Adolescent Flashcards
Age of Consent for Sexual Activity
Age of Consent in Canada
● 16 (recently changed from 14)
● Close age exception
● 14-15 years can consent to sex with someone up to 5
years older
● 12-13 years can consent to sex with someone up to 2 years older
● Must not be in a position of authority (teacher, coach, clergy etc.)
What are drug interactions with oral contraceptives
Anticonvulsants ● Many decrease efficacy of OC (and vice –versa) ● Note – valproate is not affected ● Use higher dose estrogen pill (35 mpg) ●Antibiotics: Generally NO interaction
Oral Contraceptive contraindication
● Possible pregnancy
● Unexplained bleeding
● Classic or complicated migraine ● History of thrombosis
● Uncontrolled hypertension
OCP non-contraceptive benefits
Reduction in the following: ● blood loss, anemia ● PMS, dysmenorrhea ● acne, hirsutism ● certain cancers (endometrial, ovarian) ● ovarian cysts ● PID and future ectopic pregnancies ● benign breast diseases (fibrocystic disease, fibroadenomas)
First line for reversible contraception for adolescents
Long-Acting Reversible Contraception, IUD
Depo-Provera side effects
Sideeffects ● Irregular bleeding for 3- 12 months ● Amenorrhea ● Weight gain (4 to 15 pounds) ● Reduced bone density (steroids, eating disorders, chronic renal failure, anti- epileptic meds- consider BMD) ● Depression
What situations can Depo-Provera be the preferred contraception method?
● Can’t reliably take pills
●estrogen is contraindicated
●want amenorrhea
● Should prescribe concurrent Calcium and Vit D
Symptoms of Chlamydia
Common symptoms:
● None (60 to 80%)
● Dysuria
● Vaginal discharge
● Abdominal pain
● Vaginal spotting (especially after sex)
● Systemic symptoms (rare) – joints, eyes
Diagnosis of Chlamydia
Diagnosis – several methods available, need to check with lab (culture, PCR, DNA probe)
Chlamydia Treatment
●Azithromycin – 1 gm po X 1 dose ***treatment of
choice for teens
● Other 7 day regimes (doxycycline, erythromycin, tetracycline)
Symptoms of gonorrhoea
Common symptoms
● None (75 to 90%)
● Discharge, dysuria, abdo pain
● Systemic symptoms (rare) – joints, pharynx, rectum, eye
Diagnosis of gonorrhoea
several methods available, need to check with lab (culture, PCR, DNA probe)
Gonorrhoea treatment
● Treat for Chlamydia as well if Gonorrhea +
● Option 1: Ceftriaxone 250 im x 1, PLUS azithromycin 1 gram po
● Option 2: Cefixime (Suprax) 800 mg po x 1 PLUS azithromycin 1 gram po
● For MSM or pharyngeal infections, preferred option is bullet 1
Frequency of PAP
Significant changes in screening guidelines
● Varies slightly by province
● e.g. many suggest starting at age 21, then every 3 years if sexually active
PID diagnosis
Minimum Criteria: ● Lower abdominal pain PLUS either ● Adnexal tenderness ● Uterine tenderness ● Cervical motion tenderness ● Increased specificity if also have ● fever >38.3 ● discharge ● WBC on microscopy ● elevated ESR or CRP ● positive testing for GC or chlamydia
PID treatment outpatient
Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg PO bid for 14 days
● Consider adding metronidazole
● Close F/U
Indications for PID treatment in hospital
● Concerns re. adherence ● Pregnancy ● Failure to respond to oral treatment ● Severe illness, vomiting, or high fever. ● Tubo-Ovarian abscess ● HIV infection
● Cefoxitin 2 g IV every 6 hours PLUS Doxycycline 100 mg IV or PO every 12 hours
Risk factors for suicide
▪ Males ▪ AccesstoFirearms ▪ PastSuicideattempt ▪ Exposure/FamilyHistory ▪ Bullies/beingBullied ▪ SubstanceAbuse ▪ BipolarDisorder ▪ Intent/Plan/Means ▪ SexualMinority youth
Strategies to increase adherence to treatment
● Regime (where possible) ● Simplify ● Once daily dosing ● Long acting meds ● No treatments during school day ● Take into account sleeping in on weekends and sleepovers with friends ● Meds should not be associated with eating or not eating ● Minimize side effects
● Patient-physicianrelationship
● The single most important modifiable predictor of
adherence!
● Continuity of care (see SAME MD every visit) ● Friendly clinic space and staff
● Time spent with their MD
● Direct conversations about adherence
● Be on time!
● After school appointments
● Their MD takes a personal interest in them
● If forgetfulness is the problem
● Reminders – visual cues and medication visibility can be
helpful
● Trials of alarms, texts, emails etc – not very promising, but if teen is willing – give it a try
● Reward from team or family ● Not very useful in the long-term
● Counselling
● Not helpful unless a mental illness is contributing to non-
adherence
● Motivational interviewing (if done by their MD) may be helpful
What is different in DSM-5 for anorexia nervosa?
● The word “refusal” has been removed
● There is no specific weight criteria
● Amenorrhea not necessary
Differences between anorexia in adults and children
● Compared to adults with anorexia, children and teens:
● Have a lower duration but higher acuity of illness
● Are more likely to present with Acute Food Refusal
● Are more likely to be medically unstable (low heart rate, hypotension, dehydration)
● Are less likely to purge (vomiting, laxatives, diet pills)
● Are much more likely to present with a somatic reason for not eating (not hungry, eating gives pain…)
● Are at risk of growth and pubertal delay
Medical complications of anorexia
Cardiovascular complications
● Presents in early stages of the disorder in adolescents
● Response to starvation – adaptive at first
● Functional and structural cardiac abnormalities
● Electrocardiographic
● Sinus bradycardia
● 35% to 95% adolescents
● Decreased voltage
● Prolonged QTc
● Ventricular arrhythmias
● Orthostatic hypotension
Medical complications of anorexia
Gastrointestinal Problems
● GI symptoms frequent in eating disorders
● 80 % report one or more GI complaints
● delayed gastric emptying (early satiety) ● constipation
● elevated liver enzymes
● superior mesenteric artery syndrome
● acutepancreatitis
● complications of vomiting
● Parotid swelling and increased amylase
● gastric rupture
● Mallory-Weiss tears/esophageal and or gastric bleeding
● erosion of dental enamel
Medical complications of anorexia
Interruption of puberty
● Eating disorders have variable impact on puberty
● Prepubertal onset
● Absence of pubertal development and failure of growth ● Premenarchal onset
● Causes arrest of pubertal development, which is most severe if weight loss occurs during the early stages of puberty
● Menarche may be delayed beyond the normal age
● Postpubertal
● Amenorrhea/irregular menstrual function
Medical complications of anorexia
Growth
● Dramatic alteration in the GH-IGF axis
● Low serum levels of IGF-I
● Low growth-hormone-binding protein
● State of growth-hormone resistance
● Indices of growth-hormone normalize with weight recovery
● Possible outcomes:
● Growth failure – stunting of adult height
● No impact on adult height
● Depends on timing of malnutrition
●Osteoporosis
Medical complications of anorexia
Brain and cognitive changes
● Structural brain changes: larger CSF volumes and deficits in cortical gray and white matter ● Learning and memory ● Attention ● Visual-spatial skills ● Executivefunctioning ● Abstractionanduseofstrategy ● Likely related to degree of starvation ● Hardtomeasurelosses ● Maturity, personality, ● Lifeexperiences–relationships,peers,risk taking
Indications for hospitalization
● Cardiac Abnormalities
● Cardiac arrythmias
● Severe bradycardia HR <50 bpm daytime; <45 bpm at night
● Hypotension (<80/50 mm Hg)
● Hypothermia (body temperature <96 ̊ F)
● Orthostatic changes in HR (>20 bpm) or BP (>10 mm Hg)
● Behavourial
● Acute food refusal
● Uncontrollable bingeing and purging
● Acute psychiatric emergencies (e.g., suicidal ideation) ● Comorbid diagnosis
