Adole/Psych/Gyne

Question 1

Eating disorder history and physical

Answer 1

• 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?

Question 2

Eating disorder investigations/ DDx

Answer 2

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

Question 3

Eating disorder management

Answer 3

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

Question 4

What are the key elements of family based therapy for eating disorders?

Answer 4

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

Question 5

What is ARFID?

Answer 5

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

Question 6

Menorrhagia, Oligomenorrhea 14 year old female with heavy irregular painful periods. History and physical exam.Investigations

Answer 6

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

Question 7

Management menorhaggia + OCP CI

Answer 7

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?

Question 8

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

Answer 8

□ 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

Question 9

Contraception history Anticipated side effects Benefits of OCPs

Answer 9

• 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

Question 10

Emergency contraception counselling

Answer 10

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

Question 11

16 year old girl wants to see you about lower abdominal pain. 10 minutes to take a history.

Answer 11

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

Question 12

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?

Answer 12

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

Question 13

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.

Answer 13

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

Question 14

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.”

Answer 14

**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?

Question 15

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).

Answer 15

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

Question 16

15 yo female with crampy pain, headache, nausea, and vomiting during menses. Take a history and manage.

Answer 16

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

Question 17

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).

Answer 17

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

Question 18

What are risk factors for suicide completion in adolescents?

Answer 18

[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]

Question 19

16 year old boy with cystic fibrosis referred by family doctor because not taking care of himself and deteriorating. Take history to help manage.

Answer 19

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

Question 20

16 year old girl presents with fatigue. Take a focused history (13 min) and give DDx (2 min).

Answer 20

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

Question 21

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.

Answer 21

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’ □

Question 22

16 year old otherwise healthy patient requesting information about smoking cessation. Counsel.

Answer 22

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?

Question 23

Bullying-History

Answer 23

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)

Question 24

Suggestions for addressing bullying

Answer 24

̈ 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

Question 25

You are a consultant pediatrician in a tertiary care hospital who regularly follows 17-year old Jason, who was been diagnosed with diabetes when he was 6. You have been the main coordinator of his care along with the occasional visits to other subspecialists and multidisciplinary team members. Over the years, there have been concerns that Jason has missed many appointments with specialists/team members, and his diabetes is not optimally controlled. Jason will be turning 18 in 8 months and you want to plan to transition him to adult care.

Over the next 8 minutes, take a history from Jason about his diabetes, keeping in mind his transition to adult care. In the following 4 minutes, counsel Jason about his transition to adult care.

Post-Encounter Probe:
Name four recommendations to make an admission to hospital smoother for adolescents with chronic diseases.

Answer 25

o Identifies Self
o Refers to patient by name
o Displays empathy
o Uses non-medicalized jargon o Confidentiality statement

o Discusses current diabetes management o Glucose checks

o Insulin regimen
o Last HgA1C
o Diabetes screening o Blood pressure
o Opthalmology
o Kidney function
o Episodes of DKA

o Asks about reasons for missed appointments

o Home
o Who lives at home

o Tension in family

o Help with diabetes management o Education

o Current grade in school
o Average grades in school
o Missed school due to illness
o Vocational plans
o Bullying due to chronic disesae

o Activity
o Activities with friends

o Limitations of illness on activities

o Diet
o Current diet and diet restrictions

o Body image

o Drugs
o Smoking

o Drugs

o Alcohol o Sexuality

o Sexual activity
o Current partner
o Protection during sex

o Suicidal ideation o Mood

o Anxiety

o Suicidal ideation

Counseling on Transition to Adult Care
o Asks patient about his understanding of current diabetes management
o Asks patient about his feelings regarding transition to adult care
o Acknowledges that feelings are mixed/scary
o Discusses patient’s expectations about adult care management
o Advises patient to take responsibility for/be an advocate for his diabetes care o Discusses what to expect in an adult centre

o Less family focused; more patient focused

o Fewer interdisciplinary resources
o Counsels patient about independence in diabetes management

o Glucose checks
o Gives insulin himself
o Makes own appointments
o Healthy Active Living choices (diet, lifestyle)

o Advises patient to be seen without parents for part of appointments
o Advises patient to make own appointments
o Offers a formal acknowledgement of ‘graduation’ ie. a certificate from health care

facility, seen as a ‘rite of passage’
o Discusses that a transition letter will be sent to the new specialist
o Arranges for one final meeting after the patient has met the new specialist
o Offers to provide patient with information about their condition and available

resources
o Websites (ie. Good 2 Goàwww.sickkids.ca/good2go) o Peer support groups

o Discusses available community resources with patient (may refer to social work).

Question 26

You are a community paediatrician. You are seeing a new patient, April, a 15 year old girl who has been living on the street for 6 months after being kicked out of her mother’s home. She was placed in foster care 24 hours ago after a family doctor working at a shelter called CAS.
Take a history (10 minutes).
Outline your approach to management for April including any necessary investigations, treatments and follow-up plans (5 minutes).

Answer 26

History

̈ Introduces self
̈ Displays a non-judgemental, empathetic approach
̈ Establishes rapport
̈ Confidentiality statement
̈ Date of last visit to MD
̈ Name of previous doctor and consent to obtain records as appropriate

HEADS:

̈ Home:
o How long in shelter/on the streets?
o Living conditions at shelter
o Events leading to homelessness
o Any contact with family?
o Any desire to go back home? Is this even possible? o Friends?
o Social supports?
o Involvement of CAS/social worker in the past?
o Feelings about being in foster care now

̈ Education:
o Attending school?

o Highest grade completed
o Desire to continue education? o History of learning difficulties? o Any form of employment?
o Any source of income?

̈ Alchol:
o Chronic alcohol use?

o What type of alcohol? Quantity?

o Screen for symptoms of withdrawl as appropriate ̈ Drugs:

o Types, Frequency, quantity
o IV drug use now or in past?
o Smoking?
o Screen for symptoms of withdrawl as appropriate

̈ Diet:

o Body image screen
o History or restricting/binging/purging o Patter of eating while in shelter
o Screen for malnutition

̈ Sexuality:
o Sexually active?

o Age at first sexual activity o Number of partners
o Gender of partners
o Type of sexual activity

o Contraception used?
o Safe sex?
o History or prostitution?
o Past history of pregnancy? o LMP

o Dyspareunia
o History of sexual assault/rape? o History of STIs?
o Testing for STIs/HIV

̈ Suicidal Ideation:
o Current mood/anxiety symptoms
o Past psychiatric history
o History of suicidal ideation/attempt? o Cutting/self-mutilation?

PMHx:

̈ Pregnancy History

o Prenatal exposure to drugs, alcohol

̈ Past medical illnesses

o Screen for contraindications for hormonal contraceptives

̈ Past admissions to hospital

̈ Past surgery

̈ Developmental history

̈ Medications

̈ Allergies

̈ Immunizations

o Routine childhood vaccinations o Hep B
o Meningococcal
o HPV

ROS:

̈ Vision

̈ Hearing

̈ Teeth

̈ Recent weight changes

̈ Infectious disease screen (cough, fever, chills) ̈ Rash (eg. Scabies, lice, syphilis)
̈ Joint symptoms
̈ Menstrual problems

̈ Urinary symptoms ̈ Bowel routine
̈ Sleep

FHx:
̈ Chronic medical conditions

o Screen for contraindications for hormonal contraceptives ̈ Psychiatric conditions

SHx:
̈ Details of foster home
̈ Plan for length of stay
̈ Plan for school
̈ CAS involvement
̈ History of police involvement/criminal record?

Investigations: (to be determined according to history)
̈ Bloodwork: CBC, ferritin, lead, HIV, hepatitis B and C titres, B-hCG ̈ STI screening: cervical swabs for Chlamydia, gonorrhea, PAP
̈ PPD/ CXR if indicated
̈ Further specific medical work-up if indicated
̈ Assessment of growth- obtain previous records if possible

Treatment:
̈ STI prophylaxis as appropriate
̈ Contraception as appropriate
̈ Immunizations: Obtain previous records if possible

o TdaP
o Menactra o Hep B
o HPV

̈ Hearing, vision, dental screening as appropriate ̈ Psycoed testing as appropriate

Follow-up Plans:
̈ States need for follow-up medical visit within 1 month

o Further review history including immunization status, complete physical exam, complete or review referrals for development or mental health assessments as needed.

o Ensure vision, hearing, dental assessments arranged as needed.

o Laboratory tests to be reviewed ̈ Immunizations to be completed

̈ Evaluate need for psychoed testing as well as liasing with teachers and principals. ̈ Advocate for permanency planning including placement stability
̈ Advocate for establishment of thorough medical records which should follow

patient throughout and beyond foster care placement
̈ Referral to community resources as appropriate
̈ Recognize that children/youth in foster care require more frequent monitoring

than the regular pediatric population

Question 27

You are a consultant pediatrician doing a locum in the community. You are booked to see a 17-year old male (Johnny) in clinic one afternoon who booked an appointment because he is having ‘difficulty coping’. He tells the nurse prior to seeing you that he is distressed because he is homosexual and has recently began to tell his parents and friends.

Take a history from him (8 minutes).

Post-Exposure questions:
1) What initial investigations would you perform if any?

2) Define Sexual Orientation.
3) Name 5 concerns that homosexual youth are at increased risk for.

4) You are a consultant seeing a different patient (a 16 year male for depression). How would you ask about his sexual orientation in a non- judgemental, gender neutral way?
5) The following week, the mother of 17-year old Johnny comes in to see you as she is concerned about her son “being gay”. She states she feels this is “just a phase”. Counsel the mother regarding this (5 minutes)

Answer 27

̈ Introduces self.
̈ Refers to patient by name.
̈ Uses non-medicalized jargon
̈ Displays empathy
̈ Use of a non-judgemental manner ̈ Establishes rapport
̈ Confidentiality statement

̈ Ask what he considers his sexual orientation o Attraction to others

o How long has he been aware of his sexual orientation o Personal conflict with sexual orientation (acceptance) o Any concerns with gender identity

̈ Ask who is aware of his sexual orientation (if anyone) o Parents

o Siblings o Friends o Teachers

̈ Ask what their reactions were
̈ Ask if support systems are in place

o Role models
o Other gay members in the community o Support groups in the community

HEADSS ̈ Home

o Tension with family members

o Kicked out of home or left home ̈ Education

o Current grade
o Missed school, attendance o Dropped out of school
o Current grades
o Future aspirations

̈ Activity
o Activities with friends

o Parties/clubs/raves

o Sexual orientation of peer group ̈ Drugs

o Alcohol use
o Drug use (especially E, special K, crystal meth) o Smoking

̈ Diet

o Body image ̈ Sexual Activity

o Age at first intercourse
o Number of partner(s)
o Gender of partner(s)
o Type of activity (oral, anal, genital) o Non-consensual intercourse

o Protection against STIs
o Protection against pregnancy (if necessary) o History of STIs in partner
o Personal History of STIs
o Symptoms of STI

§ Dysuria
§ Urgency
§ Discharge § Ulcers

̈ Suicidal Ideation
o Suicidal ideation

o Suicidal attempts o Mood
o Concentration
o Energy

o appetite
o Anxiety symptoms

̈ Social stresses
o Physical Bullying

o Verbal bullying
o Threats with a weapon

Post-Exposure Questions

1) Initial Investigations
Urethral, pharangeal, and anal swabs for gonorrhea (or urine culture) Urethral culture or urine for chlamydia
VDRL, HIV, Hepatitis B&C
Anal cytology
Stool cultures, O&P

2) Define Sexual Orientation
à Sexual orientation refers to whether a person’s physical and emotional

arousal is to people of the same or opposite sex, or both.

3) Homosexual youth are at increased risk for: - abuse (physical, verbal)
- drop out of school
- kicked out of home

• substance use/abuse - suicidal ideation
• STIs

4) You are a consultant seeing a different patient (a 16 year male for depression). How would you ask about his sexual orientation in a non- judgemental, gender neutral way?

“Is there anyone you are romantically interested in? When you think of people to whom you are sexually attracted, are they men, women, both, neither, or you are not sure yet?”

5) The following week, the mother of 17-year old Johnny comes in to see you as she is concerned about her son “being gay”. She states she feels this is “just a phase”. Counsel the mother regarding this (5 minutes)
- confidentiality (non disclosure of son’s information)

• likely not a phase; he is likely certain regarding sexual orientation
• important to let teen know that they still love them while they are dealing with their feelings regarding sexual orientation
• refer to support groups

i.e. PFLAG

Question 28

You are a general paediatrician who just opened up a consultant practice at the MontFort pediatric clinic. You are very excited to join the excellent team of pediatricians. One of your first consults is a referral from a local family physician. The referral note states:

“Please see this young 12 year old boy Jake in consultation. Jake’s mother has been having concerns that he is more isolated and depressed lately. His father left him and his mother at a young age. He has also missed a fair bit of school because of not feeling well. Thank you.”

Over the next 7 minutes, take a focused history from Jake. He comes to your office alone. After this time, you will be given a follow-up scenario for 8 minutes.

Answer 28

̈ Introduces self

̈ Refers to patient by name

̈ Confidentiality statement

̈ Uses open-ended and non-judgemental questions

HPI

̈ Establishes reason for visit (missing school)

̈ Addresses possible reasons for school refusal (bullying)

̈ Asks about possible reasons for bullying in a non-judgemental way (kids are

calling him “gaylord”)

̈ Discusses school performance (dropping grades)

̈ Discusses friends/supports at school (2 girls in his class)

̈ Enters into a HEADDDSS history – only answers if confidentiality discussed

o Home (doesn’t get along with brother, father leftàdon’t think about him much since he’s a “jerk”)

o Education
o Activities (football and baseball in gym class, school band, reading) o Drugs (no), Alcohol (no)
o Dieting (yes – restricting so as not to gain weight. Some body image

issues as well)
o Depression (yes – feeling down a lot)
o Sexuality (no partners, but if examiner leaves open-ended, then say you

are attracted to both males and females…you also don’t feel like you “fit”

into this body...not sure what these feelings mean) o Suicide (no)
o Smoking (tried x 4)

̈ On

computer – has a female avatar named “Jackie”

̈ PMHx elicited

̈ V accinations

̈ Allergies

̈ Medications

o (May disclose estrogen creams obtained over internet if specifically asked)

̈ Social history

o Social supports
o Family supports
o Financial situation (family)

̈ Closes appropriately (follow-up made)

Question 29

Follow up gender identity: Jake does not show up to follow-up appointments with either you or his family physician. Three years later, Jake presents to your office and has come out to you that he wants a sex change to become a female. Take a focused interval history and council over the next 7 minutes.

Answer 29

̈ Takes focused interval history

o Well, no illnesses

̈ Current home situation (living with friends, still contacts mom)

̈ School (left school completely because of bullying)

̈ Employment (not working…has been offered sex trade jobs but not taken)

̈ Drugs (marijuana, cocaine on occasion. Taking Estrogen pills he bought over

the internet to stop hair growth and pubertal signs)

̈ Diet (restricting to stay slim)

̈ Depression (mood depressed but not clinical depression)

̈ Suicide (no)

̈ Smoking (1 PPD)

̈ Puberty history

o Definetely has some coarser hair growth (axillary and pubic with penile enlargement)

̈ Services following him (none)

Counselling

̈ Non-judgemental, supportive attitude

̈ Explains diagnosis of Gender Identity Disorder

o Identifies best to start Tx’s early (tanner 2)

̈ Identifies that PRIMARY treatment must be to resolve the conflicts that are

associated with the disorder

o MUST be psychologically ready (no depression) and socially ready (no

addictions, stable home environment, promise follow-up)
o Self-acceptance, with minimal shame/guilt must be present before medical

treatment begins
o Referrals to psychology, social work, behaviour therapy, etc…
o Identifies need to reunite with family despite differences in opinion

(including family counselling)

̈ May mention that no treatments in childhood have been shown to alter the

path of sexual identity of children with gender identity disorder

̈ Asks what information patient knows about sex change

o Internet resources used

̈ Discusses Lupron treatments to stop pubertal changes

o Reversible, apart from possibly decreased fertility

o In consultation with Endocrinology

̈ Discusses possibility of sex change procedure

o Must show psychosocial stability and compliance with hormonal treatments for at least 1 year (Nelsons)

o In consultation with Surgical specialists

̈ Closes interview with appropriate follow-up

Question 30

Suicide RF

Answer 30

Access to guns

Past attempt

Substance abuse

Bipolar disorder

Sexual minority youth

Access to guns

Past attempt

Question 31

Substance abuse screen

Answer 31

CRAFFT screen (>2 increases risk)

Car use/in while intoxicated

Relax, to fit in

Alone

Friends/family asking to cut back

Forget or black out

Trouble with use (gotten into)

Question 32

Drugs that decrease effect of OCP

Answer 32

Drugs that decrease OCPs

1. Abx (+/-)
2. Antifungals (griseofulvin)
3. AEDs (but not valproate)
4. ARVs (PIs/NNRTIs)
5. Antidepressants (St. John’s Wart)

Question 33

DDx abnormal uterine bleeding

Answer 33

Abnormal vaginal bleeding

DDx of abN bleeding

1. Anovulatory cycles (most common)
2. Bleeding d/o: ITP, VWD
3. STIs: GC,CT, Trich
4. Meds: OCPs, Depot, Antipsychotics
5. Endocrine: Hypo/hyperTH, PCOS
6. Genetic: Turner syndrome
7. Uterine: carcinoma, IUD

Question 34

Amenorrhea DDx

Answer 34

Primary amenorrhea

Without 2 sexual characteristics

1. Turner, 17 alpha hydrox deficiency
2. Congenital absnce of uterus
3. Gonadal dysgenesis (with ­ gonadotropins)
4. Hypo-pit abn

With 2 sexual characteristics

1. Stress, wt loss, exercise, chronic illness, PCOS
2. Ovarian dysfunction (irradiation/chemo/trauma)
3. Abn pit gland (tumor, empty sella syndrome)
4. Abn genital tract (cervical agenesis, imperforate H, androgen insensitivity)

Pregnancy

Question 35

Gynecomastia

Answer 35

Clinical features of physiologic gynecomastia

1. 60% of 13-14 yo M
2. 75% resolve w/n 2 yrs
3. More common in obesity
4. a/w penis/pubic hair SMR 2-3
5. Often tender

Drugs a/w gynecomastia

1. Steroids, AASs
2. Antimicrobials: INH, HAART, Ketoconazole
3. GI meds: PPI, H2B
4. CVS: diuretics
5. ChemoTx: MTX
6. 7. Illicit: MJ, EtOH

Question 36

Dysfunctional uterine bleeding

Answer 36

1. Def: irr and/or prolonged bleeding in the absence of structural pelvic pathology
   
   • Anovulatory cycles (unopposed estrogen)
   • Ectopic pregnancy / threatened abortion
   • Endometriosis
   • Coag d/o (VWD), document INR, PTT
   • Hypothyroidism, document TSH
   • Do a prolactin…
   • Cervical dysplasia
   • Random: Fanconi, thalassemia, RA, meds

Question 37

Common causes of prepubertal vaginal bleeding

Answer 37

1. Ulcerated hemangiomas
2. Infxs vaginitis: Salmonella, Shigella
3. Tumor: embryonal carcinoma, RMS, vaginal tumor
4. Exogenous estrogen
5. Bleeding D/o
6. Trauma: excoriations, saddle injury, penetrating
7. Genital warts
8. Urethral prolapsed
9. Premature menarche/precocious puberty
10. Lichen sclerosis et atrophicus

Question 38

PCOS-Criteria, DDx

Answer 38

Dx criteria of PCOS

1. Oligo/Amenorrhea
2. androgens: hirsutism, alopecia, acne, cliteromegaly hyperandrogenemia
3. Polycystic ovaries on U/S

Risk factors for PCOS

1. Premature adrenarche (pubic hair <8)
2. RF for IGT or FHx of DM2

DDx of PCOS

1. Non-classic CAH
2. HYpothyroidism
3. Cushing syndrome
4. Androgen-producing tumor
5. Hyperprolactinemia
6. Metabolic syndrome

Question 39

Female athletic triad

Answer 39

1. Disordered eating
2. osteoporosis
3. Amenorrhea

Question 40

Endometrosis treatment

Answer 40

1. OCPs (first line)
2. Depot medroxyprogesterone
3. GH
   
   1. decreased BMD (vitamin D/Ca/wt bearing)
   2. low estrogen Sx (hot flashes, vaginal dryness, insomnia)
4. Surgery (rarely successful): laser, electrocautery, excision (all equivalent)