Adolescent/Gyne Flashcards
Which is true of adolescence:
b. parental conflict peaks in mid adolescence
(early, middle and late changes; physical, cognitive, moral, self-concept, family, peers, sexuality all evolve)
When does menstruation usually start in puberty?
Menstruation at Tanner stage IV
when does a boys’ voice crack
tanner 3
order of pubertal development in girls
boobs, pubes, grow, flow
14 year old male with 3cm unilateral tender breast swelling. What do you do?
F/U in 6mo
Pubertal Gynecomastia
- Up to 60% of males
- Transient imbalance of estrogen and androgen
- Onset 10-13y (SMR 3-4)
- Usually regresses within 18-24 mo
3 reasons you could breach confidentiality.
Intention to harm themselves, intention to harm others
Harm to other children
Communicable disease, conditions that impairs driving ability, GSW
- 15 year old boy with T1DM. You can only follow him in your clinic until 18 years of age. 5 things you
would do to try to help him transition to adult care.
- See teens without parents for part of appointment
- Give increasing levels of responsibility and information
- Teach skills of negotiation and communication required in the adult system
- Providing a transition letter explaining the location of the new facility, staff and what to
expect - Collaboration with GPs and adult care provider
- An adolescent is in the ED who is 65% of her ideal body weight. HR 40, T35.8, BP 90/P. What to do:
- Slow refeeding- at risk for refeeding <80% of ideal body weight
- Patients with anorexia nervosa become osteopenic due to:
c) estrogen deficiency- plus high cortisol, low IGF-1, low lean body mass, low weight,
nutritional deficiency- amenorrhea is a risk factor
- Skin change seen in anorexia nervosa:
a) lanugo
DSM V criteria for anorexia nervosa
- A. restricted intake vs requirements → low body weight (age, sex,
developmental trajectory, health) that is less than minimally expected - B. fear of gaining weight/becoming fat/ behaviour interfering with weight
gain (despite low weight) - C. disturbance in weight/shape experience/ undue influence on
self-evaluation/ lack of seriousness of current low weight - Types
- Restricting- no binge/purge
- Binge-Eating/ Purging (w.i. 3 mo)
- Stage of remission
- Severity (adults)
- Mild >17
- Mod 16-17
- Severe 15-16
DSM V criteria for bulimia nervosa
- A. episodes of binge eating
- eating more than what most would eat
- lack of control
- B. compensatory behaviours (vomiting, laxatives, diuretics, medications,
fasting, exercise) - C. 1x/wk x3 mo
- D. self-eval influenced by shape and weight
- E. not AN
- Stage of remission
What are some features of ARFID (Avoidant Restrictive Food Intake Disorder)
- restrictive due to adverse feeling resulting in nutritional deficiences/ weight loss
- psychosocial dysfunction
- no body image disturbance
What is on the differential diagnosis for eating disorder?
Differential (CBC, ESR, lytes, Ca, Mg, PO, VBG, TSH, ECG +/-LFTS, albumin, lipids, cortisol,
LH/FSH)
- GI
- IBD
- Celiac
- Infectious Gastroenteritis
- HIV, TB
- Endocrine
- Hyper/Hypothyroidism
- DM
- Addison’s
- Hypopituitarism
- Psychiatric
- OCD
- Substance Use
- Other
- CNS lesions
- SMA
What are features of refeeding syndrome?
Refeeding syndrome (intracellular shift of phosphate)
- most common in 1st week, with enteral nutrition
- low PO, K, Mg
- CHF and neurologic sx
- risky if <80% of expected weight for height
Medical reasons to admit a patient with anorexia?
- Physical
- HR <50 bpm awake (<45 asleep)
- BP < 80/50
- Rhythm disturbance/ Prolonged QT
- Orthostatic (BP >10, HR >25)
- <75-80% healthy body weight (or ongoing wt loss despite Rx)
- Laboratory
- Hypokalemia
- Hypophosphatemia
- Hypoglycemia
- Hypochloremia (BN)
- Liver, cardiac, renal compromise
Suicidality
Complete refusal to eat
- Which of the following laboratory results is very worrisome in an anorexic patient?
Hypokalemia
What leads to death in anorexia? (5-20% lifetime mortality rate)
#1 - suicide - 50% #2 - prolonged QTc and can get tachyarrhythmias
- Prevention of osteoporosis in an anorexic?
e. Calcium
Target weight related outcome for treatment of eating disorder?
- target 90% of average body weight for sex, age and height
note some patients may need over 4000 calories per day to gain weight
- standard balance of 15-20% calories protein, 50-55% carbs and 25-30% fat is appropriate
- calcium and vitamin D supplements to attain 1300mg/day calcium, for risk of low bone
mineral density
- if weight is less than 80% of expected weight for height, higher risk of refeeding syndrome and
consider restarting feeds in hospital
A mother is concerned that her teenage daughter has lost 20 pounds, has had amenorrhea for 4
months and has a poor appetite. She has complained of some vague abdominal pain. Which of the
following is not consistent with a diagnosis of anorexia nervosa:
a. HR 70
Signs of metabolic effects of eating disorders (vital sign changes)?
o metabolism:
▪ hypothermia (temp <35.5)
▪ pulse <60 bpm, and orthostatic increase >25bpm
▪ slowed psychomotor response with very low core temperature
▪ hypotension
- Teenage girl present with weight loss of 22 lbs over the last four months. She is amenorrheic. Heart
rate is 40 and lanugo hair is seen on exam. Expected ECG finding:
2) prolonged QT
What are the expected electrolyte changes associated with bulimia? (Na, K, Cl, pH, HCO3, CO2)
Na low most classic, but can be normal or high
K low
Cl low
Hypochloremic metabolic alkalosis (pH high, HCO3 high, CO2 high to compensate)
- An 11 year old boy who has had recent personality changes, decline in school performance and visual
changes. Which is the first diagnosis to rule out:
a. Brain tumour
- What is the most frequent cause of school absence in teenage girls:
(b) dysmenorrhea
- Best test to detect PCOS:
e. increased testosterone (not increased LH/FSH)
- A 13 year old female. Menarche has occurred. White vaginal discharge for several
month which is occasionally itchy and irritating. Most likely diagnosis is:
a. Physiologic leukorrhea
Causes of menorrhagia and irregular periods in an adolescent?
Continued endometrial proliferation Decreased progesterone (needed to support endometrial lining) excess estrogen
*consider heme issue if periods are regular but heavy
Causes of abnormal uterine bleeding?
Broad strokes categories:
- ovulatory dysfunction
- coagulopathy
- NYD
- A family comes in with their 12y daughter who has Down Syndrome. Menses have started and are
becoming difficult to manage. Which agent would be best to manage this?
c. 84/7 pill - will need to plan periods 3-4 times per year; no major risks
Which anti epileptic medication is made less effective when taken with combined hormonal OCP?
lamotrigine
- What would exclude PID?
d) absence of white cells in cervical discharge
Diagnostic criteria for PID?
Lower abdominal pain + either cervical motion tenderness, uterine tenderness or adnexal tenderness
- if you have this in an adolescent female, treat on spec for PID
How do you treat PID?
Ceftriaxone 250mg IM x1 dose, doxycycline 100mg po BID x14 days +/- metronidazole 500 po BID x14 days
- 6 year old child with vaginal bleeding, no foreign body, no exogenous estrogen sources. Has bone age of 7.5 years, 17-OHP normal, what is dx
b. craniopharyngioma (precocious puberty, not CAH as 17-OHP normal)
● Note: Do Pelvic US if isolated vaginal bleeding ( to R/O ovarian cyst or tumour)
- Teenager with painful menses. What medication do you offer? List the dose, frequency and the
mechanism by which this medication works.
NSAIDs (ibuprofen 200mg q4-6h) - prostaglandin synthetase inhibitor
OCPs (low dose, cyclic) - inhibition of ovulation eliminates progesterone production OR decrease of endometrial lining thickness decreased prostaglandin production
- 14 year old girl has severe dysmenorrhea and has missed 2-3 days of school with each period. What
are three causes of dysmenorrhea (3)?
○ Primary → absence of a specific pelvic pathology and the most common
■ Prostaglandins are produced by the endometrium and stimulate vasoconstriction and myometrial contractions leading to pain
○ Secondary results from an underlying structural abnormality of the cervix or the
uterus, foreign body (ie IUD), endometriosis or endometritis
How do you treat endometriosis?
leuprolide: create an environment of acyclic low dose estrogen to prevent bleeding and further seeding into the pelvis
