADHD? (5)

A
  1. Anxiety disorders
  2. Depression
  3. ODD
  4. Mood disorders
  5. Learning disability
151
Q

What are the criteria needed for diagnosis of substance abuse?

What are the criteria needed for diagnosis of substance tolerance?

A

Substance abuse:

  1. Recurrent failure to meet responsibilities
  2. Recurrent use in situations when such use is likely to be physically dangerous
  3. Recurrent legal problems arising from drug use
  4. Continued use despite knowledge of problems caused by or aggravated by use

Substance dependence:

  1. Tolerance (needing more to become intoxicated or discovering less effect with same amount)
  2. Withdrawal
  3. Using more or for longer periods than intended
  4. Desire to cut down
  5. Considerable time spent in obtaining the substance
  6. Important social/work/recreational activities given up because of use
  7. Continued use despite knowledge of problems caused by or aggravated by use
152
Q

PSTD Criteria

A
  1. History of exposure to a traumatic event of threatened death, injury or sexual violence
    AND
  2. At least 1 event of EACH of the following:
    -intrusive recollection
    -hyperarousal (hypervigilance in looking for signs of impending traumatic event)
    -avoidance of stimuli associated with the trauma
    -negative alterations in trauma associated cognitions and mood
153
Q

What are long term consequences of anabolic steroid use? (19)

A

Endocrine:
1. Testicular atrophy
2. Oligospermia
3. Gynecomastia
4. Amenorrhea
5. Breast atrophy
6. Clitoromegaly
(turns men into women and women into men)

MSK:
7. Premature epiphyseal closure

CVS:

  1. Low HDL
  2. Thrombosis
  3. Hypertension

Derm:

  1. Hirsutism
  2. Striae
  3. Male pattern baldness

GI:

  1. Cholestatic jaundice
  2. Benign or malignant tumors
  3. Hepatitis

Psych:

  1. Mood swings
  2. Depression
  3. Aggression
154
Q

What are signs of recurrent vomiting on exam in bulimia (4)?

A
  1. Russel’s sign
  2. Enlarged salivary gland
  3. Enamel erosion
  4. Angular stomatitis
155
Q

How long does pubertal gynecomastia last for?

  • what tanner stage?
  • treatment?
A
  • 2 years
  • tanner stage 2-3
  • treatment: reassure and reexamine UNLESS there is systemic symptoms or no resolution within 2 years, then think endocrine, malignancy, drug use
156
Q

When should you test for cure in chlamydia after treatment?
-how soon after treatment can patient start having sex again assuming partner has been treated?

A
  1. Pre-pubertal children
  2. No resolution of symptoms
  3. When compliance is suboptimal
  4. If an alternative regimen had been used (due to allergy)
  5. In all pregnant women

***Re-test in 1 month after treatment
-patient can start having sex again after 7 days post-single dose therapy or after 7 days of daily regimen

157
Q

What are the indications for hospitalization of PID? (5)

A
  1. Severe illness
  2. Noncompliance or unreliable
  3. Surgical emergency can’t be excluded or tuboovarian abscess
  4. Pregnancy
  5. Lack of response to oral abx
158
Q

What tests should be ordered for a patient presenting with primary amenorrhea?

A

***If secondary sexual characteristics are present: get pelvic U/S to look for a uterus

  • if uterus absent: karyotype (46XY = androgen insensitivity syndrome, 46XX = mullerian agenesis)
  • if uterus present: most likely outflow tract obstruction

***If secondary sex characteristics are not present (delayed puberty): order FSH/LH

  • if FSH/LH low = hypogonadotropic hypogonadism
  • if FSH/LH high = hypergonadotropic hypogonadism –> order karyotype (45XO = Turner syndrome, 46XX = premature ovarian failure)
159
Q

What is the concern of using prozac and risperadol together?

A

They both use cytochrome P450 and increases risperadol dosage and may cause toxicity

160
Q

A sexually active teenager presents with pruritic genital lesions. On exam there are macules and plaques with erythema, crusting and blue-grey papules. What is the diagnosis and what is your treatment?

A
  1. Pediculosis pubis - genital lice
    - grey spots: macula cerulia
    - look at the entire body because they jump around
    - children can get them in their eye lashes
    - treatment: permethrin; for eyelashes, apply petroleum jelly x 10 d
161
Q

What are side effects of 2nd generation antipsychotics (ie. risperidone)?

A
  1. Sedation
  2. Drooling
  3. Prolonged QT
  4. Hyperprolactinemia
  5. Hyperglycemia
  6. Neuroleptic malignant syndrome (fever, altered LOC, muscle rigidity, ARF, rhabdomyolysis)
162
Q

What is the definition of pubertal male gynecomastia?

  • ddx?
  • management?
A

Breast development in teenage boys between tanner stage 2 and 3 which may last for 2 years

  • can be tender
  • early in puberty, production of estrogen increases faster than testosterone and the slight imblanace leads to breast enlargement
  • in obese children, enzyme aromatase found in adipose tissue converts testosterone to estrogen
  • DDx:
    1. Endocrine: hypogonadism = Klinefelter syndrome, partial androgen insensitivity, hyperthyroidism
    2. Malignancy: Adrenal, testicular, LH or HCG producing tumors, liber tumors (look for abdominal mass or HSM)
    3. Pharmacologic: side effect of androgens, estrogens, marijuana/street drugs, alcohol, testosterone antagonists (spironolactone, ketoconazole, cimetidine)
  • management: reassure and follow up q2-3 mo for careful examination. D/C meds/drugs that could be contributing. If gynecomastia persists > 2 yrs or if features suggests systemic disease, refer to endocrinologist
  • potential medical treatment: Tamoxifen 10-20 mg PO BID, surgery, or danazol 200 mg PO BID
163
Q

An adolescent patient presents to you with clear/white vaginal discharge. There is no odor and the pelvic examination is normal. On microscopy, you see epithelial cells with some lactobacilli. What is your diagnosis and management?

A

Physiologic leukorrhea

  • treatment: proper hygiene
  • desquamation from cyclical changes in estrogen levels
164
Q

An adolescent patient presents to you with increased white vaginal discharge with clumpy appearance. She also complains of vulvar itching and irritation and on exam, you note inflammation of the vulva. What is your diagnosis and management? What would you see on microscopy?

A

Yeast vaginitis (Candida albicans or other yeast)

  • treatment: PO fluconazole 150 mg x 1 dose OR clotrimazole vaginal suppository
  • microscopy: pseudohyphae
165
Q

What drugs are associated with gynecomastia? (5 classes)

A

Think CHEPT:

  1. Calcium channel blockers (verapamil, nifedipine)
  2. Hormone medications (anabolic steroids, OCP)
  3. Experimental/illicit drugs (marijuana, heroin, amphetamines, methadone)
  4. Psychoactive drugs (phenothiazines, TCA, diazepam)
  5. Testosterone antagonist (spironolactone, ranitidine, cimeitidine, ketoconazole)
166
Q

An adolescent patient comes to you with malodorous white/gray vaginal discharge. What are the criteria she needs to fulfill in order for you to diagnose her with bacterial vaginosis?

  • etiology?
  • treatment?
A

Diagnostic criteria for bacterial vaginosis: need 3/4

  1. Positive whiff test = fishy odor when mixed with 10% KOH
  2. Vaginal pH > 4.5
  3. >20% clue cells on saline wet mount
  4. Thin, homogenous discharge that smoothly coats the vaginal walls
    - etiology: overgrowth of Gardnerella vaginalis, anaerobic bacteria, mycoplasma with decreased lactobacillus
    - treatment:
  5. Metronidazole PO BID x 7 d or topical gel applicator OD x 5 d
  6. No treatment needed for partner
167
Q

A 13 yo female patient presents to you with no signs of puberty at all. You order FSH & LH levels which are found to be high. What is your differential diagnosis (2)? What is your next test?

A

This is hypergonadotropic hypogonadism = CNS is trying to stimulate adrenal/ovary production of estrogen/androgens and thus FSH/LH is high.

  • differential diagnosis:
    1. Premature ovarian failure
  • autoimmune destruction
  • chemotherapy
  • galactosemia
  • nonclassic CAH
  • pelvic radiation
  • idiopathic
    2. Turner Syndrome (gondal dysgenesis)

***Next test: karyotype

168
Q

An adolescent patient presents to you with malodorous, yellow-green purulent vaginal discharge which sometimes looks frothy. She also complains of vulvar itching with inflammation of vulva on exam. On microscopy, you see leukocytes and motile little things. What is your diagnosis and treatment?

A

Trichomoniasis (trichomonas vaginalis)

  • treatment:
    1. Metronidazole x 1 dose
    2. Treat partner as well to eradicate
169
Q

What is the treatment for a breast abscess? (4)

A
  1. Antibiotics
  2. May need I&D
  3. Warm compresses
  4. Analgesics
170
Q

What is the differential diagnosis for a breast mass in an adolescent female?

A
  1. Benign fibrocystic changes: painless breast mass, can have cyclic (before period) tenderness, diffuse cordlike thickening and nodularity on exam
  2. Fibroadenomas (most common): no change with menstrual cycle, benign lesion, small, solid and rubbery, non-painful, found in upper quadrant of breast
    - giant fibroadenomas are >5 cm and grow rapidly and may require excisional biopsy
  3. Cystosarcoma phyllodes: rare primary tumor with firm, mobile lesion that grows quickly to > 13 cm with bloody nipple discharge and skin discoloration
    - 25% malignant
    - need excisional biopsy since US cannot differentiate between fibroadenoma and cystosarcoma phyllodes
  4. Intraductal papilloma: small benign tumor from the ductal epithelium usually associated with nipple discharge
    - excision for cytologic diagnosis and most are benign
  5. Carcinoma: very rare in patients
171
Q

An adolescent patient presents to you with a persistent breast mass. What imaging test can you order to further ellucidate the etiology of the mass?

A

Ultrasound! Can differentiate between solid vs. cystic.
-mammograms are NOT useful in adolescents because of the density of the breast tissue and because of low risk for malignancy

172
Q

What physical examination maneuveres MUST be completed in a patient presenting with nipple discharge? (3)
-what lab investigations would you order?

A
  1. Breast examination
  2. Thyroid exam
  3. Neuro exam (visual fields)

Investigations:

  1. pregnancy test
  2. Prolactin level
  3. TSH: to rule out primary hypothyroidism (increased thyrotropin-releasing hormone which stimulates prolactin release)
  4. Renal function tests: chronic renal failure can lead to hyperprolactinemia due to decreased renal clearance

***If has amenorrhea/symptoms suggestive of intracranial mass, order MRI to r/o pituitary adenoma

173
Q

What are contraindications to combined OCP use? (8)

A
  1. Severe hypertension
  2. Pregnancy
  3. Breastfeeding during first 6 wks postpartum
  4. Previous history of clots or strokes
  5. Major surgery with prolonged immobilization
  6. Liver disease
  7. Severe migraines
  8. Breast cancer
174
Q

A 13 yo female patient presents to you with no signs of puberty at all. You order FSH & LH levels which are found to be low. What is your differential diagnosis (8)? Next test?

A

Hypogonadotropic hypogonadism! Either the hypothalamus is not producing GnRH to stimulate the pituitary gland or the pituitary gland is not producing FSH/LH properly.

  1. Malnutrition/eating disorder
  2. CNS tumor
  3. Constitutional delay of growth and puberty
  4. Chronic illness (DM, immunodeficiency, IBD, thyroid disease, CRF, liver failure)
  5. Cranial radiation
  6. Excessive exercise
  7. Kallman syndrome (anosmia and failure of GnRH neuron migration so do not have adequate GnRH production)
  8. Stress

***Next test would be: MRI head to evaluate for pituitary tumor

175
Q

What is the most common skin infection leading to vulvovaginitis?

A

Molluscum contagiosum

176
Q

Differentiate between the following:

  1. Hydrocele
  2. Spermatocele
  3. Varicocele
  4. Testicular tumor
A
  1. Hydrocele: fluid collection between the parietal and visceral layers of the tunica vaginalis
    - soft, painless, fluctuant
    - transillumination
    - can appear at any age
    - communicating (surgical treatment) vs. non communicating (self resolving)
  2. Spermatocele: retention cyst of the epididymis that contains spermatozoa.
    - located behind the testes and is palpable separate from it and above it.
    - painless
    - contains dead sperm
    - usually no treatment needed
  3. Varicocele: elongated, dilated tortuous veins of the pampiniform plexus in the spermatic cord
    - MOST COMMON SCROTAL MASS AMONG ADOLESCENTS
    - asymptomatic usually but can have aching
    - “bag of worms”
    - prominent when patient is standing
    - most often occur on the left side
    - may need ligation of the internal spermatic vein
  4. Testicular tumor: well circumscribed, nontender, will not transilluminate
177
Q

A 16 year old female presents to you with secondary amenorrhea. What is the FIRST test you should order?
-if this test is normal, what are the next 2 tests to order?

A

Pregnancy test
-if negative, then order TSH and prolactin to rule out thyroid disease and prolactinoma as cause

178
Q

What is the most common scrotal mass seen in adolescents?

A

Varicocele

179
Q

What factors predispose a patient to developing an eating disorder? (5)

A
  1. Female
  2. Being in a weight conscious environment
  3. Engaging in activities that place a high value on thinness or exposure of the body (ballet, modeling, gymnastics, track, swimming)
  4. Low self esteem
  5. Traits of perfectionism, OCD
180
Q

What are physical exam findings consistent with bulimia nervosa? (5)

A
  1. Normal to overweight
  2. Salivary gland enlargement
  3. Dental enamel erosion
  4. Subconjunctival hemorrhage from vomiting
  5. Knuckle calluses (Russel’s sign)
181
Q

What immunizations are administered at 11-12 yo well visit or in grade 7 at school?

A
  1. Hepatitis B if not previously vaccinated
  2. Tdap booster if more than 5 years after 4th (usual schedule is 2, 4, 6, 18 mo, then @ 11 yo)
  3. HPV
  4. Second dose MMR if they didn’t get it previously at 4-6 yo (1st MMR at 12 mo, 2nd MMR+V at 4-6 yo recently started)
  5. Conjugated neisseria meningitidis Men-C-ACYW
  6. Influenza vaccine yearly

****Add Pneumococcal polysaccharide 23 valent if immunocompromised

182
Q

A girl with history of anorexia nervosa presents with signs and symptoms of a bowerl obstruction and bilious vomiting. What is the most likely diagnosis?

A

SMA syndrome!
-loss of intraabdominal fat leads to compression of the duodenum between the aorta and SMA leading to complete or partial duodenal obstruction

183
Q

If a cholesterol level is completed in a patient with an eating disorder, what do you expect the level to be?

A

High = cholesterol breakdown is related to T3 levels which are depressed
-also cholesterol binding globulin is low

184
Q

What investigations should be ordered in a new diagnosis of eating disorder?

A

CBC, lytes, Ca, Mg, Po4, glucose, bun, cr, LFTs, cholesterol, UA, LH, FSH, estradiol, TSH, FT4, bone mineral density, MRI brain in YOUNG children with eating disorder symptoms, ECG, prolactin (again to rule out intracranial cause)

185
Q

What are possible findings on ECG of an eating disorder patient? (4)

A
  1. Bradycardia
  2. Prolonged QT
  3. Low voltages (from loss of cardiac muscle or pericardial effusion)
  4. U waves from hypokalemia
186
Q

What is the criteria for orthostatic hypotension?

A

Increase in HR > 20 when moving from lying to standing OR Decrease in SBP or DBP > 10 mm Hg when moving from lying to standing

187
Q

To decrease risk of refeeding, what is the rate of re-feeding?
-what is the goal of weight gain in treatment of eating disorder?

A

Start at 20 cal/kg and increase by 250 cal/day

  • usually start by calculating how much they are intaking per day and add 20% to that
  • goal of weight gain = 0.2-0.5 kg/week
188
Q

What is criteria for hospital admission for eating disorders? (8)

A

Refusal to eat with ongoing weight loss despite intensive management

Dehydration and orthostatic changes in pulse (> 20 beats per minute) or blood pressure (> 10 mm Hg)

Electrolyte abnormalities (e.g., hypokalemia, hyponatremia, hypophosphatemia)

Heart rate less than 50 beats per minute during the day, less than 45 beats per minute overnight

Systolic blood pressure < 80 mm Hg

Temperature < 96° F

Cardiac dysrhythmia

Acute medical complication of malnutrition (syncope, seizure, congestive heart failure, pancreatitis)

Severe coexisting psychiatric disease (e.g., suicidality, psychosis)

189
Q

For outpatient management, what is the most effective treatment for anorexia nervosa?

A

Family based treatment

190
Q

What are possible persistent long term complications of eating disorders?

A
  1. Osteoporosis from impaired peak bone mass
  2. Puberty delay or arrest
  3. Growth retardation if occurs before closure of epiphyses
  4. Cerebral atrophy

***Most are reversible with weight gain

191
Q

What is the definition of the following:

  • polymenorrhea
  • oligomenorrhea
  • primary amenorrhea
  • secondary amenorrhea
  • metrorrhagia
  • menorrhagia
A
  • polymenorrhea: frequent bleeding 45 d intervals
  • primary amenorrhea: no menstrual flow by 16 yo
  • secondary amenorrhea: absence of vaginal bleeding > 3 mo
  • metrorrhagia:bleeding in between regular periods
  • menorrhagia: heavy long periods at regular intervals
192
Q

What is the definition of dysfunctional uterine bleeding?
-most common cause

A

DUB: PAINLESS, excessive, prolonged and irregular endometrial bleeding IN THE ABSENCE of structural pathologic features or medical illness

  • this is a DIAGNOSIS OF EXCLUSION
  • most common cause: anovulation
  • in an ovulatory cycle, the corpus luteum is able to produce progesterone to support the endometrium until unfertilization of the egg leads to corpus luteum demise, decrease in progesterone and thus menses
  • in an anovulatory cycle, there is no corpus luteum making progesterone thus leading to unopposed estrogen and get breakthrough shedding of the endometrium
193
Q

What is the diagnostic criteria for major depressive episode?

A

Need 5 or more of the following symptoms which are present for > 2 wks and at least one of the symptoms is decreased mood or loss of interest or pleasure:
MSIGECAPS
AND must cause impairment in social/occupational/other areas of functioning and are not due to substances or medical condition

194
Q

What is the only antidepressant approved for the treatment of children and adolescents?

A

Fluoxetine

195
Q

A 16 yo female presents to you with secondary amenorrhea. What are important questions to ask on history?
-physical exam?

A

Think of your ddx:

  1. Hypogonadotropic hypogonadism
    - chronic illness, malnutrition, excessive exercise, stress, cranial irradiation, Kallman’s syndrome, CNS tumor
  2. Hypergonadotropic hypogonadism: premature ovarian failure (chemotherapy, radiation, autoimmune)
  3. PCOS
  4. Outflow tract obstruction
  5. Thyroid disease

***Thus ask about: pregnancy risk factors, thyroid symptoms, stress levels, chronic illness, weight change, contraceptive use, hx of chemo/radiation, female athletic triad (disordered eating, amenorrhea, osteoporosis), headaches, visual changes, constitutional symptoms

***P/E: visual fields, fundoscopy, Tanner staging, thyroid palpation, blood pressure, compression of areola to check for galatorrhea, signs of hyperandrogenism

196
Q

What is the most common somatoform disorder of adolescence?

A

Conversion disorder

197
Q

What are the clinical criteria for somatization disorder? (4)

A
  1. Need involvement of 4 different pain sites: head, abdomen, back, joints, extremities, chest, rectum or functions (sexual intercourse, urination, menstruation)
  2. two GI symptoms other than pain (nausea, bloating, vomiting, intolerance of several foods)
  3. one sexual or reproductive symptom other than pain (eg. ED, irregular menses, excessive menstrual bleeding)
  4. one pseudoneurological symptom (impaired balance, paralysis, aphonia, urinary retention)
198
Q

What pregnancy complications are adolescents more at risk at than adult women? (4)

A
  1. Premature delivery
  2. Low birth weight
  3. Poor maternal weight gain
  4. Increased risk of pregnancy induced hypertension
199
Q

What is the most common side effect of isotretinoin (aka accutane)?
-other side effects?

A

Most common: dry eyes/skin/mucous membranes
-other side effects: abnormal liver function tests, elevated TG and cholesterol

200
Q

A tzanck preparation of scraping from a genital ulcer reveals multinucleated giant cells and intranuclear inclusions. What is your diagnosis?

A

HSV!

201
Q

How do you differentiate between chancroid and lymphogranuloma venereum?

A

Both have inguinal lymphadenopathy
-in chancroid, the inguinal adenopathy occurs AT THE SAME TIME as the genital ulcer whereas in LGV, the inguinal adenopathy occurs AFTER the ulcer has healed
(L in LGV stands for LATER which means inguinal adenopathy comes later)

202
Q

Describe the purpose of the progesterone challenge.
-estrogen-progesterone challenge?

A

Progesterone challenge is used in workup of amenorrhea to determine whether the uterus has been primed with estrogen (aka are the adrenals/ovaries still functioning to produce estrogen)

  • progesterone x 5-7 d is given, then stopped. If withdrawal bleeding occurs within 7 d of progesterone stopping, this is DIAGNOSTIC of anovulation (aka the body is making estrogen but not progesterone due to no ovulation and thus no corpus luteum to make progesterone)
  • if withdrawal bleeding does NOT occur, either the uterus outflow tract is abnormal or endogenous estrogen production is inadequate or absent.
  • Estrogen-progesterone challenge = prime the uterus with exogenous estrogen, then repeat the progesterone challenge. If withdrawal bleed then occurs, then this tells you the body is not making estrogen. If withdrawal bleed does not occur, you have outflow tract abnormality
203
Q

What type of injuries are most commonly seen in the following groups:
-swimmers
-football players
-basketball/volleyball players
-runners
-ballet
wrestlers
-skiiers

A
  • swimmers: shoulder injuries (ie. rotator cuff tendinitis)
  • football: head and neck injuries, knee injuries (ACL, PCL tears)
  • basketball/volleyball: lower extremity problems = Osgood-Schlatter disease and patellar tendinitis
  • Runners: runners knee (anterior knee pain due to patellofemoral stress)
  • Ballet: female athletic triad
  • wrestlers: shoulder subluxation, knee injuries, derm conditions (fungal infections, impetigo, staphylococcus furunculosis or folliculitis)
  • skiiers: skier’s thumb (abduction and hyperextension of the thumb causing sprain of ulnar collateral ligament)
204
Q

A 16 yo female presents to you with secondary amenorrhea. Her pregnancy test, thyroid tests, and prolactin levels are normal. What is your differential diagnosis? What are the next steps in management?

A

Ddx currently:
1. Anovulation
2. Hypergonadotropic hypogonadism
3. Hypogonadotropic hypogonadism
4. Outflow tract obstruction
5. PCOS
Next step:
Progesterone challenge test = give progesterone x 5-7 days
-if withdrawal bleeding occurs after progesterone is finished, this means that the patient is able to produce estradiol to prime the endometrium and thus, the amenorrhea is due to anovulation (no progesterone and thus endometrium keeps growing)
-if withdrawal bleeding does NOT occur, then ddx is:
1. hypergonadotropic hypogonadism
2. hypogonadotropic hypogonadism
3. outflow tract obstruction (cervical stenosis or Asherman’s)
-next step is to administer estrogen first, then repeat progesterone challenge:
if withdrawal bleed occurs, then this is a hypoestrogenic state = check FSH/LH
-if withdrawal bleed does not occur, this is outflow tract obstruction –> get pelvic ultrasound

**if pt has hyperandrogenism features, then PCOS most likely

205
Q

In a patient presenting with abnormal menstrual bleeding, what key history/physical/investigations would you like to complete?

A
  1. History:
    - age of menarche
    - menstrual pattern, amount of bleeding
    - sexual history
    - STI symptoms
    - history of bleeding elsewhere
    - trauma history
    - meds: NSAIDs/OCP?
    - screen for thyroid symptoms
    - screen for hirsutism/glucose intolerance
    - lactation
  2. P/E:
    - postural vitals
    - thyroid exam
    - bimanual and speculum exams
    - Pap smear
    - acanthosis nigricans
    - hirsutism
  3. Investigations:
    - pregnancy test
    - TSH/FT4
    - STI screen
    - FSH/LH/prolactin/serum androgens (free and ttal testosterone, 17-hydroxyprogesterone, DHEA-S)
    - pelvic U/S if abnormal pelvic/abdo exam
    - CBC
    - PTT/INR/fibrinogen, won willebrand screening if family history of bleeding disorders or excessively heavy menses
    - liver function tests
206
Q

What is Asherman’s syndrome?

A

Acquired condition - intrauterine adhesions secondary to scarring usually seen in patients who have had uterine instrumentation (D&C)

207
Q

What is the leading cause of missed school in adolescent girls?

  • pathophysiology?
  • workup?
  • treatment?
A

Dysmenorrhea

  • myometrial contractions and local vasoconstriction due to prostaglandin production by corpus luteum after ovulation
  • no workup necessary UNLESS the patient is sexually active. If they are, then do complete pelvic exam to rule out secondary dysmenorrhea (pregnancy, STIs, outflow tract obstruction, endometriosis, adenxal or adrenal mass)
  • treatment: NSAIDs (inhibit prostaglandins) and/or OCP (inhibits ovulation and thus no corpus luteum and thus no prostaglandin production)
208
Q

What is the most common cause of chronic pelvic pain?

  • pathophysiology?
  • treatment?
A

Endometriosis
-implantation of endometrial tissue to areas outside the uterus - bleeding stimulated by menstrual cycle
-treatment: GnRH agonist (lupron) to suppress menstrual cycle by suppressing LH/FSH production
(consistent stimulation of GnRH receptors results in downregulation)

209
Q

What are 2 risk factors for ectopic pregnancy?

A
  1. History of PID
  2. Chlamydial infection
    - adolescents have the highest mortality rate from ectopic pregnancy!!!
210
Q

What are the 3 mechanisms of actions of OCP?

A
  1. Suppresses ovulation
  2. Endometrial atrophy
  3. Thickens cervical mucus
211
Q

What is the differential diagnosis for abnormal uterine bleeding?

A

STRUCTURAL:

  1. Foreign body (IUD, retained tampon)
  2. Uterine fibroids/polyps/tumor
  3. Cervical polyps/malignancy
  4. Ovarian tumor/cyst
  5. Trauma

PREGNANCY-RELATED:

  1. Ectopic pregnancy
  2. Threatened or spontaneous abortion

COAGULOPATHY:

  1. VWBF deficiency
  2. ITP

HORMONE-RELATED:

  1. Anovulation (dysfunctional uterine bleeding)
  2. Thyroid dysfunction
  3. PCOS
  4. Adrenal tumor
  5. Prolactinoma
  6. Hormonal contraception
212
Q

What is the mechanism of action of emergency contraception?
-time limit of use?

A
  1. Delays ovulation
  2. Alters endometrial lining to prevent implantation
    - does NOT interfere with an already existing pregnancy
    - must be used within 72 hrs of unprotected sexual intercourse with a second dose 12 hrs later
213
Q

What are 3 signs of pregnancy on pelvic exam?

A

What are 3 signs of pregnancy on pelvic exam?

  1. Chadwick sign: cervical cyanosis
  2. Hegar sign: softening of the uterus
  3. Goodell’s sign: softening of the cervix
214
Q

An adolescent patient comes to you with brown-green vaginal discharge with an odor. You note she is wearing tight pants. Microscopy is negative. What is your diagnosis and management?

A

Nonspecific vulvovaginitis (70% of cases)

  • often associated with coliform bacteria secondary to fecal contamination; can also be caused by hemolytic strep, coag pos staph
  • usually due to poor hygiene, tight clothing, chemical irritants
  • treatment:
    1. Hygiene
    2. Avoid tight clothing and chemical irritants
    3. Sitz baths
    4. If recurrent, may need PO amoxil or keflex
215
Q

Teenage development

A
  1. Early adolescence (10-13 yo): concrete thinkers
    - cannot conceptualize the future
  2. Middle adolescence (14-16 yo): formal operational thinkers
    - can start thinking abstractly
    - egocentric and feel invincible
    - autonomy is chief concern
    - period of most conflict with parents
  3. Late adolescence (>17 yo): abstract thinkers
    - can think about future plans/actions
    - solid concepts of right and wrong
216
Q

When does beta-HCG become positive for pregnancy:
-serum vs. urine beta-HCG

A
  • Serum BHCG: can be detected as early as 6 days post conception
  • urine BHCG: may not be positive until 1 wk after missed period, concerns with false negatives
217
Q

What is more risky: pregnancy/labor vs. abortion in an adolescent patient?

A

Pregnancy/labor! = adolescents are at greater risk than adult women for preeclampsia/eclampsia, cephalopelvic disproportion, prolonged labor, premature labor and maternal death, uterine perforation

218
Q

What are the risks of unprotected sex in adolescents leading to unplanned pregnancy? (6)
-outcomes for child of adolescent mom? (7)

A
  1. Social and family difficulties
  2. Living in group home, detention centers or streets
  3. Family member (mom/sister) who was adolescent mother
  4. Substance use
  5. Early puberty
  6. Sexual abuse
  • outcomes for child of adolescent mom:
    1. infant mortality = 2-3x higher
    2. Prematurity
    3. Low BW
    4. Behavioural issues
    5. Drop out of school
    6. Become teen parents
    7. Incarceration
219
Q

What is Reiter syndrome?

  • pathophysiology?
  • infectious causes?
  • timing after infection?
A

Reiter syndrome aka reactive arthritis = classic triad of: “can’t see, can’t pee, can’t climb a tree”

  1. bilateral conjunctivitis
  2. urethritis
  3. arthritis
    - pathophysiology: joint inflammation due to a sterile inflammatory reaction following a recent infection (deposition of immune complexes and antibodies)
    - joint swelling usually lasts
220
Q

What lab findings are suggestive of PCOS diagnosis?

A

Increased LH:FSH ratio (usually 3:1)
-also see increased free testosterone, DHEAS

221
Q

PID RX

A

Outpatient:

  • Ceftriaxone IM x 1 + doxycycline PO BID x 14 d +/- metronidazole BID x 14 d
  • inpatient: IV cefoxitin q6h + doxycycline PO/IV q12h; if clinically improved, can switch to doxycycline PO BID x 14 d total
222
Q

What is the treatment for HSV genital infection?

  • primary
  • recurrent
  • what is the criteria for use of daily suppressive therapy?
A
  • Primary HSV genital infection: acyclovir PO x 7-10 d
  • Recurrent disease: acyclovir to start as early as the onset of prodromal symptoms (itching, burning, tingling sensation)
  • daily suppressive therapy for those with recurrent HSV episodes > 4x/year
223
Q

Which pap test results should trigger referral for colposcopy?

A
  1. ASCUS: atypical squamous cells of undetermined significance
  2. High-grade or persistent low grade squamous intraepithelial lesion
224
Q

A male patient presents to you with urethral discharge and dysuria. What are 3 tests to order?

A
  1. first void urine:
    - should see > 10 WBC per high power field on microscopy
  2. Urethral discharge microscopic examination:
    - should see >5 WBC per high power field
    - may see gram negative diplococci (gonococcal)
  3. urine PCR for chlamydia and gonorrhea

***Need these objective findings to diagnose a patient with urethritis

Paediatrics Royal College (11 decks)

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