Adolescent Med Flashcards
When does growth velocity, and peak velocity occur for boys and for girls.
11 years for boys and 9 for girls, peak height velocity occurs mean of 13.5 years for boys (Tanner 3-4) and 11.5 for girls (Tanner 2-3).
Definition of emancipated minor
Less than 18 years of age but, is either financially independent, married, in the military or has their own children
What are exceptions to adolescent confidentiality
abuse, activity causing harm to others or to self
What are indicators for obesity that require intervention
BMI> 95th = obesity
or 85th to 95th = overweight
and
family history of premature CAD, obesity, HTN or DM
Cholesterol > 200
increase in > 2 points in BMI in 12 months
adolescent expresses concern
What are indicators for eating disorder that require intervention
BMI < 5th
weight loss > 10% of prior weight
distorted body image
dieting when not overweight
When should vision be tested
at 12, 15 and 18 or when clinically indicated
referral is vision < 20/30 in either or both eyes
When is a pelvic exam indicated
Sexually active
over 21
symptoms: pelvic pain, vaginal discharge refractory to treatment, menstrual problems
What is the recommended annual screening for sexually active adolescents?
NAAT for gonorrhea and chlamydia
If positive repeat in 3 months
HIV testing, especially annually for those who are high risk
Other screening such as syphilis for MSM and possibly HIV more often every 3-6 months depending on risk
What other laboratory testing should be considered in adolescents?
anemia: girls with heavy menses, vegetarians, underweight, chronic illness
Cholesterol: once between 9 and 11. Again once 17-21
If non HDL > 145 or HDL < 40, obtain 2 fasting lipid panels and take an average of results
MMR and varicella recommendations
If they have not gotten 2 of each, give 2nd dose as soon as you can.
When to give Tdap?
Due at 11-12 and then once every 10 years
Recommendations for Hepatitis B?
If they haven’t gotten the series, give it.
Recommendations for HPV
May start at age 9 particularly those who with history of sexual assault, abuse or HIV
Recommended age: 11-12
2 dose series if started between ages 9-14
Give at 0 and 6-12 months, invalid second dose if given before 5 months
3 dose series if started age 15 and up
give at 0, 1-2 and then 6 months after. Minimum of 4 weeks between 1st and 2nd dose and 12 weeks between 2nd and 3rd, minimum of 5 months between 1st and 3rd.
Recommendations for MCV 4
11-12 years with booster at 16 years
13-15 years give 1 dose and then repeat dose at 16 years of age with minimum of 8 weeks in between
16 year old and up just get one dose
Must be given either before or at same time as dtap
Recommendations for Meningococcal B
May be given to those who want it 16-18 years of age.
can be given up to 23 years old
Bexsero: 2 doses 1 month apart
Trumenba: 2 doses 6 months apart
Recommendations for pneumococcus
Single dose of PCV 13, if asplenic, HIV, cochlear implant, CSF leak, immunocompromised.
PPV23 8 weeks later.
Repeat PPV23 5 years later.
reasons to drug screen
Unexplained accident or trauma Loss of interest in activities that were once important New onset psychiatric symptoms deterioration in school performance Unexplained chronic illness Increased absenteeism Suicide attempt Altered mental status
List complications of refeeding the anorexic patient
hypophosphatemia hypokalemia hypomagnesemia cardia arrhythmia volume overload, edema Vitamin deficiency, thiamine
Criteria for hospitalization of anorexic patient
< 75% of ideal body weight, despite intensive outpatient care refusal to eat, uncontrolled binging and purging, dehydration Body fat < 10% Medical complications (pancreatitis, heart failure) Hypotension < 80/50 HR < 50 Orthostatic Hypothermic < 96 Electrolyte disturbances Arrhythmia Suicidal ideation failure of outpatient treatment
What cardiac changes are seen in the anorexic patient
ST segment depression QT prolongation Bradycardia U waves (hypo k) Risk of heart failure is greatest in first 1-2 weeks of refeeding. Limit weight gain to 2-3 lbs per week
What are the criteria for hospitalization of the bulimic patient?
syncope K < 3.2 Cl< 88 esophageal tears cardiac arrhythmias, prolonged Qtc hypothermia suicidality intractable vomiting hematemesis not responding to outpatient therapy
Describe most common breast mass and management in an adolescent
solitary cyst
more than 50% resolve in 2-3 months
Follow with serial exams
Ultrasound if can not tell if cystic or solid
Persistent cystic lesions can be evaluated and treated with needle aspiration
persistent larger or suspicious lesions should be excised
Asymptomatic solid mass < 3 cm and consistent with fibroadenoma can be observed
Definition of primary amenorrhea
no menses by 16 with normal secondary sexual development
by 14 with no secondary sexual development
by 14 with clinical or karyotype consistent with Turner’s syndrome
no menses with sexual maturity rating of 5 for > than 1 year or no menses with thelarche 4 years prior
By 12-13 if cyclical pelvic pain is present
Definition of secondary amenorrhea
loss of menses for 6 consecutive months in those with regular periods
length of time equal to three cycles in some one with irregular cycles
Causes of central amenorrhea
Inhibition of GnRH (gonadotropin releasing hormone
functional hypothalamic amenorrhea: nutritional deficiencies / weight loss / stress / medications
panhypopit: tumor, infiltrative disorder (sarcoidosis, hemochromatosis, TB.
Sheehan syndrome: infarction
definition of microadenoma and macroadenoma and treatment.
micro: < 10 mm
macro > 10 mm
Bromocriptine
How is PCOS diagnosed?
adolescent women with both features that are not otherwise explainable
hyperandrogenism
abnormal menstrual pattern
Syndrome associated with anatomic amenorrhea
Rokitansky syndrome: Mullerian agenesis with primary amenorrhea, absence/hypoplasia of vagina, cervix and or uterus.
Describe assessment and work up of amenorrhea
- Pregnancy test
- tanner staging
- signs of hyperandrogenism, thyroid, hyperinsulinism, galactorrhea, anosmia, turner syndrome
- LH ad FSH to see if central vs ovarian, TSH, prolactin, if hyperandrogenism check testosterone and dehydroepiandrosterone. Karyotype
- Progesterone challenge
What causes dysmenorrhea and how is it treated.
Prostaglandin production causes vasoconstriction, smooth muscle contraction, nausea, vomiting, headache and fatigue.
Treat with NSAIDS. Can use OCPs if ineffective
Name causes of congenital scrotal masses
scrotal dermoid, polyorchism and scrotal rests
Describe the presentation and cause of epididymitis
Due to usually C. trachomatis or N. gonorrhoeae. Can be e. coli in MSM
subacute onset of pain, urinary frequency, dysuria, urethral discharge, fever. Swollen and tender epididymis.
Describe hydrocele, spermatocele and varicoceles.
hydrocele: non-tender fluctuant mass that transilluminates due to fluid between the parietal and visceral layers of the tunica vaginalis
Spermatocele: retention cyst of spermatozoa in the efferent ductal system of the epididymis. smooth cystic nodule above and posterior to the testes
Varicocele: dilated scrotal veins due to increased abdominal pressure or incompetent venous valves, usually left sided, bag of worms, increase with Valsalva. repair only if semen analysis is abnormal, or testicular volume is < 2-3 ml than the right or painful
Clinical signs of spermatic cord torsion
diffusely swollen, painful testicle that usually lies higher than the other side and is horizontal rather than vertical. absent cremasteric reflex.
Need US with doppler and to get to surgery in < 6 hours.
Describe torsion of the testicular appendage
tender pea-sized swelling at the upper pole of the testis with a “blue dot” a blue hue visible through the scrotum. Normal color doppler flow on US. Treat with NSAIDS. Spontaneous resolution in 2-12 days.
List contraindications for oral contraceptives
Absolute: abnormal vaginal bleeding of unknown cause estrogen dependent tumor liver disease thromboembolic disease cerebrovascular events migraine with aura Relative contraindications: DM Seizures vascular headaches severe to moderate hypertension tobacco smoking
What is the screening test and then the confirmatory test for HIV.
antibody for HIV 1 and 2 usually and enzyme immunoassay (EIA). If reactive EIA is repeated.
Confirmatory western blot or indirect immunofluorescence, or RNA.
Antibodies are usually present with in 3 months of infection
Signs of acute HIV infection. What is the confirmatory test?
Fever, headache, pharyngitis, malaise, myalgia, lymphadenopathy skin rash.
RNA will be positive (no antibodies yet).
How does HSV present and what testing should be done?
Tender grouped vesicles.
low grade fever, headache, myalgia, malaise, and painful pruritic vesicular lesions, vaginal or urethral discharge and inguinal lymphadenopathy.
PCR assays for HSV DNA and cell culture. Can use serologic testing for those with recurrent genital symptoms.
Tzank preparations (multi-nucleated giant cells)
HSV treatment.
acyclovir, valacyclovir or famciclovir with in 24 hours of symptom onset. Same drugs can be used for suppressive therapy.
Acyclovir can be given IV for severe disease.
Describe primary syphilis infection
painless ulcer at the site of inoculation. 3 weeks after exposure. Punched out, clean appearing with sharp, firm slightly elevated borders
Describe secondary syphilis infection
1-2 months after chancre
generalized hyperkeratotic rash on the palms
lesions on trunk and extremities that follow lines of cleavage, mucocutaneous lesions and lymphadenopathy
can have flu like symptoms too
resolves in 3-12 weeks
condylomata lata
What are the diagnostic tests for syphilis
Dark field exam or direct fluorescent antibody testing of exudate from tissue.
- VDRL and RPR : screening test and used to monitor response to treatment
- FTA-ABS and TP-PA: confirmatory testing
Caveats of testing CSF for neurosyphilis
CSF-VDRL is specific but not sensitive, a negative result does not rule out disease.
Treatment of syphilis
Primary, Secondary or Early latent
Penicillin G
2.5 million u IM.
if < 48 kg 50,0000 U/KG IM in a single dose
only drug to use during pregnancy.
those allergic are desensitized
Doxycycline in those who are not pregnant and penicillin allergic
check VDRL or RPR at 6 and 12 months
Jarisch-Herxheimer reaction-acute febrile response in the first 24 hours after initiation of treatment
latent or unknown duration:
benzathine penicillin G 2.4 million U IV 1x week for 3 weeks
Check VDRL or RPR at 6, 12 and 24 months
When can neurosyphilis occur and how does it present
occurs at any stage of syphilis
cognitive dysfunction, eye or hearing deficits, cranial nerve deficits, meningitis, sensory deficits
Name the clinical manifestations of trichomoniasis
diffuse, bubbly, or frothy malodorous yellow-green discharge with dysuria, pruritus and vulvar irritation. Cervicitis may been seen on exam
What is the laboratory testing and treatment of trichomonas?
pear shaped motile organisms on wet mount
Rapid vaginal sample testing
Metronidazole 2 gm single dose - this is the preferred treatment during any stage of pregnancy
What is bacterial vaginosis and how is a diagnosis made?
polymicrobial syndrome due to replacement of normal vaginal flora with anaerobes such as gardnerella, prevotella, mobiluncus.
Need 3 of the 4 for diagnosis
1. homogenous grayish-white noninflammatory discharge that smoothly coats the vaginal walls
2. clue cells
3. ph of vaginal fluid > 4.5
4. Fishy odor before or after addition of KOH
Treatment of bacterial vaginosis
Metronidazole orally or vaginal cream, can use clinda vaginal cream
Do not treat male partners
Should treat pregnant women with symptoms with oral metronidazole or clindamycin
Describe the symptoms of vulvovaginal candidiasis
itching, dysuria, buring, excoriations, dysuria, vulvar erythema, whitish curd-like adherent vaginal discharge
Define complicated vulvovaginal candidiasis and who is at risk?
If it is severe, or recurrent ( > 4 in 1 year) or non-albicans
uncontrolled diabetes, HIV, immunosuppression, debilitation, pregnancy, recent antibiotic use and OCPs
Confirmation of diagnosis of vulvovaginal candidiasis
wet prep with saline or KOH, budding yeast and pseudohyphae. pH < 4.5
Treatment of vulvovaginal candidiasis
topical azole therapy - especially if pregnant
Oral fluconazole if refractory
Only treat partner if there is evidence of balanitis
Recurrent and severe forms require same treatment just for longer duration
Diagnostic criteria for pelvic inflammatory disease and name some of the other supporting evidence.
Empiric therapy is recommended if a sexually active women presents with 1 of the 3:
1. uterine tenderness
2. adnexal tenderness
3. cervical motion tenderness
Other supporting evidence:
temperature > 101
tenderness to palpation in lower abdomen
friable inflamed cervix
abnormal cervical or vaginal discharge
Predominance of WBCs on saline microscopy
Elevated ESR and or CRP
a do not miss diagnosis due to possible loss of long term fertility
specificity increases if leukocytes in vaginal secretions, cervical exudate or friability,
When should an adolescent be hospitalized for PID?
surgical emergency can not be excluded
pregnancy
tubo-ovarian abscess
severely ill
did not respond to outpatient therapy or can not comply with therapy
Parental and oral therapies with similar efficacy
Treatment of PID
cefotetan or doxycycline and cefoxitin
clindamycin and gent if allergic to cephalosporins
outpatient: ceftriaxone IM
treat most recent partner and any partners in last 60 days
Clinical presentation of epididymitis
unilateral testicular pain, tenderness, urethral discharge, epidydimal swelling and tenderness of reactive hydrocele.
Make sure its not a torsion
How is diagnosis of epididymitis confirmed
either:
gram stain smear of urethral exudate with > 5 PMN /hpf
NAAT positive for Chlamydia or gonorrhea
positive leukocyte esterase or > 10 WBC/hpf on 1st void urine
Treatment of epididymitis
Test for syphilis and HIV and treatment of partners
empiric antibiotic treatment, ceftriaxone IM plus doxycycline
or if suspect bowel flora, ofloxacin or levofloxacin
Which HPV type cause warts and which cause squamous cell carcinoma
Warts: 6 and 11
cancer: 16, 18, 31, 33, 35
Name treatments for genital warts due to HPV. Which are contraindicated during pregnancy?
Podofilox, imiquimod, sinecatechin - all patient applied topical
cryotherapy, podophyllin resin, trichloroacetic acid or bichloracetic acid, surgery - provider applied
for vaginal warts - cryotherapy and TCA or BCA acid
all patient applied and podophyllin are contraindicated during pregnancy
Describe hepatitis A vaccine timing.
2 dose series given usually at 12 -23 months. Should give to adolescents who are not previously vaccinated, same two dose series 6-18 months apart.
Treatment for hepatitis A exposure
Give vaccine with in two weeks of exposure
What to do if an adolescent who is unvaccinated for Hep B is exposed?
Give hep b immunoglobulin and vaccine at same time, different injection sites. 7 days max for percutaneous exposure and 14 for sexual contact
If household exposure or sexual assault with status of offender unknown: give vaccine only
