Adolescent Flashcards
What are the 3 clinical symptoms required to make up a minimal set of clinical criteria for PID (pelvic inflammatory disease) to initiate empiric therapy?
- Cervical motion tenderness
- Uterine tenderness
- Adnexal tenderness
What is the most common orthopedic complication of repetitive tennis playing?
Lateral epicondylitis
(Tennis elbow)
-reproducible pain on and around lateral epicondyle, & with resisted wrist extension and supination
-no warmth or erythema
What is the most common orthopedic complication of repetitive golfing?
Medial epicondylitis
(Golfer’s elbow)
-pain on and around medial epicondyle and during wrist flexion
What accounts for the high incidence of new HPV infections in sexually active adolescents?
Metaplasia within cervical transformation zone (columnar epithelium transform into squamous epithelium)
- very active during puberty until early 20’s
- 90% of infections are transient & clear w/in 2 years
What is the criteria to be an emancipated minor? (3)
1) < 18 years old
2) married/ previously married, a parent, serving in military, living independently
3) managing own finances
What is Asherman syndrome?
secondary amenorrhea due to avascular intrauterine adhesions (synechiae) & fibrosis after endometritis
-diagnosis with hysteroscopy or sonohysterography
What is the best initial treatment of a non-pregnant patient with Chlamydia infection?
Azithromycin 1 gram orally with retest in 3 months (to assess for reinfection)
-test of cure done in pregnant pt’s after 3 weeks
What is Fitz-Hugh-Curtis syndrome?
extrapelvic manifestation of PID due to ascending infection
- infection & inflammation of hepatic capsule & right diaphragm
- LFT normal, elevated acute phase reactions
What medication used to treat STIs results in a disulfiram-like reaction if the patient consumes alcohol?
Metronidazole
- used for bacterial vaginosis (500 mg BID for 7 days)
- flushing, tachycardia, palpitations, nausea, vomiting
What is the most common bacteria that causes breast abscesses in newborns?
Staph aureus
-tx w/ Clindamycin, Bactrim, Vanc if MRSA risk
What antimicrobial medication can result in decrease serum estrogen & progrestin levels from OCPs; and, therefore, backup method of contraception should be used?
Rifampin
-remember anti-seizure meds (phenytoin, carbamazepine, barbituates, topamax, oxcarbazepine) can have same effect
What is the best initial treatment for pt with fibrocystic breast changes (tender cystlike mobile mass associated with fibrotic tissue, pain worse just prior to menses)?
NSAIDs (ibuprofen) and recheck in 1-2 months
- usually resolve over 1-2 menstrual cycles
- caffeine can make worse
What are the 3 most common causes of death in adolescents?
- Unintentional injury (MVA, drowning, ATV, guns accidents)
- homicide
- suicide
What is the preferred outpatient treatment for gonococcal urethritis (or vaginitis)?
Cefriaxone 250 mg IM with azithromycin 1gram oral
treat for gonorrhea and presumptive chlamydia coinfection
What is the most common cause of death in adolescents?
Unintentional injuries (~40% of deaths)
What is the treatment for congenital syphillis?
1) Aqueous penicillin G 50K units/kg IV q 8-12 hrs for 10 days
2) Procaine penicillin G 50K units/kg IM for 10 days
A child aged weeks to 2 years old presents with diffuse reddish papulosquamous rash that fades to copper, hepatomegaly, lymphadenolpathy, jaundice, hemorrhagic rhinitis, elevated LFTs, hemolytic anemia, thrombocytopenia most likely suffers from…?
Congenital Syphillis
check VDRL and RPR
What lab abnormalities is associated with bulimia/ purging disorder? (2)
1) Hypokalemia
2) Hypochloremic metabolic acidosis
What is the lab abnormality associated with cardiac failure (arrhythmias) ad respiratory compromise in severe anorexics undergoing treatment?
hypophosphatemia
refeeding syndrome- phosphate needed for myocardial & diaphragm contractility
What organism is characterized as rod-shaped, oval organisms (safety pin shaped encapsulated bacilli) within the cytoplasm of mononuclear phagocytes on Wright Stain and can cause painless genital ulcers?
Klebsiella granulomatous
- Donovan bodies
- aka granuloma inguinale (Donovanosis)
- more common in India, Carribbean, south Africa
During which sexual maturity rating is the peak height velocity for girls?
SMR 2-3 (~11.5 years)
-boys occur during SMR 3-4 (~13.5)
What diagnosis is characterized by the triad of migratory arthritis, tenosynovitis, and dermatitis (painless pustules) especially in a sexually active pt?
Disseminated gonococcal infection
- 2-3 weeks of primary GU infection, often w/ menses
- dxw/ nucleic acid amplification testing (NAAT)
What is the outpatient treatment for PID (pelvic inflammatory disease)?
IM Ceftriaxone 250 mg plus Doxycycline 100 mg BID to complete 14 day course
or
Azithromycin (500 mg once followed by 250 mg to complete 7 days)
What is the most common cause of abnormal uterine bleeding (AUB) in adolescents during initial 1-2 years of menarche?
Anovulatory cycle
- due to immarturity of hypothalamic-pituitary-ovarian axis
- tx w/ monophasic OCPs at set interval until bleeding stops
What is the cause of vaginal discharge that is most often associated with increase vaginal pH?
Bacterial vaginosis (vaginal pH > 4.5, clue cells on wet mount, positive Whiff test, thin grayish-white discharge)
What is the average peak height velocity in girls?
8.3 cm per year
What is the average peak height velocity in boys?
9.5 cm per year
What disease is the groove sign (tender femoral lymphadenopathy and inguinal lymphadenopathy) characteristic of?
Lymphogranuloma venereum
-due to Chlamydia trachomatis (L1, L2, L3)
True or false. Women should be encouraged to used OCPs for birth control if they have liver disease.
False
-OCPs are metabolized by liver so should discourage if have liver disease or tumor
An athlete who develops peripheral edema, insulin resistance, hyperglycemia, and HTN most likely using what performance-enhancing drug?
Recombinant human growth hormone
What is the most common structural cardiac complication among pt’s with anorexia nervosa?
mitral valve prolapse
-late systolic murmur at apex preceded by a click
What is Russell sign and what diagnosis is it associated with?
calluses on knuckles due to hand continually hitting teeth associated with self induced vomiting in bulimia
What is the first sign of puberty in boys?
increased testicular size
What is the diagnostic finding for bacterial vaginosis?
Clue cells (vaginal epithelial cells with a stippled membrane covered with adherent bacteria)
What is the treatment for primary syphillis infection?
single dose of Penicillin G benzathine 2.4 mil units IM
What is the likely diagnosis for an adolescent presenting with mobile, painless, rubbery, well circumscribed breast mass?
juvenile fibroadenma
- if < 3 cm w/out concerning features, can be observed for 1-2 months
- ultrasound if large or uncharacteristic
What is the initial manifestation of puberty in females?
Thelarche (Breast/ areolar development)
How long after thelarche does menarche usually occur?
2-2.5 years
What is the most common cause for a painful ulcerative lesion (mainly single, but can be multiple) with grayish-yellow exudate and inguinal lymphadenopathy?
Haemophilus ducreyi
- small papule that erodes over days
- tx w/ Azithromycin 1g PO or Ceftriaxone 250 mg IM
What is the most appropriate management of a breastfeeding baby when mother has mastitis?
continue to breastfeed from both breast
- helps mother resolve infection
- avoid if there is open wound (from I&D)
Delayed development in boys is defined by lack of testicular enlargement by ___ years old.
14
2.5 standard deviations beyond average age of onset of 11.6 years
What is the most concerning side effect related to use of oral contraceptives?
Deep vein thrombosis (DVT)
-history of thromboembolism is contraindication for estrogen-containing contraceptives
What is the most common cause for postcoital bleeding in female with normal Pap smear?
Endocervical polyp
Does the sexual partner need to be treated if a female is diagnosed with bacterial vaginosis?
No
What are the two mainstay treatments for dysmenorrhea (N/V, abdominal cramps, headaches) associated with menses?
- NSAIDs
2. OCPs
What is Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome?
mullerian aplasia
- vagina and uterus are underdeveloped (primary amenorrhea)
- still have breast and axillary/ pubic hair development
- can have abnormal kidneys and urinary tract
What is the organism responsible for tender papule with surrounding erythema (chancroid) with gram stain showing gram negative rods in chains (with appearance of school of fish, railroad tracks, fingerprints)?
Haemophilus ducreyi
What is the likely diagnosis for a patient presenting with purulent, malodorous, green-yellow thin discharge, pruritis, dysuria, urinary frequency dyspareunia, and cervix with punctate hemorrhages?
Trichomoniasis (due to trichomonas vaginalis)
-tx w/ metronidazole
What is the most common cause of epididymitis (scrotal edema, swollen tender epididymis)?
Chlamydia trachomatis and/or Neisseria gonorrhoeae
-tx w/ Ceftriazone plus doxycycline/ azithromycin
What are the indications for hospitalization for pt with anorexia nervosa? (9)
- wt < 75% ideal body wt
- body fat < 10%,
- dehydration or electrolyte imbalance
- cardiac arrythmias
- orthostatic hypotension (pulse increase by > 20, or SBP decreased by > 10)
- hypothermia (temp < 96)
- failed outpatient tx
- psych emergencies or suicidal ideation
- refusal to eat
What is the female athletic triad associated with increase risk of stress fractures?`
- menstrual disturbances (hypothalamic amenorrhea)
- disordered eating (inadequate Ca intake)
- decreased bone mineral density (osteoporosis)
What is the testicular volume associated with the various sexual maturity rating (SMR) level for boys?
SMR 1: < 4ml SMR 2: 4-8 ml SMR 3: 8-12 ml SMR 4: 12-20 ml SMR 5: ~20ml
What diagnosis is associated with numerous pale blue 0.5-1cm macules over the lower abdomen, proximal thighs and buttocks?
Pediculosis due to pubic lice
-tx with permethrin 1% cream
What is the best pharmacologic method of birth control for a patient who has a seizure disorder and on anti-seizure therapy?
Depo medroxyprogesterone acetate (DMPA)
-may have intrinsic antiseizure properties & efficacy not affected by antiseizure meds
What is the best post-exposure prophylaxis for individuals exposed to Hep A infected individual?
administer hep A vaccine or immunoglobulin to unimmunized exposed individuals
What are common side effects of progestins in OCPs? (3)
- oily skin and acne
- weight gain
- hirsuitism
What is the pathophysiologic cause for anovulatory menstruation in pt who experienced menarche < 2 years?
absence of LH midsurge so no ovulation and no functional corpus luteum formation
What is the most likely diagnosis for a pt with acute testicular pain, swollen testicle, tenderness to palpation of testes, absent cremasteric reflex on affected side and affected testicle high riding?
Testicular torsion
- twisting of the testis and spermatic cord
- usually 12-18 years of age
What is the prehn sign?
relief of pain following elevation of scrotum
-associated with epididymitis
What is the likely diagnosis of a pre-menstruating female who presents with grayish-white vaginal discharge, wet prep showing numerous lactobacilli and few leukocytes, and vaginal pH 4-4.5?
Physiologic leukorrhea
-occurs 6-12 months prior to menarche
What is the gram stain for Neisseria gonorrhea?
gram negative intracellular diplococci
True or False. Females with Mullerian agenesis have normal levels of luteinizing hormone and follicle-stimulating hormone.
True
What are the indications for hospitalization for pelvic inflammatory disease (PID)?
- pregnancy
- surgical emergency (appendicitis, etc)
- suspected pelvic/tuboovarian abscess
- N/V precluding oral therapy
- failed oral tx after 24-48 hrs
What is the most likely diagnosis of adolescent who presents with generalized rash (macular & papulosquamous rash characterized by reddish-brown, sharply demarcated lesions following lines of cleavage), lymphadenopathy (rubbery firm painless lymph nodes), and flu-like symptoms?
Secondary syphilis
What is the “female athlete triad”? And what is the treatment?
- eating disorder
- amenorrhea
- osteoporosis
Increasing caloric intake with dietitian assistance
What are the absolute contraindications to combined hormonal OCPs? (7)
- hx of DVT, PE, and known thrombogenic mutation (Factor V Leiden, Protein S/C deficiency)
- Migraine with aura or focal neuro deficit
- complicated valvular disease
- Hypertension (SBP> 160, DBP > 100)
- active liver disease
- hepatic tumor
- breast cancer
What is a relatively likely complication of a post-partum women who had significant post-partum hemorrhage?
Sheehan syndrome
Hypopituitarism due to pituitary infarction from postpartum hemorrhage and shock
What is spondylolysis?
vertebral injury involving fracture of pars interarticularis is due to overuse and repetitive stress
What is the purpose of the 10 day progestin challenge for an adolescent with secondary amenorrhea (absence of menses > 3months if have regular menses or 6 months if had irregular cycles)?
to assess adequate uterine endometrial lining due to adequate endogenous estrogen
(if no withdrawal bleed, consider eating disorder, excessive stress/ exercise)
What is the treatment for lymphogranuloma venereum?
Doxycycline 100 mg PO BID for 3 weeks
asymptomatic genital ulcer followed by lymph node inflammation
A female who presents with severe pain & swelling that interferes with walking/ sitting and worsens with sex with a tender mass at the 4 or 8 o clock position with respect to the vaginal opening most likely has ….
Bartholin gland abscess
tx: I&D, warm compresses, sitz baths
What are the benefits of Depo (IM progestin only birth control)?
- protection against endometrial hyperplasia
- protection against PID
- regulation of menstrual cycle or amenorrhea
What is the mean age of onset for male gynecomastia?
13 years old
A male who presents with weight loss, proximal lower extremity pain, elevated alpha-fetoprotein/ beta-HCG and painless nodule/ swelling of testicle most likely suffers from ….
Testicular cancer
What is the function of the progesterone challenge in secondary amenorrhea?
to assess adequate estrogen effect on the building of the uterine lining
(PCOS- would have estrogen but no progesterone)
What are the most common complications of intrauterine devices (IUD)? (3)
- uterine perforation
- menstrual cycle abnormality
- IUD explusion
What is a common side effect of Depo (injectable progesterone only)?
delayed return to fertility
What is the most likely diagnosis for male presenting with painless cystic like nodule above the upper pole of the testicle which transilluminates?
Spermatocele
What is the best step in management of individuals exposed to a Hep A positive close contact?
Provide Hep A vaccine (or Immunoglobulin if vaccine not available) to unimmunized individuals
What are the 3 indications for involuntary drug testing?
1) unexplained seizure
2) emergency (accident)
3) attempted suicide
What are indications for breaking confidentiality with a mature minor/ teen? (3)
1) sexual/ physical abuse
2) threat of harm to self or others
3) nonadherence to treatment for chronic disease
How long after the onset of puberty (usually thelarche) does menarche begin?
2-2.5 years later
What is a common cardiac complication of anorexia nervosa?
Mitral valve prolapse
end systolic murmur at apex followed by click
What is the female athlete triad?
1) dysmenorrhea/ amenorrhea
2) low bone density
3) disordered eating/ energy deficiency
What is a common laboratory finding in patients with athlete triad?
low FSH and low LH
What are the 3 definitions for abnormal uterine bleeding (AUB)
1) cycle occurs less than 20 days or more than 45 days apart
2) menses lasts more than 8 days
3) large amount of blood loss per period (more than 80 ml or 6 pads a day or results in anemia)
What is the most likely diagnosis for patient (likely homeless or unkempt) who presents with numerous pale bluish 0.5 to 1 cm macules on abdomen, thigh, and buttocks?
Pubic Lice
