Adole/Psych/Gyne Flashcards
Eating disorder history and physical
- Explore eating behavior o Different meals from family o Avoid eating in public o Bathroom after eating o Preoccupation with food o Weighing o Dieting, exercise o Excessive concern about weight o Fear of weight gain, body image issues o Guilt and shame about eating o Denial of hunger o Complaints of feeling full after normal food o Weigh and measure of body proportions o Vomiting, laxatives, exercise o Binge eating and purging - Mental health o Depression o Withdrawal o Irritability o Self-critical - HEADS history o Preface with confidentiality - Diet history o Request 3 day dietary recall in advance o Amounts, fluids o Foods that are avoided - Family history o Depression, substance use, obesity o Organic things - ROS o Dizziness, syncope, weakness, fatigue, pallor, bruising, bleeding o Skin: lanugo o Menstrual history: oligo or amenorrhea o Joint pain, chest pain o DM symptoms o Malignancy, infection, IBD - Drugs o Laxatives, diuretics Physical Exam - Assess stability: admission vs outpatient management - Vitals: lying and standing HR and BP - When weigh and measure: underwear, bra and hospital gown o Avoid heavy objects in pockets, many layers of clothing o Void first o Show weight to patients?
Eating disorder investigations/ DDx
Differential Diagnosis - Eating disorder - Malignancy - GI: IBD, malabsorption - Endo: DM, thyroid, pituitary, addisions - Mental health: depression, OCD - Chronic infection - SMA syndrome Investigations - CBC - ESR, CRP - Lytes, BUN, Cr - Extended lytes (Mg, PO4, Ca) - Glucose - Albumin, protein - LFTs CPS - Gas - LH, FSH, estradiol - BMD - EKG - Nutritional: lipids, carotene
Eating disorder management
Management - Family based therapy o Inpatient vs outpatient based on stability o Eating disorder day programs (long wait lists) o Office-based management - Psychology, psychiatry - Nutrition (RD) - Social work - Close follow up and reassessment - Education - Support groups - Years for recovery - Discuss internet: pro Ana websites
What are the key elements of family based therapy for eating disorders?
Parents: Do not cause eating disorders and should not be blamed Can be angry at the eating disorder, not at their child who is suffering with an eating disorder. A child or teenager with an eating disorder is not doing it on purpose or for attention Need to understand that anorexia nervosa is a serious condition that probably would not improve without treatment Need to be responsible for their child’s weight gain. Weight restoration is the first step in treatment Must be in charge of eating and exercise until the child has returned to health Should support and supervise their child’s meals and snacks Must appreciate that eating disorders affect a child’s ability to make reasonable decisions about food and exercise; parents must temporarily manage these areas of the child’s life Medical visits: Should be frequent at first, such as weekly or biweekly Should include checking the patient’s weight and vital signs at each visit Should include meeting with the patient alone to review his or her eating attitudes, behaviours and challenges at each visit Should include feedback about weight and vitals to both the parents and patient at each visit Should include frequent reminders and encouragement to the parents about the need to insist on adequate nutrition and limit setting Behavioural management: Encourages parents to use ‘natural consequences’ for food refusal. For example, do not allow the teenager to attend a sports practice until a proper dinner is eaten Involves a gradual return of the responsibility from the parents back to the child once the refeeding is going well Includes slowly integrating exercise back into the child’s life once weight is steadily increasing
What is ARFID?
Avoidant/restrictive food intake disorder Avoiding or restricting food intake, which may be based upon lack of interest in food, the sensory characteristics of food, or a conditioned negative response associated with food intake following an aversive experience (eg, choking). The eating behavior leads to a persistent failure to meet nutritional and/or energy needs, manifested by at least one of the following: •Clinically significant weight loss, or in children, poor growth or failure to achieve expected weight gain •Nutritional deficiency •Supplementary enteral feeding or oral nutritional supplements are required to provide adequate intake •Impaired psychosocial functioning ●The eating or feeding disturbance is not due to lack of available food or associated with a culturally sanctioned practice ●The disturbance does not occur solely in the course of anorexia nervosa or bulimia nervosa, and body weight and shape are not distorted ●Not due to general medical condition
Menorrhagia, Oligomenorrhea 14 year old female with heavy irregular painful periods. History and physical exam.Investigations
History - Confidentiality - Duration, frequency and quality of cycles - Cramping - Volume (number of pads and tampons), large clots - Other vaginal discharge - Menarche and progression since then - Characterize pain o Quality - Tried anything? Meds, hot packs - Other bleeding symptoms o Epistaxis, GI bleeding o Bruising o Severe bleeding symptoms o Anemia symptoms (fatigue, pallor, SOB) - Any chance of foreign body - Galactorrhea - Pubertal history o Onset, progression (pubic hair, axillary hair, etc) o Acne, weight gain - Obesity, insulin resistance - ROS o Weight gain/loss o Headaches o Constitutional symptoms o Appetite o Jaundice, hemolytic anemia - PMHx o Bleeding disorder o PCOS, CAH o Surgery - Birth and developmental history o Amb genitalia o Surgery, NICU admission - Medications o OCP o Tried NSAIDs? Dose frequency, specific products - Allergies - Vaccines - Family history o Insulin resistance, infertility o Bleeding disorders (PPH, transfusions, vWF) and clotting disorders o Endometriosis o Moms pubertal history - Social history o HEADS § Trauma § Physical abuse, sexual abuse § School § Activities- and impact § Dietary history, body image § Substances, cigarettes, EtOH, sexual activity § Sexual activity: pain with intercourse? § Any chance of pregnancy § Suicidality o Impact on her: missing school? Physical Exam - Vitals: stable vs unstable, orthostatic vital signs - Growth parameters and plot - General: dysmorphisms, obesity, acanthosis, striae - H+N: no bleeding in nose or gums o Thyroid exam - CVS - Respiratory - Abdominal exam: o Distension, pain on palpation, location of pain o Flank tenderness o Lymphadenopathy - Tanner staging o Clitoromegaly o Hirsutism o Galactorrhea - Dermatologic exam: bruising, bleeding o Hirsutism - GU exam o If suggestion of infection or trauma Investigations - CBC + diff - Retic count - Lytes, BUN, Cr - TSH, T4 - Prolactin - INR, PTT, fibrinogen - LFTs - vWF screen - ESR, CRP - Iron studies - Pregnancy test - STI swabs - Abdominal ultrasound
Management menorhaggia + OCP CI
Management - Counsel re: menorrhagia and secondary anemia likely secondary to anovulatory cycles o Explain pathophysiology o Reassure o Expectations: resolution in 3-4 months o Handouts: sexualityandu.ca - Diary/period calendar - NSAIDs before and during period - Iron supplement if needed and repeat CBC - Gardasil - Moderate to severe: o TXA? o OCP if no contraindications Contraindications to OCP: absolute vs relative - 35 - VTE - Ischemic heart disease - Migraine headache with neuro symptoms - Uncontrolled HTN - Known pregnancy - Migraine with aura - Uncontrolled HTN - Thromboembolic - Undiagnosed vaginal bleeding - Severe liver disease, kidney disease?
Seetha is a 16year old adolescent was seen in the ER the day before for abdominal pain, nausea and vomiting. A pregnancy test done was positive. Since she does not have a family doctor she was referred to your office. Take a history focusing on issues related to her pregnancy. Counsel Seetha regarding her options. Provide a management plan. (10 minutes) Take a history focusing on issues related to her pregnancy List 5 factors for teen pregnancy
□ Age at first intercourse □ Date of LMP □ Paternity? □ Rule out ectopic □ Assess for underlying health issues/complications □ Physical & emotional effects of her pregnancy □ Partner’s opinion and role □ Support system: who has she told, what was their response? □ Substance abuse & high risk behaviours □ Housing & school status □ Personal and academic goals Counsel Seetha regarding her options □ Determine her knowledge of her options and feelings about her options □ Explore family, cultural and community issues □ Can palpate uterus at 9-12 weeks □ Serum BHCG + @ 6days □ Urine BHCH +@10-14days Provide a management plan □ U/S for dates, BHCG □ Arrange follow up □ Refer to community services □ Adoption:nutrition,breastfeeding □ Medical termination: MTX & misoprostol (only in 1st trimester, needs close f/u and monitoring) □ Surgical termination: vacuum/D & C (adverse events include uterine perforation, hemorrhage, infection) □ Contraceptivecounseling □ STDtesting Post encounter probe (5 minutes):List 5 risk factors for unprotected intercourse and pregnancy in adolescents. □ Mother was an adolescent mother □ Sibling with adolescent pregnancy □ Social & family difficulties □ Hx of sexual abuse □ Frequent school absences/lack of vocational goals □ Substance abuse □ Street youth/living in a group home
Contraception history Anticipated side effects Benefits of OCPs
• Sexual activity prior/present/planned • Type of sexual activity • Male/female/both partners • # partners • Safe sex practiced? • Pregnant currently? – consider emergency contraception, BHCG as indicated • Pregnant previously • STI’s in the past • Previous STI testing • Previous contraception/emergency contraception use • Drug plan – how will they pay for it, how important is cost • Why did they decide to get contraception today • What methods have they heard about/want to try Anticipated/possible side effects • Breakthrough bleeding or amenorrhea from OCPs, depo provera, and the transdermal patch • Nausea, breast tenderness with hormonal methods • Depression mainly with progestin only pill or depo provera • Rash and itching at the application site of the transdermal patch • Weight gain? – maybe with depo provera but not proven • Osteopenia with depo provera? – make sure diet is good, exercise • Vaginal irritation and discharge with vaginal ring Benefits of OCPs and the transdermal patch: • Improved bone density Protection against: • Ovarian cancer • Endometrial cancer • Salpinitis • Ectopic pregnancy • Benign breast disease • Dysmenorrhea • Iron deficiency
Emergency contraception counselling
Counselling: • Praise for coming in for emergency contraception! Discuss possibility of failure of the method Next period might be early, on time or late If she is going to have intercourse before her next period, she should use a barrier method (teens should always use barrier as well!) Can start a new pack of pills the day after taking emergency contraception Doesn’t prevent STI’s Return for a pregnancy test if their next period is more than one week late or if the next period is unusual in any way Return if they have heavy bleeding or pain Appointment can be scheduled for one week after the next expected menstrual period
16 year old girl wants to see you about lower abdominal pain. 10 minutes to take a history.
Basic pointers • Ensure privacy • Maintain confidentiality Symptoms and signs: Hx of th e abdominal pain: onset, course ,duration, radiation, quality, severity, location , radiation. Associated factors: • Anogenital discharge • Dysuria • Dyspareunia • Pelvic pain • Genital/perianal ulcers or lumps • Rashes • Itching What makes it better , what makes it worse. Ask if it is possible that she is pregnant, symptoms of pregnancy ( nausea, fatigue, breast tenderness ) any history of abd trauma., , travel, sick contacts ROS Sore throat , mouth ulcersespecially if she had oral sex. GI: nausea , vomiting, and distention, diarrhea, constipation Any urinary symptoms Joint pains and swellings, skin rashes especially around the joints Sexual behaviours/risk markers .Regular/casual sexual partner(s) • Last sexual contact • Gender of partner(s) • Type of intercourse – oral, vaginal, anal • Use of condoms • Injecting drug use • Tattoos • Blood product exposure .Any history of sexual abuse Menstrual history: with details as your time permit Contracention history: OCP, condom use , how frequent Full HEADSS review: Past medical history: previous history of STD, other chronic illneses including abdominal surgeries, abortions Immunization: Hep B
PID immediate management (5) What you would do if she refuses to be admitted to hospital (2 lines) What long-term issues/follow-up/management would you arrange/be concerned about (4 lines) Complications of PID?
1- CBC, Blood culture if febrile, urine analysis, urine for chlymedia and Gonococcos, pregnency test 2-cervical swabs, speculum and bimanual exam 3- start empirical Abx treatment inpatient /out patient depend on how sever the condition is.. 4-Abd U/S, to role out abcess. 5-Gyne/surgery consult 1-Offer oral Cefixime or IM ceftriaxon and oral Doxycycline+/- Metronidazole 2- follow up in two days, if no improvement admitt 1-If treated as out patient, she needs F/U in 48 hrs, if no improvement , needs parentral Abx 2-High risk of HIV, Hep B, C, syphilis, needs testing and counselling 3-Mental health, depression and suicide 4Teen Pregnency 5-Tracing of contacts through public health 6-Risk reduction counselling (needle and syringes exchange programs) and patient education. 7-suggest no sex until test of cure, or completion of medication Complications of PID (6 lines): Infertility, ectopic pregnancy, tubo-ovarian abscess, chronic pelvic pain, dyspareunia, Reiter syndrome, Fitz –hugh-Curtis syndrome
A 16 year old female who you have followed as a primary care patient presents to your office wanting information about smoking and quitting. She is an otherwise healthy adolescent, dealing with typical adolescent issues. She is the oldest of 4 kids, the others are 12, 7, and 2. Counsel.
Questions from SP What happens if I quit smoking cold turkey? What is nicotine withdrawal? Will I die? What harm does smoking do? I understand about the long-term effects, but I’ll be old then. It doesn’t hurt now does it? My friend is pregnant, she smokes too. Should she be worried about her baby inside her? What about after the baby is born? Does quitting cold turkey work? I tried quitting before, I couldn’t. What can be done to help me quit this time? Approach to patient qConfirms nature of situation Nicotine withdrawal q Identifies withdrawal as a concern q Reviews common symptoms (strong desire for nicotine, irritability, frustration, anger, anxiety, depression, difficulty in concentrating, increased appetite, H/A, and GI disturbances.) q Reviews common signs (decreased HR, weight gain, decreased BMR, and alteration of REM sleep patterns.) q Addresses fatality concerns Long Term Effects qIdentifies mortality attributable to smoking (20 + 5%) qIdentifies CV disease as major cause of M&M q Identifies COPD and neoplasms as the other major adverse health consequences of smoking. Passive Smoking Effects Fetal 1/20th of perinatal deaths. q Notes that smoking during pregnancy accounts for ~ 1/5 of LBW infants, and CPS q Increased risk of successive preterm deliveries Child q Increased risk of sudden infant death syndrome q Increased rate of hospitalizations for respiratory problems q Increased risk of wheezing and asthma q Impaired lung function q Increased risk of otitis media q Increased risk of atopic dermatitis q Exacerbation of respiratory allergies Short-term Effects qStained teeth and fingernails qOral sores qFoul-smelling breath and clothes qNegative athletic performance due to decreased endurance and shortness of breath Method of Quitting individual dependant Quitting Resources qIdentifies incompatible activities (eg, smoking and sports) qProvides advice on skills to counter peer pressure q Provides advice on noticing subtle pro-smoking marketing q Offers suggestions on where to find self-help materials q Contracts for a quitting date q Suggests follow-up visits q Provides consideration of pharmacological assist devices qDiscusses both the patch and gum q Encourages further attempts to quit, and advises that many smokers try a few times before quitting successfully CPS approach: • ASK about tobacco use • ADVISE urge to quit • ASSESS willingness to attempt quitting • ASSIST – counselling and pharmacological therapy • ARRANGE follow-up
14-year-old girl comes to your office as a drop-in late in the day for assessment of abdominal pain. When she gets into the exam room she tells your nurse that she is looking for the “Morning After pill.”
**Confidentiality*** History of Sexual Contact □ When, type, protection (STD and contraception) □ STD screen – discharge, dysuria, rash History for Emergency Contraception □ Understanding of emergency contraception □ Asks about expectations from visit □ Asks about prior use of emergency contraception □ Last period □ Likelihood of already being pregnant □ Plans if became pregnant Contraception History □ Current method of contraception □ Past methods o Reason for discontinuation □ Compliance, side effects Screen for Sexual Assault □ Consensual, number of partners, intoxication, regret □ Other injuries Sexual History □ Age, number/gender of partners, age of partners □ Types of sexual contact □ Previous internal examination □ Previous STDs Contraindications to Emergency Contraception □ Pregnancy □ DUB without diagnosis □ History of stroke □ Estrogen-sensitive tumour □ Liver disease CPS Statement CI: Allergy or current pregnancy Other Medical History □ Past medical history □ Medications – Teratogens, Accutane, Anti-convulsants □ Immunization - Hepatitis B □ Allergies □ Family history – stroke, clot □ HIV status Management □ Praises patient for seeking help □ Identifies need for complete physical exam □ Identifies need for genital exam □ Identifies need for chaperone for examination □ Obtains consent for examination Sexual assault □ Explains that she is not at fault □ Explains need to notify CFS □ Offers to refer to counseling CPS □ Gives help phone number □ Seeks consent for forensic exam □ Ensure safe place for discharge □ Treats other injuries □ Tetanus prophylaxis Emergency Contraception □ Pregnancy test □ Discusses side effects, what to expect □ Discusses potential for failure □ Discusses options if becomes pregnant □ Explains that next period might be late □ Levonorgestrel (Plan B) x2 doses q12h □ Gravol with each dose STDs □ Offers STD testing □ Offers STD/HIV/HBV prophylaxis Contraception □ Offers routine contraception □ Start once emergency contraception is completed Follow-up □ First follow-up in 2 weeks □ Review STD results PEP: What are contraindications to giving emergency contraception? PEP: If you are suspicious on history that there was some degree of sexual assault, what would be your next steps?
15 year old referred by school guidance counsellor due to concerns about possible substance use and some feelings of depression. Take history (10 min) and formulate problem list/plan (5 min).
Intro: q Ensure confidentiality (except if harm to self or others) q state reason for referral (i.e. concerns about substance abuse, depression); can elect to defer discussion of these issues rapport established - i.e. ‘I want to get to know you first’) q ask patient why she’s there, if there are any specific problems/issues she wants to address HEADSS/Social history: Psych History/ROS: qMood o MSIGECAPS (mood, sleep, interest, guilt, energy, concentration, appetite, psychomotor agitation, suicidality) o Suicide (previous attempts, plans, hopelessness, safety, supervision) o GSTPAID (grandiosity, sleep, talkative, pleasurable activities w/ painful consequences, agitation, ideas –flight of, distractible) qAnxiety o Panic attacks, OCD, Agoraphobia qPsychosis qSubstance use o specific types: ask about EtOH, smoking, cannabis, ecstasy, LSD, ‘shrooms (psilocybin), cocaine, heroin, PCP, crystal meth o onset, duration, frequency, quantity o EtOH: CRAFFT (car, relax, alone, forget things, family and friends, trouble) o attempts to stop o peer pressure, use by friends o methods of obtaining o parents’ awareness q Eating disorder screen: body image, dieting/wt loss q Past psych history: psychiatrist, counselling, therapy, meds PMH: q General health - any chronic illness? q Medications q Allergies q Immunizations FHx: q Family history of mental health issues, substance use Management: Substance abuse: The 5As: ask, advise, assess, assist, arrange** q Chronic interventions: family, group, individual counseling,12-step programs, behavioural or cognitive- behavioural methods, pharmacologic (methadone, buproprion, nicotine patches/gum, disulfiram) q Regular follow up appointments Depression: qTherapy - CBT (psych referral) qPharmacologic qSocial work qRegular follow up appointments **The 5 As: • Ask: age of onset of substance abuse details of substance abuse (how often, how many times, with whom and where, money source) Assess: qimpact on (family, emotional & physical health, school performance) qfriends qillegal issues/violence qrisk behaviour (CRAFFT) qreadiness to reduce risk behavior: o pre-contemplation o contemplation (pt wants to change but in doubt) Advise: qexplain risk of drug abuse (health, mental, family, community) qto stop all substance use qharm reduction plan Assist: qfamily support qcommunity support qpharmacology qwritten plan/agreement Arrange: qfollow up qfamily meeting if agree qmeeting with friend qmeeting with support group
15 yo female with crampy pain, headache, nausea, and vomiting during menses. Take a history and manage.
Syndrome specific qOPQRST of dysmenorrheal pain qAssociated symptoms – nausea, vomiting, diarrhea, headache qMenarchal history (pain with first period?), duration of period, impact on daily life, dyspaurenia qSTD history qMedication use qContraceptive history qDifferential diagnosis – family history, bowel symptoms, chronic abdominal pain syndromes Generic Adolescent stuff qPMH, including immunizations, chronic illnesses qHEADSS Diff Dx Primary versus secondary Secondary – gynecologic vs. nongynecologic Gyn: Endometriosis, adenomyosis, ovarian cysts, PID, polyps, cervical stenosis, pelvic adhesions post PID Nongyn: IBD, IBS, UPJ, psychogenic Treatment NSAIDs – start at onset of menses, continue1-2 dats OCPs – suppress ovulation
Amber, a 15 year old adolescent, has been stabilized medically after a Tylenol ingestion. She is hospitalized with her mother after taking a substantial amount of Tylenol before going to bed. She told her mother, who immediately brought her to the hospital. She has seemed depressed for the past few months. She is sleeping after the ER and ICU have stabilized her medically, and your job is to take a history from her mother regarding her suicidality (10 minutes). You will then be asked a series of questions (5 minutes).
History qIf interviewing adolescent → address CONFIDENTIALITY qNeed to meet with adolescent alone qParental knowledge regarding adolescent’s suicidal behaviour and accompanying psychiatric symptoms o History of the ingestion (timing, amount, circumstance) o Prior suicidal behaviour o History of mood change (MSIGECAPS) □ Sad, mad, irritable feelings □ Appetite, sleep changes □ Problems with concentration o Stressors o Risk behaviours □ Drug use □ Alcohol use □ Trouble with the law o Type of friends, relationships o Change in school performance o Loss of interest in activities which used to interest patient o History of past trauma (e.g., abuse, bullying) o Psychotic symptoms (e.g., visual/auditory hallucinations, delusions, flight of ideas, disorganized speech) o Manic symptoms (grandiosity, sleep (decreased need), talkative, pleasurable activities with painful consequences, activity increased (goal-directed), ideas (flight of), distractibility) qHome o Who lives in the home? o Status of family relationships o Adolescent’s adaptation to mother’s remarriage q Education o School history □ Level, grades, absentism □ Learning problems qSocial o Peer relationships (girl and boy friends, homosexuality (if known)) o Extra-curricular activities o Part time job qFamily history of complete suicide and other psychiatric history qPast medical history o Hospitalizations o Medications o ER visits o Early history (developmental and birth issues of relevance) qDid the candidate provide the following advice or suggestions either during the interview or during the counseling? o Address parental questions regarding medical status re: Tylenol overdose o Address parental questions regarding adolescent psychiatric status o Address safety for discharge
What are risk factors for suicide completion in adolescents?
[list 2] A: Sex [Assign one point only if male] Age [Assign one point only if 45 years old] Depression, bullying, homosexuality Previous attempts Ethanol abuse [alcohol or substance abuse] Rational thinking loss Social supports lacking [lack of family, friends, etc] Organized plan [lethal, affairs in order, note] No spouse [divorced, widowed, separated, single, no children] Sickness [chronic, debilitating and severe]
16 year old boy with cystic fibrosis referred by family doctor because not taking care of himself and deteriorating. Take history to help manage.
History qEnsure confidentiality qDiscuss impact of chronic illness (e.g., patient understanding of disease, natural history) o Chronic pulmonary disease (bronchiectasis +/- hemoptysis, ABPA, recurrent infections) o Aspermia o Abnormal glucose tolerance, diabetes mellitus o Malabsorption (if pancreatic insufficient) o Focal biliary cirrhosis, gallstones o Growth, energy level, participation in sports/activities qManagement of chronic illness to date o Respiratory (sputum for C&S, chest physio, medications (e.g., salbutamol, tobramycin)) o Acute chest exacerbations (PFTs, CXR, antibiotic treatments, hospitalizations) o GI/Nutrition (enzyme replacement, diet, diabetes) qHEADDSS o Home interview (focus on independence, peers) o Education, Employment o Activities o Drugs o Sex o Suicidality qRecent behaviour qRecent stressors qPsychiatric history Management and Counselling qMedical o Discuss importance of regular follow-up (PFTs, prescription refills, etc) o Discuss importance of healthy diet (to fell better, have more energy, etc) qPsychosocial o Provide counselling o Group sessions, community and peer supports, family assistance o Respect autonomy but involve parents
16 year old girl presents with fatigue. Take a focused history (13 min) and give DDx (2 min).
qConfidentiality qFatigue: time of day, onset, progression, worse with exertion, better with rest qExercise: sports, motivation, energy qSleep: time goes to bed, difficulty falling asleep, wake up in middle of night, snoring, apnea, time wakes up in AM, feels refreshed? qMenstrual hx qSexual hx qPsych hx qDiet: appetite, types of foods, weight gain/loss qROS: qGeneral: pallor, jaundice qConstitutional including fevers qCNS: Headache, seizures, vision/hearing, qHypothyroidism (cold, dry, hair, bradycardia, constipation) qRESP, CARDIAC, GI, Gyne qMSK: focal muscle weakness (unilateral, proximal vs distal), arthalgias qDERM: Rash qSick contacts, travel history qSocial: qHEADS qFunctional impairment qStressors qAbuse qMedications: OTC, Rx, herbal Diff Dx: qCNS: qCentral: tumor, other lesion qPeripheral: neuropathy, NMJ disease (myasthenia gravis), muscle (muscular dystrophy) qPSYCH: Depression, Anxiety, Eating Disorder qDRUGS: side-effect of meds or substance abuse qHEME: Anemia qENDOCRINE: hypothyroidism, Addisons, Cushings, DM qRHEUM: SLE, JIA, JDM, fibromyalgia qID: EBV, CMV, HIV, Parvovirus, Lyme, other qRESP: OSA, CF, Asthma qCARDIAC: CHD, CHF qGI: IBD, liver disease qGU: Pregnancy, renal failure, STI qONCOLOGY: Leukemia, Lymphoma qCHRONIC FATIGUE SYNDOME qDifficult to diagnose in children who cannot describe symptoms (need self-report), usually more applicable to > 11y qIf does not meet criteria, then Idiopathic Chronic Fatigue qNeeds BOTH criteria: qUnexplained persistent/relapsing new onset fatigue, not due to exertion, not relieved by rest, results in substantial reduction in previous levels of activity q4+ in six months: qImpaired memory or concentration (severe enough to affect function) qUnrefreshing sleep qPost-exertion malaise (> 24h) qMuscle pain qMultiple arthralgias (no arthritis) qSore throat qTender cervical/axillary LNs qNew headaches Management: Bloodwork is appropriate to at least reassure of absence of organic disease: qCBC, ferritin qESR qLytes, Ca, PO4, glucose qBUN, Cr qLiver enzymes qProtein, Albumin qTSH qMonospot qConsider BHCG qDepends on history! Treatment geared towards cause CFS = CBT and graded exercise therapy, close follow-up
15-year-old girl arrives in your ED and says that she was raped at a party 2 hours ago. Take a focused history, perform a pertinent physical exam, order relevant investigations, and provide a management plan.
General qWant to be somewhere with the appropriate supports (e.g., ER) qFirst priority is to deal with acute medical issues and ensure that the patient is stable qPraises patient for seeking help qIdentifies need for complete physical exam, including genital exam qObtains consent for examination qExplains that she is not at fault History qConfidentiality o Also address ‘age of consent to sexual activity’ □
16 year old otherwise healthy patient requesting information about smoking cessation. Counsel.
Confidentiality
ASK about smoking
When started
How many cigarettes per day
Where do they get them from
What drives them to smoke (stress, social, etc)
Who knows about their smoking
Sequelae: chronic cough, exercise intolerance
Social history
Include HEADS
Psychiatric history, substance use important
ADVISE
Discuss complications of smoking briefly:
Nicotine withdrawal
Identify withdrawal as a concern
Reviews common symptoms (strong desire for nicotine, irritability, frustration, anger, anxiety,
depression, difficulty in concentrating, increased appetite, H/A, and GI disturbances.)
Reviews common signs (decreased HR, weight gain, decreased BMR, and alteration of REM sleep
patterns.)
Addresses fatality concerns
Short-term Effects
Stained teeth and fingernails
Oral sores
Foul-smelling breath and clothes
Negative athletic performance due to decreased endurance and shortness of breath
Long Term Effects
Identifies mortality attributable to smoking (20 + 5%)
Identifies CV disease as major cause of M&M
Identifies COPD and neoplasms as the other major adverse health consequences of smoking.
Passive smoking effects Fetal
Spontaneous abortion and stillbirth Placental abruption/placenta previa Prematurity
Low birth weight
Child
Increased risk of sudden infant death syndrome
Increased rate of hospitalizations for respiratory problems
Increased risk of wheezing and asthma
Impaired lung function
Increased risk of otitis media
Increased risk of atopic dermatitis
Exacerbation of respiratory allergies
No completely safe smoking practices: ie concept of third hand smoke
ASSESS readiness to quit
Determine quit date, contract
Determine reasons for quitting (in patients own words) Clarify goal of complete abstinence
ASSIST
Method of quitting depends on the individual
Inform as many people (family, friends) of quit date as possible (ie if they know they smoke!)
Many smokers try a few times before quitting successfully
Throw out existing cigarettes and paraphernalia
Identify triggers and difficult situations (eg: alcohol, coffee, tiredness)
Develop coping strategies for above
Identify incompatible activities (eg, smoking and sports) and encourage these
Anticipate barriers
How to counter peer pressure
Dealing with subtle pro-smoking marketing Lessons from past quit attempts
Non-pharmacological resources/interventions
Where to find self-help materials (internet, Canadian Cancer Society, brochures) Community agencies (CCS), behavioral therapy, telephone hotlines
Identify a support person to turn to when having difficulty with quitting
Pharmacological assist devices
Patch and gum
Bupropion not approved under 18!
ARRANGE follow-up Questions from SP
What happens if I quit smoking cold turkey? What is nicotine withdrawal? Will I die?
What harm does smoking do?
I understand about the long-term effects, but I’ll be old then. It doesn’t hurt now does it?
My friend is pregnant, she smokes too. Should she be worried about her baby inside her? What about after
the baby is born?
Does quitting cold turkey work?
I tried quitting before, I couldn’t. What can be done to help me quit this time?
Bullying-History
Bullying - Checklist
̈ Introduces self
̈ Establishes rapport
̈ Addresses parent by name
History
Sleep
̈ Bed time week days
̈ Bed time week ends
̈ Usual routine before bed: meals, bath, read, tv ̈ Time falls asleep
̈ Nightmares
̈ Night terrors
̈ Nighttime awakening
̈ Morning wake-up time
̈ Naps
̈ Enuresis (primary or secondary)
̈ OSA: Snoring, respiratory pauses, daytime sleepiness, h/a ̈ Night cough, wheeze, PND
Constitutional
̈ Energy level ̈ Appetite
̈ Wt loss / gain ̈ fevers
Hyperthyroidism symptoms
̈ growth
̈ palpitations
̈ abdo pain, diarrhea, wt loss
Academics
̈ Decline in school performance
̈ ↓ attention / concentration
̈ somatic complaints: abdo pain, h/a ̈ school refusal
Family / Social
̈ Recent stressors / changes (E.g. move)
̈ Family situation / dynamics (E.g. unemployment, divorce) ̈ Possibility of abuse
Peer relations
̈ Friends
̈ Socially awkward (E.g. asperger features) ̈ Bullying
̈ Bully
̈ Bullied
̈ Physical or verbal
̈ Cyberbullying
̈ School / Teachers aware?
̈ What has been done?
Psychiatric
̈ Anxiety, OCD
̈ Depression
̈ Behavior disturbance (oppositional, tantrums)
PMHx
̈ Recent hospitalization ̈ Asthma, atopy
̈ Thyroid disease
̈ Meds (E.g. stimulants)
Fam Hx
̈ Sleep problems
̈ Issues with social interaction (E.g. Autism)
Suggestions for addressing bullying
̈ Bullying is a common problem
̈ Do not overreact, remain calm, tell Paul you will not just run to the school
principal (children are afraid things will get worse if they are seen as a tattle)
̈ Listen to what Paul has to say
̈ Let Paul know that you do not blame him, that it is not his fault
̈ Identify leaders and supporters of bullying
̈ Notify appropriate authorities if child is at physical risk (E.g. weapons)
̈ Notify school authorities and/or other parents depending on severity
̈ Work in collaboration with the school (teachers and principals often unaware) –
teachers should be aware about when and by whom bullying occurs
̈ Ask teacher to help Paul get a “buddy” (older child or classmate), or organize and
supervise a fun activity at recess, so Paul can be social and safer
̈ Avoid comments such as “why don’t you just stand up for yourself?”
̈ Talk to Paul about what makes people act like bullies (usually, they are unhappy)
̈ Not a good idea to tell Paul to respond kindly to the bullies
̈ Not a good idea to tell Paul to go along with what bullies say
̈ Suggest that Paul use comments such as “I don’t like teasing. Stop.” And then
walk away from the situation ignoring any further taunt.
̈ Praise Paul for facing up to his fears (boost self-confidence)
̈ Role play situations
̈ Encourage Paul’s participation in activities he enjoys, and in which he excels
(E.g. chess, book club)
̈ Enroll Paul in community social clubs – developing friendships in or outside
school has a strong buffering effect
̈ Big brother / support group for Paul
̈ Consider SW / psychology consult
̈ Pediatrician to give a talk at the school if NO “no tolerance” bullying policy in
place
̈ Parent support group
̈ Videos, Books: “Bullies and victims”
̈ Written documentation, websites on bullying
