Adolescent

Question 1

Age of Consent for Sexual Activity

Answer 1

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.)

Question 2

What are drug interactions with oral contraceptives

Answer 2

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

Question 3

Oral Contraceptive contraindication

Answer 3

● Possible pregnancy
● Unexplained bleeding
● Classic or complicated migraine ● History of thrombosis
● Uncontrolled hypertension

Question 4

OCP non-contraceptive benefits

Answer 4

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)

Question 5

First line for reversible contraception for adolescents

Answer 5

Long-Acting Reversible Contraception, IUD

Question 6

Depo-Provera side effects

Answer 6

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

Question 7

What situations can Depo-Provera be the preferred contraception method?

Answer 7

● Can’t reliably take pills
●estrogen is contraindicated
●want amenorrhea
● Should prescribe concurrent Calcium and Vit D

Question 8

Symptoms of Chlamydia

Answer 8

Common symptoms:
● None (60 to 80%)
● Dysuria
● Vaginal discharge
● Abdominal pain
● Vaginal spotting (especially after sex)
● Systemic symptoms (rare) – joints, eyes

Question 9

Diagnosis of Chlamydia

Answer 9

Diagnosis – several methods available, need to check with lab (culture, PCR, DNA probe)

Question 10

Chlamydia Treatment

Answer 10

●Azithromycin – 1 gm po X 1 dose ***treatment of
choice for teens
● Other 7 day regimes (doxycycline, erythromycin, tetracycline)

Question 11

Symptoms of gonorrhoea

Answer 11

Common symptoms
● None (75 to 90%)
● Discharge, dysuria, abdo pain
● Systemic symptoms (rare) – joints, pharynx, rectum, eye

Question 12

Diagnosis of gonorrhoea

Answer 12

several methods available, need to check with lab (culture, PCR, DNA probe)

Question 13

Gonorrhoea treatment

Answer 13

● 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

Question 14

Frequency of PAP

Answer 14

Significant changes in screening guidelines
● Varies slightly by province
● e.g. many suggest starting at age 21, then every 3 years if sexually active

Question 15

PID diagnosis

Answer 15

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

Question 16

PID treatment outpatient

Answer 16

Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg PO bid for 14 days
● Consider adding metronidazole
● Close F/U

Question 17

Indications for PID treatment in hospital

Answer 17

● 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

Question 18

Risk factors for suicide

Answer 18

▪ Males
▪ AccesstoFirearms
▪ PastSuicideattempt
▪ Exposure/FamilyHistory ▪ Bullies/beingBullied
▪ SubstanceAbuse
▪ BipolarDisorder
▪ Intent/Plan/Means
▪ SexualMinority youth

Question 19

Strategies to increase adherence to treatment

Answer 19

● 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

Question 20

What is different in DSM-5 for anorexia nervosa?

Answer 20

● The word “refusal” has been removed
● There is no specific weight criteria
● Amenorrhea not necessary

Question 21

Differences between anorexia in adults and children

Answer 21

● 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

Question 22

Medical complications of anorexia

Cardiovascular complications

Answer 22

● 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

Question 23

Medical complications of anorexia

Gastrointestinal Problems

Answer 23

● 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

Question 24

Medical complications of anorexia

Interruption of puberty

Answer 24

● 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

Question 25

Medical complications of anorexia

Growth

Answer 25

● 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

Question 26

Medical complications of anorexia

Brain and cognitive changes

Answer 26

● 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

Question 27

Indications for hospitalization

Answer 27

● 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