Adolescent Flashcards
Age of consent
16 years old
x3 close age exceptions to consent
- 14-15 years old = up to 5 years older
- 12-13 years old = up to 2 years older
- Not in a position of authority
What class of medications may reduce efficacy of OCP?
Anti-epileptics
What supplementation may you add if on Depo-Provera?
Calcium and vitamin D for BMD
Treatment for chlamydia STI
Doxycycline 100mg PO BID x7 days
Or Azithromycin 1g PO x1 dose
Treatment for gonorrhea STI
Ceftriaxone 250mg IM x1
Azithromycin 1g PO x1
PID complications if untreated
- Ectopic pregnancy
- Chronic pain
- Infertility
Criteria for PID
- Minimum = lower abdo pain PLUS either: adnexal, uterine, and/or cervical motion tenderness
- Increased specificity = fever, vaginal discharge, WBC, ESR/CRP, +G/C
Age range for thelarche + how far ahead before menarche
8-14 years old
Precedes menarche by 2 years
Dosing schedule for HPV for child > 15 years old?
Three doses - now, x1 month, x6 months
Cannabis Withdrawal Syndrome criteria
2/5 psychological symptoms = irritable, anxiety, depressed mood, sleep disturbance, appetite change
1/6 physical symptoms = abdo pain, shaking, fever, chills, headache, diaphoresis
Nicotine replacement therapy - contraindication
None
Chlamydia trachomatis testing
First catch void urine
Vaginal swab
Endocervical/urethral swab
First line treatment for AN
Family based therapy
Only FDA approved medication for Bulimia Nervosa
Fluoxetine
Most common cause of abnormal uterine bleeding
Anovulatory bleeding
Best medications to consider for acute heavy menstrual bleeding
- OCP
- TXA
- NSAIDs
For adolescents how much estrogen do you want in an OCP
At least 30 mcg
Two most important labs for heavy menstrual bleeding
B-HCG
CBC
MOA of contraception
- Progestin = thickens cervical mucus, alter tubal transport time, inhibit ovulation
- Estrogen = blunt FSH release
- Endometrial atrophy
Fitz-Hugh-Curtis Syndrome = cause
- Majority caused by Chlamydia, complication of PID
What type of urine sample is preferred for G+C testing?
- First catch preferred over midstream
Most common cause of school absenteeism in females?
Dysmenorrhea
Classic definition for primary amenorrhea
- No menses by 14 WITHOUT secondary sex characteristics
- No menses by 16 WITH secondary sex characteristics
First part of work-up for amenorrhea (first 4 steps)
- Urine B-HCG
- TSH/T4
- Prolactin
- Progesterone withdrawal bleed challenge
Complications of PCOS
- Infertility
- Metabolic syndrome
- Unopposed estrogen (endometrial cancer, breast cancer)
HPV - clinical manifestations
- Subclinical
- Anogenital condyloma acuminata (genital warts, HPV 6+11)
- Cervical dysplasia and cancer (HPV 16+18)
- Cancer = vulvar, vaginal, oropharyngeal, penile, oral
- Non-sexually transmitted warts
STI - why increase prevalence among adolescents?
- Less likely to use barrier protection
- Cervical ectropion (have more columnar epithelium, which is more vulnerable)
- Cervical metaplasia in transformation zone (also more vulnerable)
Most common adolescent STI
HPV
Goal weight gain per week for eating disorders
0.2 - 0.5 kg
What information to consider for treatment goal weight?
- Series of accurate anthropometric measurements (ht, wt, BMI)
- Age, sex, race
- Pre-morbid exercise and dietary history
- Age at pubertal onset and current pubertal stage
- Age at menarche and weight at which menses ceased
Physical complications of dieting
- Growth deceleration
- Menses irregularity
- Excess weight gain + over-eating
- Nutritional deficiencies
- Bone health
Psych complications of dieting
- Food pre-occupation
- Irritable
- Distractible
- Fatigue
- MH
- Eating d/o
- Worse self-esteem
PID critieria
- Sexually active
- Pelvic or lower abdo pain
- Adnexal, cervical motion, and/or uterine tenderness
- Other: fever, discharge, elevated CRP
PID bugs
G+C, mycoplasma, gram negative rods, CMV, gardenella, H.flu
PID outpatient treatment
- x1 CTX IM
- 14d of doxy
- 14d of flagyl
PID complications
- Chronic abdo pain
- Ectopic pregnancy
- Infertility
- Recurrence
- Abscess
- Fitz-Hugh-Curtis syndrome = perihepatitis, PID+RUQ PAIN
Genital ulcer syndromes
- HSV
- Syphilis
- Chancroid
- Lymphogranuloma venereum
Most sensitive and specific test for G+C?
NAAT
What samples can you do NAAT testing for G+C?
- First catch void (or midstream)
- Vaginal or endocervical
- Urethral
- Pharyngeal
- Anal
What kind of contact do you worry about for hep A?
Oral-anal
Indication to test for hep B?
No vaccine or low immunity
Indication for testing for hep C?
IVDU
Cannabis Use Disorder - definition
Problematic pattern of use that leads to clinically significant impairment in areas of function and distress within a 12 month period
Timeframe for Cannabis Withdrawal Syndrome - onset of symptoms, persistence of symptoms
- Onset within 24-72 hours
- Persistent 1-2 weeks
Criteria/symptoms for Cannabis Withdrawal Syndrome
- 1/6 physical sx = abdo pain, headache, fever, chills, diaphoresis, shaking
- 2/5 psych sx = change in appetite, change in sleep, irritable, anxiety, decreased mood
Other substances commonly used with cannabis
- Alcohol
- Tobacco
- Ecstasy
- Synthetic cannabinoids
Associated mental health complications to cannabis use
- Psychosis
- Schizophrenia
- Anxiety
- Depression
x6 features to explore of suicide risk assessment
- Hx of mental illness
- Psychosocial support
- Impulsivity
- Precipitating factors
- Previous attempt
- Family factors
x4 ways to determine Treatment Goal Weight
- Based on previous growth
- Based on mBMI
- Based on weight + 2kg prior to menses cessation
- Weight at same as heigh percentile
Individual RF’s for dieting
- Women and girls
- Overweight and obesity
- Distortion of body image and body dissatisfaction
- Lower self-esteem
- Low sense of control over life
- Psychiatric symptoms - anxiety, depression
- Vegetarianism
- Early puberty
- Certain chronic conditions (DM, asthma, ADHD, epilepsy)
- Other risky behaviours (smoking, substance use, unprotected sex)
Family RF’s for dieting
- Low family connectedness
- Absence of positive adult role models
- Parental dieting
- Parental endorsement or encouragement to diet
- Parental criticism of child’s weight
Factors that may make an individual more likely to quit smoking
- Older teenager
- Male sex
- Pregnancy/parenthood
- Scholastic success
- Team sport participation
- Peer + family support for cessation
- CYP2A6 slow nicotine metabolizer
Options for NRT + x1 option that is NOT recommended
- Gum, transdermal patch, lozenge, nasal spray
- E-cig = NO
x3 main SE for NRT
- Increased HR + BP
- Mouth/skin irritation
x2 meds that could be considered for smoking cessation (+ contraindications of one)
- Bupropion = not for seizure disorders or ED
- Varenicline
x2 strongest factors to adolescent initiation of smoking
- Parental smoking
- Parental nicotine dependence
x6 chronic illnesses that are mentioned in the CPS statement to have specific consequences of smoking in adolescence
- Asthma
- CF
- Sickle Cell
- Cancer
- JIA
- Diabetes
Resp complication of vaping
Vaping product use-associated lung injury = sterile inflammatory pneumonitis
Risks/harms of vaping
- Resp: VALI, chronic cough, asthma exacerbations, decreased exercise tolerance
- Unintended injuries: burns, driving, ingestions
- MH: inc of substance use, depression, nicotine toxicity, withdrawal
What adolescent development stage: unable to perceive long term outcomes of decision making?
Early
What adolescent development stage: Self-conscious about appearance + attractiveness?
Early
What adolescent development stage: increased need for privacy + bid for independence?
Early
What adolescent development stage: Seeks same sex peer affiliation
Early
What adolescent development stage: peak of conflict
Middle
What adolescent development stage: initiation of relationships + sexual activity
Middle
What adolescent development stage: intense peer group involvement
Middle
What adolescent development stage: future-orientated + able to think things through independently
Late
What adolescent development stage: emotional + physical separation from family
Late
What adolescent development stage: consolidation of sexual identity
Late
What adolescent development stage: intimacy + commitment takes precedence with peer relationships
Late
Age for “late adolescence”
17-19
Age for “middle adolescence”
15-16
Age for “early adolescence”
12-14
x4 leading causes of unintentional injury leading to adolescent morbidity/mortality
- MCV
- Drowning
- Poisoning
- Falls
Which of the biochemical abnormalities are you most likely to see in setting of binge eating + self-induced vomiting:
- Urine alkalosis
- Metabolic acidosis
- HyperK
- HypoPO4
-Urine alkalosis
ARFID Criteria
Eating/feeding disturbance associated with failure to meet nutritional needs AND 1 of the following:
- Weight loss or growth failure
- Nutritional deficiency
- Dependence on enteral feeds or liquid nutrition
- Marked interference with psychosocial functioning
- No evidence of body image disturbance
- No medical illness to explain symptoms
Criteria for Bulimia nervosa
- Binge eating = eating an excessive amount of food and sense of lack of control during binge episode
- Recurrent inappropriate compensatory behaviours for binge episode to prevent weight gain (purging, laxative use, fasting, excessive exercise)
- Episodes occur on average once weekly for 3 months
- Self-evaluation is unduly influenced by weight/shape
- Does not meet criteria for AN - of normal or increased body weight
Criteria for anorexia nervosa
A. Restriction of energy intake relative to requirements –> significantly low body weight for age, sex, developmental trajectory, and physical health
B. Intense fear of gaining weight or becoming fat OR persistent behaviour that interferes with weight gain even though at a significantly low weight
C. Disturbance in the way in which one’s body weight/shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight
What is atypical anorexia nervosa?
When meets B + C criteria but has not developed significantly low body weight
x3 biochemical findings of refeeding syndrome
HypoK, hypoPO4, hypoMg
x4 risk factors for refeeding syndrome
- Little or no intake x5-10 days prior to refeeding
- Rapid weight loss
- Extremely low weight (current weight <70% treatment goal weight)
- Baseline low PO4, K, and Mg
Endocrinology related complications for eating disorders
- Bone loss
- Sick euthyroid
- Hypercortisolemia
- Hypoglycemia
- Hypothermia
GI related complications for eating disorders
- Constipation
- Reflux
- Decreased gastric motility
- Elevated transaminases
Heme related complications for eating disorders
Anemia > leukopenia > thrombocytopenia
Derm related complications for eating disorders
- Xerosis
- Lanugo
- Telogen effluvium
- Carotenoderma
- Acrocyanosis
- Livedo reticularis
Indications for hospitalization for eating disorders
- Acute food refusal
- Significantly low weight (<75% below mBMI)
- VS: bradycardia (<50 day, <45 night), hypotension (<90/45), hypothermia (<35.6), orthostatic changes
- Acute medical complications: arrhythmia, syncope, seizures, pancreatitis
- Dehydration + lytes abnormalities
- Comorbid condition that limits outpatient tx (T1DM, severe depression, SI)
- Discontinue cycle of binge/purge
- Failure of outpatient tx
- Arrest of growth + development
What is the new name and what is included within the female athlete triad?
=Relative energy deficiency in sport
-Oligo/amenorrhea, low bone mineral density, low energy availability
Symptoms/signs of intoxication for (a) nicotine and (b) cannabis?
(a) Tachycardia, HTN, appetite suppression
(b) Tachycardia, HTN, increased appetite, conjunctival injection, dry mouth
CRAFFT
- Car
- Relax
- Alone
- Forget
- Family/friends
- Trouble
Definition for abnormal uterine bleeding?
Any menstrual bleeding that is out of the normal range for duration, frequency, or amount of bleeding
What is the most common cause of non-amenorrhea AUB in adolescent patients?
Physiologic adolescent anovulation
Why does physiologic adolescent anovulation occur?
Progesterone deficiency results in thick + unstable endometrium
Causes of non-amenorrhea AUB (x7)
- Physiologic anovulation
- Pregnancy related (pregnancy, ectopic, loss, molar)
- Contraception
- Infection
- Bleeding disorder
- PCOS
- Thyroid dysfunction
Investigations for non-amenorrhea AUB
- CBC
- Ferritin + iron studies
Consider:
- Pregnancy test
- Bleeding d/o work-up
- PCOS w/u: testosterone, DHEA
- TSH
- STI screen
Tx for non-amenorrhea AUB
- Physiologic cause: no tx needed unless acute bleed
- Hormonal tx, NSAIDs, TXA, iron supplementation
Which of the following is an ABSOLUTE contraindication to estrogen for contraception?
A. Mild cirrhosis
B. SLE with unknown antiphospholipid Ab
C. Symptomatic gallbladder disease
D. Uses medication that interferes with estrogen metabolism
B
MOA of estrogen containing contraception (x4)
- Inhibits ovulation
- Thick cervical mucous
- Endometrial atrophy
- Affects fallopian peristalsis
Benefits of contraception (apart from pregnancy prevention)
Decreased:
- Dysmenorrhea
- Amount of bleeding
- Acne
- Hirsutism
- Risk of endometrial cancer
- Fibroids + ovarian cysts
- Benign breast disease
Estrogen SE’s
- Irregular bleeding
- Breast tenderness
- Nausea
- Headaches
- Increased risk of VTE + stroke
Absolute contraindications to estrogen (x12)
- <6 weeks post-partum
- HTN (>160/100)
- Current or past history of VTE
- Ischemic heart disease
- Complex valvular heart disease (SBE, PHTN)
- History of cerebrovascular accident
- Migraine with focal neuro symptoms
- Breast cancer (current)
- DM with retinopathy, nephropathy, and neuropathy
- Liver tumor
- Severe cirrhosis
- SLE with +/unknown antiphospholipid Ab
Relative contraindications to estrogen
-Medications that interfere with OCP MOA
-HTN that is adequately controlled or 140-159/90-99)
-Migraine + >35 y/o
-Mild cirrhosis
-Symptomatic gall bladder disease
History of combined hormonal contraception related cirrhosis
MOA of levo IUD
- Prevent fertilization
- Increased cervical mucus thickening
Contraindications for IUD
- Pregnancy
- Purulent cervicitis
- AUB not w/u
- Abnormal anatomy
- Pelvic TB
- Wilson’s disease (with copper IUD)
SE’s of IUD
- Bleeding (+ or amenorrhea)
- Pain/cramping
- Hormonal (acne, breast tenderness, headaches, mood lability)
Time of insertion:
- Uterine perforation
- Expulsion
x3 emergency contraception options in order of effectiveness
- Copper IUD
- Ulipristal acetate
- Plan B (levonoregestrel)
Timeframe when you can use copper IUD for emergency contraception
Up to 7 days
Timeframe when you can use Ulipristal acetate
Up to 5 days
Timeframe when you can use Plan B
Up to 3 days
What emergency contraception options loose efficacy with increasing body weight?
- Ulipristal acetate
- Plan B
SE’s of Depoprovera (x5)
- Mood lability
- Weight gain
- Decreased bone mineral density
- Irregular bleeding + amenorrhea
- Delay in return of fertility
Complication of untreated chlamydia in females
PID
Symptoms/signs in a G+C infection for M+F
- Asymptomatic (60-80%)
- Penile + vaginal discharge
- Urethral pruritis/burning
- Dysuria
- Pelvic pain
- Dyspareunia
- Vaginal bleeding
- Testicular pain/swelling
Tx for chlamydia
Azithro 1g PO x1
How often should we be screening for G+C?
Yearly in sexually active adolescents
Reportable + non-reportable STIs
- Reportable: HIV, syphilis, G+C
- Non-reportable: trichomonas, HPV, HSV
Complication of untreated gonorrhea infection
- PID
- Epididymitis
- Disseminated infection
Tx for gonorrhea
- Azithro 1g PO x1
- CTX 250mg IM x1 or cefixime 800mg PO x1
Test of cure indications for C+G
Chlamydia:
- Concern for compliance
- High risk for re-infection
- Second line therapy
- Pregnancy
Gonorrhea - all of the above PLUS:
- Previous tx failure
- Disseminated
- Pharyngeal or rectal infection
- Abx resistance is of concern
What infection if yellow/off-white vaginal discharge, strawberry cervix, and dysuria?
Trichomonas vaginalis
x4 ddx for vaginal discharge
- Physiologic
- Vulvovaginal candidiasis
- Bacterial vaginosis
- Trichomonas
Dx for vaginal discharge with clue cells
BV
What is the dx for vaginal discharge if (a) thin-grey, (b) white + clumpy, and (c) thin green-yellow?
(a) BV
(b) Candida
(c) Trich
Abx for BV and trich
metronidazole
What tx modalities would you consider in gender affirming care for (a) early pubertal youth (SMR 2-3) vs (b) late pubertal youth (SMR 4-5)
(a) Pubertal suppression with GnRH agonist
(b) Menstrual suppression (GnRH agonist, contraception), gender affirming hormones, gender affirming surgery
What is the recommended catch up schedule for >15 years old for HPV vaccination?
3 dose schedule - now, 1 month, and 6 months
A teenager tells you he enjoys drinking energy drinks. You advise him against this because of the dangerous levels of:
a) Ginseng
b) Sodium Chloride
c) Guarana
d) Vitamin B Complex
C - caffeine source
If the patient vomits can they retake their emergency contraception?
Yes - if within 2 hours of initial dose
When should you repeat the pregnancy test following emergency contraception?
If no bleeding within 3 weeks following EC
How much ethinyl esterase should COC contain as a starting point?
30-35mcg of ethinyl esterase
The x2 most closest mental health associations with cannabis?
- Depression
- Psychosis
What could you combine a nicotine patch with for best pharma management?
Short acting nicotine (gums, lozenges) to reduce breakthrough cravings
x3 main categories of adverse effects of vaping (as per CPS statement)
- Mental health: depression, suicidality, nicotine toxicity
- Pulmonary: chronic cough, increased risk of infections, VALI
- Injuries: MVC, burns, ingestions
