Adolescent and Gyne Flashcards

1
Q

T or F: parental conflict peaks in mid-adolescence.

A

True

Also: abstract thinking.

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2
Q

When does menstruation occur?

A

Tanner Stage 4

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3
Q

What occurs in Tanner Stage 4?

A

M:

  • *- max penile growth
  • axillary hair, voice change

F:

  • *- double breast contour
  • *- menarche
  • coarse, curly hair
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4
Q

What occurs in Tanner Stage 2?

A

M:

  • *- testicular enlargement
  • pubic at base

F:

  • *- breast bud
  • hair on labia
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5
Q

What occurs in Tanner Stage 3?

A

M:

  • *- penile growth
  • voice break

F:

  • breast + areola enlarged; no sep contour
  • *- peak ht velocity
  • acne
  • dark hair start too curl
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6
Q

14 y.o. M 3cm unilateral tender breast.

  • US
  • F/U 6 mo
  • Karyotype
  • CT scan
A

F/U in 6 month

Pubertal Gynecomastia

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7
Q

When does preoccupation with body image occur?

A

Early adolescence

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8
Q

3 reasons to breach confidentiality:

A
  • harm to self or others
  • harm to other children
  • communicable dx (reportable diseases)
  • impaired driving ability (report any >16 y.o. suffering condition that make it diff to drive)
  • gun shot wounds
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9
Q

5 things to help transition teen to adult care:

A
  1. see teen w/out parent for part of apt
  2. give increasingly level of responsibility or info
  3. peer support meetings
  4. provide transition letter
  5. collaborate w/ adult care provider
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10
Q

Which is more commonly seen in bulimia nervosa compared to anorexia nervosa:

  • cachexia
  • hypothermia
  • low BP
  • enlarge salivary glands
  • extremely dry skin
A

Enlarged salivary glands

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11
Q

Kids with AN becomes osteopenia because:

A

Estrogen deficiency

+ high cortisol, low IGF-1, low lean body mass, low wt, nutritional, amenorrhea

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12
Q

Is lanugo or alopecia seen in anorexia nervosa?

A

Lanugo

AN= full thinning scalp hair. 
Other AN signs
- orthostatic change
- low temp
- thinning hair
- draw skin, lanugo
- delayed pubertal
- atrophic breast
- cold limb
- orange skin (carotenemia)
- edema of limbs
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13
Q

List criteria for Anorexia Nervosa?

A
  • Fear of gaining wt
  • Disturbance in wt/shape
  • Restricted intake for requirements (leading to low wt for age, sex, developmental trajectory)
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14
Q

List criteria for Bulimia Nervosa?

A
  • Self-evaluation influenced by shape + wt
  • Binge eating (eat excessive amount + lack of control during episode)
  • Compensatory behaviour (vomit, laxative, diuretic, med, fasting)
  • 1X/ wk x 3 month

Note: Binge Eating Dix is just the binge without compensatory behaviour.

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15
Q

What comorbidities do you see with Bulimia?

P/E findings?

A
  • Depression
  • Anxiety
  • Substance use
  • Cluster B/ borderline PD

P/E:

  • Older
  • large parotid
  • oral ulcer
  • dental enamel erosion
  • russell sign (callus on knuckle)
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16
Q

What is ARFID?

A

Eating disturbance=
- Result in wt loss or nutritional deficiency or depend on enteral feed or interfere w/ f’n

  • No body image disturbance
  • Not due to other medical illness
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17
Q

List 3 DDX of eating disorders:

A

GI: IBD, Celiac, Infectious Gastro, HIV
Endo: Thyroid, DM, addison’s
Psychiatric: OCD, Substance use
Other: CNS lesion, SMA syndrome, CA

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18
Q

T or F: growth, atrophy, bone density issue are irreversible issues with eating disorder.

A

True

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19
Q

What is the tx target avg body weight for kids with ED?

A

90% of average body wt for sex, ht, age

Goal: nutritional rehab by parents -> then switch of responsibility to teen (wt already restored) -> focus on teen development

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20
Q

Reasons to admit for eating disorder:

A

Physical:

  • *- T < 36.1
  • *- HR < 50 bpm awake (< 45 asleep)
  • *- BP < 80/50
  • *- orthostatic BP
  • dehydration, syncope
  • *- rhythm/ long QT
  • < 75-80% body wt
  • body fat < 10%

Psych:

  • *- SI (intent + plant)
  • poor motivation to recover
  • coexisting psych d/o

Lab:

  • low K, Phos, BG, Cl
  • liver, cardiac, renal compromise

Other:

  • *- failed outpatient tx
  • *- refusal to eat/ intractable vomiting
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21
Q

What are common comorbidities with anorexia nervosa?

A
  • Anxiety

- Depression

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22
Q

Which is most worrisome in anorexic pt?

  • low K
  • WBC < 1000
  • Met alkalosis
  • low protein
A

Low K

BW AbN:
- usually low WBC, low Hb, low K, if ++ vomit then low Cl- and met alkalosis in severe vomiting, elevated liver enzyme, long QTc

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23
Q

How do you prevent osteoporosis in an anorexic?

  • Ca
  • Vit D
  • Estrogen
  • Gain wt to min. 10% ideal wt
A

Calcium

** always Ca+ and vit D supplement for risk of low bone mineral density.

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24
Q

White early teen F with above avg intelligence and is avoidant perfectionist struggling with mood or anxiety. Anorexia Nervosa or Bulimia Nervosa?

A

Anorexia Nervosa

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25
List some effects of starvation:
Brain: hypothalamic, depression, irritable Cardiac: sinus brady, long QTc, MV prolapse Refeeding: risk low Phos, K, Na, Mg etc. GI: delayed gastric emptying, constipation, SMA syndrome Gonads: amenorrhea, erectile dysfunction Bones/ Osteopenia Growth failure
26
List bulimia BW
- Low Na (can be hi/N) - Low K - Low Cl - Metabolic Alkalosis - Co2 up (compensation)
27
What is the most f cause of school absence of teen F: - h/a - dysmenorrhea - asthma - sore throat
Dysmenorrhea AAP 1980 - "dysmenorrhea is leading cause of recurrent short term school absenteeism among teen F"
28
List a ddx for dysmenorrhea?
- Primary dysmenorrhea * * if pain between menses= NOT primary! ``` - Secondary > Endometriosis >Pelvic inflammatory dx >Preg complication > Mullerian anomalies w/ partial outflow tract obstruction > Abuse ```
29
Best for PCOS: increased LH/FSH, HTN or increased testosterone.
Testosterone ++
30
Just menarche. Pre and Post White vag d/c intermittent. Occasional irritation or itch. Likely dx?
Physiologic leukorrhea
31
Menometrorrhagia x 6 months. Bleed x 3 month. - LOW E - HIGH progesterone - vWF deficiency - LOW progesterone
=LOW progesterone. (Remember E makes the grass and P is the lawn mower) Menometrorrhagia= prolonged bleed irregular or more f than usual. Irregular means not VWF
32
12 y.o. with T21. Menses hard to manage. Best option? - depo - IUD - Continuous OCP x 84 days - LHRH agonist
Continuous OCP x 84 weeks. AAP 2016: OCP still most commonly used.
33
What excludes PID? - neg. preg test - neg. screen GC - neg. screen Chlam - no WBC on cervical d/c
Absence of WBC in cervical d/c
34
What is pelvic inflammatory dx?
Infection of F upper genital tract. Etiology: polymicrobial. - STI (chlamydia, gonorrhoea, HSV) - mycoplasma, ureaplasma - anaerobic - other: E coli, gardnerella vaginalis, haemophils influenzae CC: abdo pain + fever - abdo + pelvic exam
35
Pelvic inflammatory disorder dx criteria:
``` Clinical dx: Lower abdo Pain + 1= = adnexal tender = cervical motion tenderness = Uterine tenderness ``` To add specificity: - mucopurulent d/c or WBC on saline prep - fever - high ESR, CRP - document of infection Definitive dx if endometrial bx, US show fluid filled tubes, or Laparoscopy show abnormalities w/ PID
36
Treat of pelvic inflammatory disease:
+/- Hospitalization Cefotixin IV + doxy IV then Doxy x 14d Otherwise IV= PO i.e. ceftriaxone x 1 and doxy x14d +/- flagyll
37
T or F: early dx and tx of PID key to maintain fertility.
True
38
What are PID complications:
CAFE PID - chronic pelvic pain - abscess - fitz-hugh-curtis syn - peritonitis - infertility - disseminated infection
39
Define precocious puberty
M < 9 (9-14 Norm) | F < 8 (8-13 Norm)
40
T or F: premature thelarche only if < 5.
False. Only if < 2. + no ht acceleration, no adv bone age, no other sign. If > 3= ensure no central cause.
41
T or F: premature menarche can be normal.
False! Must always look for a cause!
42
Dysmenorrhea. 3 causes? What two meds you can offer? How does it work?
3 Causes: - primary/ idiopathic - endometriosis - uterine polyps - ovarian cyst - PID - FB Treatment: - Exercise - Well balanced Diet - Topical heat Two med Classes: 1. NSAID (take as soon as you know menses coming) (prostaglandin synthetase inhibitor) 2. OCP
43
Started menarche but irregular. No dysmenorrhea. Likely cause and 2 Tx?
Likely cause: - anovulatory cycle due to immaturity of HPO axis Tx: - Reassurance - Consider oral iron supplementation - Consider OCP if troublesome
44
4 things on dx of vaginal bleeding in 8 y.o.
- FB (toilet paper) * *- Sexual Abuse - ** Trauma - Central (Tumour affecting HPO axis) * *- Hypothyroidism Other - Vulvovaginitis - McCune Albright Syn - genital tract malignancy - estrogen exposure - hemangioma
45
Absolute contraindication to OCP
*Migraine w/ aura *Severe cirrhosis *Uncontrolled HTN *DM w/ neuropathy, nephropathy, retinopathy *Acute DVT or PE Known thrombophilia *Hx of Stroke Valvular Heart Dx *SLE w/ antiphospholipid antibodies Current breast CA Note: smoking RELATIVE and really if ++ older
46
T or F: IUD cause infertility.
False.
47
T or F: you must do urine beta HCG before taking morning after pill.
False. Not necessary.
48
What are absolute contraindication to morning after pill?
1. Known pregnancy * can give without preg test as even if (+) won't cause therapeutic abortion. 2. Known allergy (anaphylaxis to product)
49
Chlamydia urethritis teen. Before can have sex again: - must complete 7d of tx - after partner tx - after 6d - until retested and found negative.
Can resume sex activity ONCE HE completes 7d of TX - 1x azithro OR 7d course doxy - sexual partners should be treated if contact within 60d of symptom onset - most recent partner always treated - no sex until 7d after single dose or after complete 7d regiment
50
T or F: most teenage pregnancies end in abortion
True | - just over 50%
51
T or F: most pubertal teen with chlamydia are asymptomatic.
True
52
Best tx of gonorrhoea?
Tx: Ceftriaxone (or cefixime) x1 and Azithro x 1 (*always tx presumptive chlamydia) Other: - Gram neg. diplococcus - most F asymptomatic and most men symp. - NAAT
53
T or F: you can immediately give contraception after an abortion. Versus 2 wk later.
True - give immediately!
54
When do menses return after emergency contraception
Return within 7d within expected date - if next period more than 1 wk late = do pregnancy test
55
Sexually active teen. Pruritic genital lesions. Red macule and papule and blue-grey. Dx? Tx?
Dx: Pubic Lice Key: pruritus, bites (blue-grey; look like bruises) Dx: ID egg (nits), nymphs, lice with make eye Tx: 1% Permethrin Cream rinse Eyelid: petrolatum ointment x 8-10d Prevention: - machine wash + dryer everything hot - vacuum everything - avoid sex until tx - tell all sex partners in last month
56
Most common bug of urethritis:
- N. gonorrhea most likely Other: ureaplasma urealyticum, mycoplasma genitalium, trichomonas
57
Teen comes in for morning after pill. Latest after intercourse it is effective? Two things in management after?
*Maximum 72-120h Subsequent: - counsel for pill failure - if period doesn't return within 1 wk of usual timing then need preg testing - if becomes pregnant discuss options - counsel safe sex (does not protect against STI) - encourage barrier protection
58
T or F: liver CA is one potential long-term sequelae of anabolic steroid use.
True Other listed AE: - aggression, anxiety, depression + others - HTN - low glucose tolerance - hepatic transaminitis - poor sperm count and testicular atrophy - menstrual irregularities
59
Most important reason to be concerned about teen alcohol abuse: - risk taking behav while drinking - assoc. depression - liver dx - poor school performace
Risk taking behaviour while drinking.
60
List fives things that would increase concern for substance abuse in patient:
- type of drug - circumstance (alone vs. group) - f and timing - premorbid mental health dx - general functioning CRAFT Mnemonic: screen fo substance use in primary care. In last 12 months... - CAR- ridden in car who was high or using - RELAX- used to fit in - ALONE- use - FORGET- thing while using - FAMILY + FRIENDS- tell you to cut down - TROUBLE- while using
61
4 clinical manifestations of cocaine use?
- euphoria - psychosis - motor agitation - decreased fatiguability - mental alertness - sympathomimetic: all UP (pupils dilated, tachy, HTN, high T, high RR)
62
T or F: antidepressants can cause sexual dysfunction in teens.
True- SSRI Other: GI symptom, h/a, insomnia, appetite change, anxiety, increased SI thoughts
63
Why are testes small if anabolic steroids used?
``` Exogenous steroid = suppress HPA = less FSH + LH = less T and spermatogenesis = less size of testes ```
64
T or F: parenting classes do not affect rate of child abuse.
False. HELP REDUCE RISK.
65
Risk of depression recurrence within first year of d/c SSRI tx?
40%
66
Child on fluoxetine and risperidone. High DTR + tremor + ataxia. Which drug is the problem: fluoxetine? Risperidone?
** Serotonin= d/c +/- cyproheptadine ``` Serotonin Syndrome: HARMED - hyperthermia (all VS up) - agitation - reflexes ++, rigid - myoclonus - encephalopathy - diaphoresis ``` ``` Risperidone: - EPS (dystonia, restless, tremor, tardive dyskinesia) - long QT - metabolic syn - wt gain -DM - high lipid - high prolactin - hepatotoxicity - low WBC, neut (= agranulocytosis) - sz - NMS = FEVER (slow onset with more generalized rigidity) - fever, encephalopathy, VS unstable, high CK, rigid (lead pie) muscles ```
67
Suicide RF for teens. List what you remember.
- M - Low SES - homosexual - mental health dx - substance abuse - impulsivity - low self-esteem - perfectionism - hopelessness - parental divorce or death - adverse childhood exerpeince - hx of abuse - bullying - parent mental health - fhx (+) suicide
68
T or F: tourettes is min. 2 motor + 1 vocal x 6 month.
False. x1 year <18 y.o. Co-morbid: ADHD, OCD, LD if interfere w/ life= Tx= Clonidine
69
T or F: oral sex is more common than sexual intercourse?
True
70
T or F: 1/3 of grade 10 F and M have had sex.
True.
71
How can you remember Age of Consent in Canada?
16 unless authority or exploitative. Close age exception: "2 and 2; 5 and 5" 12-13= consent with someone up to 2yr older 14-15= can consent up to 5yr older
72
T or F: pregnancy rates among Canadian teens are rising.
False; declining.
73
T or F: > 1/3 of teen who deliver will have another preg within 2yr.
True.
74
T or F: post partum depression risk in teens > older mom.
False. | Post partum depression rate similar to non-teen mom.
75
List the failure rate of the following contraceptive methods: - chance - withdrawal - condom - combined pill - depo - LARC
``` Chance= 85% Withdrawal= 22% Condom=18% Combined= 9% Depo= 6% LARC= 0.2 % ``` Note: if < 90kg combined pill even less effective.
76
T or F: LARC fertility takes 6 month once its removed.
False. | 1-2 cycles.
77
T or F: there is a increase risk of STI or PID post LARC insertion.
True | BUT only for first 21d
78
List IUD AE:
Increasing spotting | Amenorrhea
79
List OCP Pro and Con:
Pro: - easy to use - shorter, less dysmenorrhea - less acne and hirsutism Con: - breast tender - nausea - h/a - breakthrough bleed (resolves) Serious AE: - thrombosis (2X VTE or stroke risk but still very minimal. Increased if migraine w/ aura. Either= less than if got pregnant) Troubleshooting: if frequent breakthrough= E up, too much nausea= E down; headache then lower E
80
What are OCP drug interaction?
``` - Anti-Sz = decrease efficacy of OCP i.e. carbamazepine, clobazam, fosphenytoin - Rifampin - St John's Wart ``` FINE: * * VPA FINE * * Abx FINE
81
T or F: it is safe to do "Extended cycling" with the OCP.
True. = 21-21-21-21- then no pills for 5 d OR 12 week pill and 7 days off.
82
List Depo-Provera AE:
Pro: - good if E contraindicated - amenorrhea Con: - irregular bleed - wt gain (5-15 lb) - reduced bone density (**take with Vitamin D and Ca)
83
T or F: in most children, gender dysphoria will persistent into adolescence.
False. If (+) as child -> most don't If (+) in teen -> most do.
84
T or F: highest risk of suicidal behaviour in transgender youth is while awaiting consult.
True.
85
What is gender dysphoria?
Marked incongruence between experienced gender + assigned. x 6 month. min. 6 of: - strong desire to be other gender - cross-dressing - cross-gender role in play - presence toward stereotypical toys - preference for playmate of other gender - rejection of stereotypical toy of same sex - dislike for sexual anomy - desire for pubertal traits + significant distress or impairment in social, school or other
86
For fun: options for transgender youth
Pubertal suppression - Lupron Menstrual suppression - Continuous OCP Masculinizing hormone= T Feminizing hormone= Estrogen, sprinolactone Sx: top- Sx as teen (can't do bottom Sx till adult)
87
T or F: you must always treat for chlamydia if Gonorrhea (+).
yes! Ceftriaxone IM x1 + Azithro x 1 OR cefixime PO + azithro.
88
What is the most common STI?
HPV!
89
What is the current recommendation for PAPs?
Start at age 21 Every 3 yr If sexually active.
90
When do you consider hospitalization for PID?
- pregnancy - failed PO tx - adherence concern - severe illness, vomit, high fever - tuba-ovarian abscess - HIV infection
91
``` 16 y.o. with unilateral PAINLESS breast mass. Likely dx? - fibroadenoma - adenocarcinoma - fibrocystic change - met tumour - lipoma ```
Fibroadenoma Most= BENIGN fibroadenoma! Other: trauma , abscess, node. Fibrocystic= Bilateral < 1%= malignant
92
Breast Pain. Thoughts?
``` Common in puberty. OCP may better or worsen it. R/O mass, infection Avoid tight fitting bra during exercise NSAID + supportive. ```
93
What is the order of substance use prevalence for: | alcohol, high energy drinks, cannabis
``` Alcohol Prev > high energy drinks > Cannabis ```
94
Teen where symp get better w/ hot showers?
Hyperemesis Cannabinoid Syndrome.
95
Heavy menstrual bleeding typically caused by an ovulation. Most common reasons:
#1= HPO axis maturation Other causes of an ovulation: - pregnancy - thyroid dx - chronic liver/renal dx - Cushing - PCOS, CAH - wt loss/stres/ exercise - premature ovarian failure
96
Heavy menstrual bleeding. Tx options?
- Contraception - NSAID (start few days before helps with pain and lightens menses) - Antifibrinolytic= Tranexamic Acid
97
What is primary versus secondary amenorrhea?
Primary= no menses ever! > no puberty + no menses by 13 > secondary trait but no menses by 15 ** most commonly gonadal dysgenesis and mullerian agenesis. Secondary= 3 months of amenorrhea. ** most commonly stress, wt loss, disordered eating or preg!
98
List causes of amenorrhea:
Hypothal > Chronic dx, familial delay, stress, ED, Kallmann, Tumour, Drugs Pit > Infarct, Sx, Radiation Thyroid Adrenal: CAH, cushing, tumour Ovary: gonadal dysgenesis, AI failure, Fagile X, PCOS, irradiation Uterus= pregnancy And other gyne congenital anomalies (i.e. cervix genesis or transverse septum in vagina, imperforate hymen)
99
Amenorrhea W/U
``` beta-HCG CBC U/A TSH, FT4 FSH, LH Prolactin Pelvic US ``` +/- androgen panel if think (PCOS, late CAH, Cushings etc.) If high FSH= gonadal dysgenesis, ovarian failure Low FSH= hypothalamic if pituitary issue. Note: Progestin challenge= withdrawal bleed. Confirm E made. If negative= E not made!
100
What should you do if you miss an OCP pill?
Take 1 pill ASAP and take daily until end of pack. If missed 3 pills = back up contraception x 7d!
101
List common RF for vulvovaginitis
``` Tight clothes Overweight Bubble baths Urinating knee together Wipe back to front ```