Adolescent Med and Gyne - 2019 Updated! Flashcards
1
Q
Parents come to you worried that their teenaged son has a problem with alcohol.
What are four signs of problem drinking in teenagers?
A
● CRAFT Mnemonic designed to screen for adolescents’ substance use in primary setting= CAR,
RELAX, ALONE, FORGET, FAMILY and FRIENDS, TROUBLE= During the past 12 months…
o Ridden in car driven by someone (incld. Yourself) who was high or had been using
alcohol or drugs?
o Used drugs to relax, feel better about yourself, or fit in?
o Used alcohol or drugs while you were by yourself?
o Ever forget things you did while using alcohol or drugs?
o Family and friends ever tell you to cut down your drinking or drug use?
o Ever gotten into trouble while using alcohol or drugs?
2
Q
14 year old with genital pain and mild headache. On exam, you find two 0.5 cm ulcers in the inside of the labia majora. Besides herpes simplex virus, what 4 diagnoses should you consider?
A
- Syphilis
- Bechets
- Crohns
- Lipshutz ulcer (non infectious genital ulcer)
- Chancroid (caused by haemophilia ducrey)
- EBV or mycoplasma
3
Q
Gardasil vaccine - what age is it recommended and what do you tell mom about need for routine pap smears when she is an adult
2 dose schedule for children age 9-14 years 6 months apart
3 dose schedule >=15 years
Pap - Age 25
A
2 dose schedule for children age 9-14 years 6 months apart
3 dose schedule >=15 years
Pap - Age 25,
4
Q
The 5As of motivational interviewing for smoking cessation
A
Ask Advise Assess Assist Arrange
5
Q
What is on the differential diagnosis for eating disorder?
A
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
6
Q
16 yo boy has admitted to using anabolic steroids. His testes appear small.
1) Why are his testes small? (1 line)
2) What test(s) would you do to confirm your suspicion of why testes are small.?
A
1) Anabolic steroid-induced hypogonadism
Exogenous steroid suppresses the hypothalamic-pituitary axis, thus decreasing the release FSH/LH = decrease stimulation to produce endogenous testosterone and spermatogenesis, thus decreasing size of testes
2) Test to confirm: LH/FSH, Testosterone (total and free)
7
Q
- Teenager with painful menses. What medication do you offer? List the dose, frequency and the
mechanism by which this medication works.
A
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
8
Q
Guidance counselor calls you about 12 y.o. from Inuit population. Thinks he may have ADHD. Give
four other things on your differential diagnosis.
A
● Neurodevelopmental: ASD, FASD, Fragile X, Specific LD
● Psych : Depression, Anxiety, Neglect,
● Neuro: Seizure disorder,
● Hearing or vision impairment
● Substance abuse
● Other organic: Iron deficiency anemia, Sleep apnea, lead poisoning
9
Q
A 13 year old girl presents with a history of significant weight loss crossing percentiles, with normal height and otherwise normal exam. She has always been a picky eater, but now her repertoire of foods that she will eat has decreased even further. She has no history of purging.
1) What are the TWO elements of history that would help to determine what kind of eating disorder this girl has? (2 points)
2) What is the differential diagnosis (2 points)
A
1)
- Fear of gaining weight
- weight or shape has undue influence on self-evaluation
- lack of seriousness of current low weight
2) ARFID, Anorexia Nervosa, EoE
10
Q
- Teenager, sexually active, pruritic genital lesions. On exam there are macules and plaques with erythema, crusting and blue-grey 3-5 mm papules.
What is the diagnosis (1). What is your treatment (1)
A
● Pediculosis Pubis ( pubic lice, aka “crabs”)
- examine all areas with coarse hair (eyelashes, eyebrows, beard, axilla, perianal area)
● tx: manually remove lice and their eggs (or hair shaved to limit infestation)
● tx: 1% permethrin cream rinse
- treat eyelash lice with petrolatum ointment 2-4x daily x10 days
● prevention: very contagious
○ machine-wash bedding, towels, clothes in hot water; dry in hot dryer
○ vacuum home, including mattresses
○ avoid sexual contact until successfully treated
○ tell all sex partners in last month about pubic lice
11
Q
Skin change seen in anorexia nervosa:
a) lanugo
b) eczema
c) acne
d) alopecia
A
a) lanugo
12
Q
- Girl started menarche 10 months ago, irregular every 1-3 months and heavy flow. No dysmennorhea.
What is the most likely cause and name 2 suggestions for management.
A
Immature HPG axis (no LH surge mid cycle leads to anovulation and abnormal bleeding)
- ddx: ectopic pregnancy, threatened abortion, endometritis
- mgmt: iron supplementation
- reassurance that expect this to resolve with time given only 10 months post menarchal and likely have anovulatory cycles
- consider OCPs
13
Q
14 year old male with 3cm unilateral tender breast swelling. What do you do?
Ultrasound
F/U in 6mo
karyotype
CT scan
A
b. 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
14
Q
A 15 year old otherwise healthy female is sexually active and comes in for a annual health check. According to the Greig health record, which of the following should she get:
- Chlamydia, gonorrhea testing
- Chlamydia, gonorrhea and HIV testing
- Chlamydia, gonorrhea, HIV testing and Pap smear
A
- Chlamydia, gonorrhea and HIV testing
But should also consider Syphillis
15
Q
Which of the following is found more commonly in patients with bulimia nervosa
compared with anorexia nervosa:
a) cachexia
b) hypothermia
c) low blood pressure
d) enlarged salivary glands
e) extremely dry skin
A
d) enlarged salivary glands
16
Q
A teenager is suspected of having depression by her parents. What five questions would you ask her to make your diagnosis of depression.
A
1) Sad Mood **
2) Anhedonia? ***
3) Guilty-feeling?
4) Energy level low, Sleep changes
5) Concentration difficulties
6) Appetitie – poor vs. hyperphagic
7) Psychomotor slowing
8) Suicidal ideation
17
Q
15 year old boy with a history of significant school absenteeism. He has had symptoms of intermittent
abdominal pain and recently has developed daily headaches with onset in the later afternoon. He
continues to get As despite missing 40% of the days in school. His height and weight continue along the
same percentiles as previously. What is the most likely diagnosis:
A
a. Anxiety
18
Q
What is post-OCP amenorrhea? how is it managed?
A
Most have menses in 30 days, almost all within 90 days.
- failure to resume menstruation within six months after discontinuation of oral contraceptives
- mgmt: only needed if pregnancy desired - bromocriptine and clomiphene; otherwise reassure (do rule out pituitary tumours and endo abnormalities)
19
Q
Kid with signs of increased ICP, teased at school because of obesity and acne. PE reveals papilledema, MRI head normal. No sexual activity.
What is the most likely cause?
- Oral contraceptive
- Minocycline
A
b. Minocycline ( tetracycline Abx, used for acne, AE include raised ICP (IIH), bleeding, oliguria, N/V,
pancreatitis and skin rashes)
20
Q
13 y.o with menometrorrhagia for 6 months. Menarche at 11 y.o. Bleeding x 3 weeks.
Causes of menorrhagia and irregular periods in an adolescent?
- estrogen deficiency
- progesterone excess
- continued endometrial proliferation
- ectopic pregnancy
- Von Willebrand’s disease
A
Continued endometrial proliferation.
*consider heme issue if periods are regular but heavy
In early postmenarchal years - most common cause of AUB is an ovulation (HPO axis’s is immature) . no midcycle surge of LH to stimulate ovulation -> no corpus luteum production of progesterone. W/O progesterone effects of stabilizing the endometrial lining, increased risk of irregular bleeding
21
Q
Girl on Plan B vomits 90 minutes after dose. What do you tell her?
a. Take another dose now
b. Repeat in 12 hours with gravol
c. Does not need anymore doses
A
c. Does not need anymore doses
IF they vomit <1hr after taking dose of EC then retake it. If more than 1 hour then do not need to repeat.
22
Q
A girl with anxiety wants to be taken off of her SSRI because of side effects. You:
a) Discontinue it right away
b) Discontinue it slowly to avoid withdrawl symptoms
c) Discontinue it and replace with benzdodiazepines
d) Discontinue it slowly to avoid serotonin syndrome
A
b) Discontinue it slowly to avoid withdrawl symptoms
23
Q
Pt treated with prozac for 2 years. What is the chance of recurrence of depression once she is taken off this medication.
1. 10%
2. 20%
3. 40%
4. 75%
5. 90%
A
- 40%
Response rates to SSRIs in the treatment of depression are 40-70%.
- once treatment started, should continue for 6-12 months to decrease relapse risk
- risk of recurrence is 34-50% in first year after discontinuation
24
Q
The most important reason to be concerned about adolescent alcohol abuse is:
a. Risk-taking behaviour while drinking
b. Depression associated with alcohol use
c. Liver disease
d. Poor school performance
A
a. Risk-taking behaviour while drinking
25
Options for emergency contraception
Hormonal: May be effective up to 5 days later.
- Levonorgestrel : single dose 1.5 mg, or 2 doses 0.75mg q12h (Plan B). Not as effective for BMI > 25
- Yuzpe (estrogen+progestin) - more SE.
- ELLA (Ulipristal acetate 30mg) - only by Rx. Okay for high BMI. Delay in next menses (can cause anxiety).
Non-Hormonal
- Copper IUD - effective if used within 7 days
26
15yo M with symptomatic urethritis, homosexual, yellow discharge when glans compressed?
a) what is the most likely
b) list 4 other causes
a) N. gonorrhea
b)
Chlamydia trichromatis
Trichomonas vaginalis
mycoplasma genitalium, ureaplasma urealyticum
HSV
Adenovirus
Trauma - contact with spermicide, recent instrumentation, vigorous sexual activity
Idiopathic
27
Which medication class causes sexual dysfunction in adolescents?
a) calcium channel blockers
b) antidepressants
c) beta-2 agonists
d) theophylline
b) antidepressants (specifically SSRIs)
28
You are treating a 17-year-old male for gonorrhea. Before treating his 15 year old female partner, what additional steps should you take?
A) get consent from her parents
B) get consent from her parents and then treat
C) inform child protection authorities
D) no steps needed
d) No steps needed
29
What are side effects of Plan B (Levonorgestrel)?
o side effects: headache, fatigue, nausea, dizziness
30
A teenage boy admits to having violent thoughts that overwhelm him. He says the thoughts are frequent and that he has not hurt anyone yet but fears he will soon. What diagnosis is most likely?
Behavioural problem
OCD
Schizophrenia
Antisocial personality
b. OCD - thoughts are egodystonic
31
List three things that are part of diagnosis of Autism.
1) Deficits in social communication and interaction across multiple contexts
2) Restricted, repetitive patterns of behaviour, interests, or activities.
3) Symptoms present in early development period
4) Symptoms cause clinically significant impairment in social/occupational/other important areas of functioning.
32
A description is given of an early-adolescent girl who is overweight. She is wondering what her ideal body weight should be. What is considered a normal BMI for her age.
normal BMI is between 5th to 85th percentile
33
36. A mother who has been abused as a child asks you about advice for preventing child abuse. What is
the evidence
a. Nurse home visitor program reduces the risk of child abuse
b. Parenting classes reduce risk
c. Frequent visits to paediatrician can reduce risk
a. nurse home visitor program reduces the risk of child abuse
Child abuse can be prevented by: supportive family environments and supportive social networks,
parental employment, adequate housing, access to healthcare and social services
34
45. 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.
1. See teens without parents for part of appointment
2. Give increasing levels of responsibility and information
3. Teach skills of negotiation and communication required in the adult system
4. Providing a transition letter explaining the location of the new facility, staff and what to
expect
5. Collaboration with GPs and adult care provider
35
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
36
What is the most frequent cause of school absence in teenage girls:
(b) dysmenorrhea
37
A 13 year old boy presents to your office with a history of being argumentative with his teachers at school, skipping class and refusing to obey his parents rules at home. What is the most likely diagnosis? Name 2 treatment modalities that may be beneficial in this situation.
Oppositional Defiant Disorder
- triple P positive parenting program; CBT, family therapy
- medications: stimulants (for co-morbid ADHD) or atypical antipsychotics (risperidone)
38
A mother is concerned that her thirteen year old boy has recently started spending more time in his room, he is more tired and has difficulty awaking in the morning. He doesn’t participate in sports, and spends all of his time on his computer or with his friends. He is doing just below the average in school. When you speak to him, he says he smokes occasionally but denies any other alcohol or drug use. What do you do next:
A) Psychological assessment
B) Trial of stimulant medication
C) Reassure
A) Psychological assessment
39
Causes of abnormal uterine bleeding?
Broad strokes categories:
- ovulatory dysfunction
- coagulopathy
- NYD
40
Most critical finding in anorexia nervosa
1. HR 40
2. Hypokalemia
3. temp >35
2. Hypokalemia - Has risk of torsades and can be a sign of refeeding syndrome.
41
15 year old girl with frequent brief attacks where she feels short of breath and vaguely uneasy.
Which of the following would support your diagnosis:
a) Fear of episodes recurring and sudden onset of episodes
b) Family history of OCD
c) History of emotional trauma
d. Fear of episodes recurring and sudden onset of episodes (panic attacks)
42
A 15 year old girl comes to you for emergency contraception. Besides the fact that she may have significant nausea with the pill, you tell her the following in your counseling:
a) If she has a period in about 3 weeks there is no need for a pregnancy test
b) She will have a period in about 2 weeks and should have a pregnancy test
c) She will have menstrual bleeding in 2 to 3 days
a)If she has a period in about 3 weeks there is no need for a pregnancy test
F/U: A routine follow-up office visit is not required. With any form of emergency contraception, a pregnancy test should be performed to exclude the possibility of an intrauterine or ectopic pregnancy if bleeding has not occurred within three to four weeks or if there is abdominal pain or irregular bleeding
43
40. 13 year old girl is sexually active. She sees you and has a normal pap smear with no STIʼs and uses
barrier protection. She doesn't want you to tell her parents. What do you do? (3 lines)
Counsel on safe sex practices, encourage the use of oral contraception and reassure that you will not
speak to her parents about this. She is entitled to complete confidentiality unless there is a situation that
may harm her or harm others
44
Which anti epileptic medication is made less effective when taken with combined hormonal OCP?
lamotrigine, phenytoin, carbamazepine, topiramate
- VPA is NOT affected
45
Girl with PTSD – list 4 characteristics of PTSD
exposure to significant event
+ intrusive symptoms (e.g. flashbacks, dreams)
+ avoid triggers (thought,
memory, feeling, people, places)
+ negative cognition and mood (forget, anhedonia, detachment)
+ hyperarousal or
hypervigilance (reckless, irritable, startled easily)
- duration > 1 month
- clinically significant distress or functional impairment
46
Teenage girl with trisomy 21 is interested in Depo-provera. Name 2 long term side effects to this medication.
decreased BMD
amenorrhea
weight gain (though 20-40% may lose wt)
47
A 7 year old girl presents with vulvar pruritis. On exam, her labia minora and the skin of her perineum is white, shiny and thin, with a few scattered petechiae.
a. What is your likely diagnosis?
b. How would you treat?
c. What other 2 causes of vulvar itching in a pre-pubertal girl?
a. Lichen schlerosis
b. Topical steroid cream: Clobetasol 0.05% daily x 3 mos
c. Pinworms, vulvovaginitis
48
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
49
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
50
Teenager with PID. Cervical discharge and adnexal tenderness. Best treatment is:
1) IV cefoxitin and po doxycycline for 7 days
2) penicillin
3) Probenecid
IV cefoxitin and po doxycycline for 7 days
(should be 14 day course)
For MILD:
- CTX 250 mg x 1 IM and
Doxy 100 mg BID x 14 days and ± metro 500 mg BID
51
8 year old with ODD.
a. List 2 non pharmacological strategies.
b. What are 3 psychiatric comorbidities?
a. Parenting Training Program, Social competence training, Family based therapy, Academic engagement + skills building, Youth anger management, Social skills + problem solving training
- classroom based management
- daily routine and structure
b. ADHD, Anxiety, Depression, Substance use disorders, specific learning disorder
52
38. What is the most common presentation of Chlamydia in a postpubertal adolescent?
a. Cervicitis
b. Asymptomatic
c. PID
d. vaginitis
b) asymptomatic
- up to 75% of women with chlamydia have no symptoms
- asymptomatic urethral infection is common in men
- can cause urethritis, epididymitis, cervicitis, salpingitis, proctitis, PID
- less acute symptoms compared to gonorrhea (mucoid discharge, not purulent)
53
16y sexually active male referred for scrotal mass/swelling: associated dull ache, on exam there is an irregular mass palpable in the left scrotum that increases when standing (no vitals given). The left testis is of normal size. diagnosis:
Spermatocele
Inguinal hernia
Epididymitis
varicocele
Varicocele
- Dull ache
- Heaviness
- Often on the Left
- "bag of worms" when palpated
54
A 15 year old female in your practice is about to become sexually active. When does she need her first gynecological exam including pap smear?
Pap smears now not recommended until age 25 q3years
55
An adolescent is in the ED who is 65% of her ideal body weight. HR 40, T35.8, BP 90/P. What to do:
3. Slow refeeding- at risk for refeeding <80% of ideal body weight
56
A 6 y/o boy with 2 weeks of sudden onset of OCD behaviours. Which infectious agent would you be
concerned about:
1. Strep pneumonia
2. Group A Strep
3. E. Coli
4. H. Flu
5. Echovirus
2. Group A Strep - team Pandas is back!
PANDAS - pediatric autoimmune neuropsychiatric disorder associated with strep infection
- sudden onset neuropsychiatric disorders (particularly OCD, tic, tourettes) with possible
relationship with GAS- hypothesized (not proven)
57
How do you treat endometriosis?
leuprolide: create an environment of acyclic low dose estrogen to prevent bleeding and further seeding into the pelvis
58
An adolescent girl with diabetes for the last ten years is seen in diabetes follow up clinic. Her HbA1c is 7.6%. She is a straight A student. She has no complaints. Her weight has dropped from the 25th to the 5th percent. What is the most likely cause of her symptoms?
Eating disorder
Celiac disease
Hypothyroidism
Eating disorder
59
Factors that make a youth more likely to quit
```
Older teen
Male
Teen pregnancy + parenthood
Scholastic success
Team sports
Peer and family support
Low nicotine metabolizer
```
60
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
61
Diagnostic Criteria for ADHD:
≥ 6 Inattentive:
- Careless mistakes
- Doesn't pay attention
- Doesn't listen
- Doesn't follow-through
- Not organized
- Loses things
- Distracted
- Forgetful
≥ Hyperactivity
- Can't sit still
- Fidgets
- Runs about
- Can't play quiet
- Driven by a motor
- Talks excessively
- Burts out answers
- Can't wait turn
- Interrupts others
Mixed is ≥ 6 in both categories
Present in >1 setting
Present before 12 years
Functional impairment
62
A teenage boy is having difficulties functioning because he constantly has to watch his hands and has obsessive thoughts.
Which of the following medications may help him?
1. Amitryptiline
2. Clonazepam
3. Clozapine
4. Fluoxetine
4. Fluoxetine - SSRI first line
Second line - Atypical antipsychotic or clomipramine (TCA)
63
A 15-year-old athletic boy comes in for his regular check up, and he tells you that he is using anabolic
steroids. Which of the following is a potential long-term sequelae of anabolic steroid use:
a) dementia
b) liver cancer
c) myositis ossificans
d) hemorrhagic cystitis
e) interstitial pneumonia
b) liver cancer
64
What are 2 treatment modalities for panic disorder?
1) SSRI
2) CBT
(avoid Benzes)
65
12. Which of the following is true regarding the morning after pill:
a) It is 75% effective at preventing pregnancy
b) You should have patient sign a consent form prior to prescribing it
c) It should not be used if patient has undiagnosed vaginal bleeding
a) It is 75% effective at preventing pregnancy
(from UTD)
Mifeprisone or Ulipristal - prevents 66% when used within 72h
Levonorgestrel - 50% when used within 72h
Copper IUD: prevents 95% when used within 72h
66
17. Which is true regarding pregnancy and abortion in adolescents:
a ) the majority of teenage pregnancies end in abortion (50%)
b) proper counseling of post-abortion teenagers will prevent psychosocial problems
c) there is increased post-abortion mortality in teenagers compared with adult women
d) there is a similar rate of post-abortion infection in adolescents and adult women
a ) the majority of teenage pregnancies end in abortion (50%) - as per CPS statement
67
46. 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
68
Teenager took 15 tabs of an oral hypoglycemic and hospitalized. 48 hours later is stabilized. Demanding to leave. She is homeless and lives on the street. What is her greatest risk factor for repeated suicide attempt?
1) Mechanism of suicide attempt
2) Female
3) Being alone
4) Spontaneous suicide attempt
2) Female
CPS Statement: Previous suicide attempt is one of the strongest predictors of suicide during adolescent and life long
Females are 3-4x more likely to attempt suicide.
69
What is the treatment of gonorrhoea?
o evaluate for concurrent syphilis, Hep C, HIV and chlamydia
o sexual partners in preceding 60 days should be cultured and started on presumptive
treatment
o combo therapy with ceftriaxone 250mg IM x1 AND azithro 1g PO x1 dose or doxy
100mg po BID x7 days
▪ if no ceftriaxone can used cefixime
70
13 year old girl is sexually active. She sees you and has a normal pap smear with no STI’s and uses barrier protection. She does not want you to tell her parents. What do you do?
1) Ensure she understands the elements of confidentiality
2) Ensure she is in a consenting relationship (peer is no more than 2 years older and not in position of authority)
3) Educate - safe sex practices, contraception, STI prevention
4) Follow-up!
71
Which of the following is true in puberty?
a) menstruation at Tanner stage IV
b) maximum penile growth at Tanner stage II
c) axillary hair in males at Tanner stage III
d) voice change at Tanner Stage III
e) Double breast contour in girls at Tanner stage III
a) menstruation at Tanner stage IV
voice drops between 3-5
double breast counter - 4
Axillary - stage 1-2
Boobs, Pubes, Grow, Flow
72
List 3 serious side effects of Risperdol in addition to weight gain.
- hypertension
- Hyperprolactinemia
- Metabolic syndrome: weight gain, diabetes, dyslipidemia
- Prolonged QTc syndrome
- Agranulocytosis, neutropenia, leukopenia
- Extrapyramidal side effects (dyskinesia, akinesia, akathesia (inner restlessness), dystonia
(involuntary contractions), pseudoparkinsons (tremor, rigidity, postural instability))
73
Marijuana has been shown to cause which of the following
- Gynecomastia
- Glaucoma
- Decreased heart rate
Gynecomastia
SE:
- tachycardia, increased BP
- tachypnea
- conjunctival injection
- dry mouth
- increased appetite
- nystagmus
- ataxia
- slurred speech
74
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
75
What are absolute contraindications to oral contraceptives?
```
- Absolute
o Migraine with aura
o Hx of DVT or PE
o <6 weeks post-partum
o Severe hypertension (>160/100)
o Severe cirrhosis
o DM with complications
o CVA or disease
o Ischemic heart disease
o Breast cancer
o Complicated valvular heart disease (pHTN, aFib, Hx of endocarditis)
o DM with complications
```
*cigarette smoking is not a contraindication in adolescents
76
Indications for inpatient management of PID
Suspect tubo-ovarian abscess, pregnancy, severe pain, failed outpatient management
Treatment with Cefoxitin IV q6h and doxycycline 100mg po/IV q12h
77
A 15-year-old girl requests your advice regarding contraception. You would NOT give her an IUD because of concern for:
a) infection
b) pregnancy
c) amenorrhea
d) copper toxicity
e) uterine perforation
b) pregnancy
You can give IUD after treating for infection.
IUD Contraindications:
- Active pelvis infection
- Abn uterus
- Wilson's disease
- Known/suspected pregnancy
- Breast Ca
- Undiagnosed abnormal uterine bleeding suspicious for serious disorder
78
Factors that make a youth less likely to quit smoking
```
Nicotine addiction
MH conditions
Drug/EtOH use
Chronic Illness
Family stress
Peer/Family Smoking
Overweight
Fear of peer rejection
```
79
62. 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
80
Which of the following is true regarding the morning after pill:
a) it is an acceptable form of contraception
b) it must be given within 72 hours of intercourse
c) it is not necessary to do a urine beta-HCG before giving it
d) it is given for a total of 6 doses
e) gravol is given half and hour after taking it
c) it is not necessary to do a urine beta-HCG before giving it
Should be taken within 72 hours but can be used up to 120 hours
81
Prevention of osteoporosis in an anorexic?
a. Calcium
b. Vit D
c. Estrogen
d. Gain weight to at least 10% ideal weight
d. Gain weight to at least 10% ideal weight
Nelsons: ‘restoration of weight marked by return of menses is most effective method of improving bone mineral density’, estrogen replacement by transdermal patch may partially increase bone mineral density in adolescents. Does also recommend vitamin D and calcium supplementation.
82
What leads to death in anorexia? (5-20% lifetime mortality rate)
```
#1 - suicide - 50%
#2 - prolonged QTc and can get tachyarrhythmias
```
83
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:
Brain tumour
DM
ADHD
a. Brain tumour
84
Excessive menstrual bleeding in an adolescent is most likely associated with:
a) excess estrogen
b) decreased estrogen
c) excess progesterone
a) excess estrogen
85
You are seeing a teen with depression. Peds Psych manual/GLAD-PC
a. What medication for depression has the most evidence for pediatrics.
b. The mother of the teen brings up that the medication can lead to suicide. What 2 points do you discuss with her.
c. What other 2 points do you mention when you counselling.
A. Fluoxetine
B.
Risk of untreated depression is higher than risk of SI with starting treatment.
- risk is still very low
- most of the studies looked at older age group
- studies never looked at completed suicides (looked at thoughts and acts)
Close monitoring is required (once weekly x 4 weeks, biweekly x 2 weeks, then qmonthly and RA)
C. Ensure access to medications and firearms at not available.
Do not abruptly stop due to discontinuation symptoms
Important to combine non-pharm management (CBT, exercise, etc)
86
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
HR 70
BP 95/65
RR 14
Temp 35.4 degrees
a. HR 70
87
When can you give contraception after an abortion?
a. Immediately
b. 2 weeks later
c. 1 month later
a) Immediately
88
What does guarasil protect against and how?
a. live attenuated against CA
b. recombinant against CA
c. live attenuated against CA and condylomata
d. recombinant against CA and condylomata
d. recombinant against CA and condylomata
```
Guardasil 9 (types 6, 11, 16, 18, 31, 33, 45, 52 and 58) -- recombinant HPV vaccine
types 16 and 18 alone account for ~70% of cervical cancers ; 6 and 11 benign and cause 90% of warts
```
89
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
90
The estrogen part of the OCP causes what? (2009 MCQ)
a. moodiness
b. salt and water retention
c. acne
b. salt and water retention
| - not weight gain (Except Depo-provers)
91
Repeat - Teen with anxiety, want to start fluoxetine. What would be concerning on history?
1. Family history of bipolar disorder
2. Family history of suicide
1. Family history of bipolar disorder
| - can induce mania - make sure you rule out mania
92
order of pubertal development in girls
boobs, pubes, grow, flow
93
14 year old girl, had menarche at age 12. Now presents with menorrhagia (current period has lasted 10 days). What four conditions would you consider?
- Anovulation
- vonWillebrand disease
- Plt disorders
- Hypothyroidism
- Infection (cervicitis, PID)
- Anatomic (polyps, hemangioma, vascular malformations)
94
AN: Criteria for admission
HR <50 daytime, <45 asleep
- Systolic BP <90
- Orthostatic changes in pulse >20 BPR or BP >10
- Arrhythmia
- Temp <35.5
<75% ideal body weight
- Ongoing weight loss despite intensive management
- body fat <10%,
- refusal to eat
- failure to respond to outpatient treatment.
95
Anxious adolescent boy who is a good student. Had appendicitis and got to stay home for over a week. Now refusing to go to school.
What 4 things can you do for him?
- Parent mangement (send to school calmly, reward for going)
- Work with the school (write a letter for modification)
- meet with the school
- discuss his concerns about returning to school
- If ongoing, refer to psych
- Consider SSRI
96
11. Description of a child with florid autism.
A) Name 3 tests you should order.
B) Which 2 consultants or services would you involve to help you with your diagnosis?
A) Hearing test, vision assessment, microarray, wood's lamp exam for TS,
Consider: MECP2 in females, fragile X, consider Lead (if pica)
2) Optho, Audiology, Psychology, OT, Dev Peds Specialist
97
A young man drinking an energy drink. What do are you most concerned about?
Guarana
Caffeine
Ginsing
Guarana (a naturally occuring source of caffeine) - because they don't tell you how much is in it.
98
when does a boys' voice crack
tanner 3-5
99
Child presents with recurrent episodes of tachypnea, tachycardia, diaphoresis, nausea and vomiting. This occurs 2x weekly, never at school, for six months. What is the cause?
a) Panic attack
b) Social phobia
c) Arrhythmia
a) Panic attack
100
Adolescent female with ADHD and slightly decreased mental capabilities presents with school difficulties. She is started on concerta 36mg OD x 7 days/week. At followup 3 months later she has lost 15 pounds. What would be you management?
a) Decrease Concerta to 5 times per week
b) Discontinue concerta and start strattera
c) Refer to psychiatry
b) Discontinue concerta and start strattera
101
A 13 year old female. Menarche has occurred. White vaginal discharge for several month which is occasionally itchy and irritating. Most likely diagnosis is:
Physiologic leukorrhea
Group A strep
Chlamydia
Gardnerella
Physiologic leukorrhea
- (Vulvo)vaginitis - most common in children is poor hygiene or chemical irritants
BV - thing grey d/c, burn + itch, fishy odor. Clue cells. PH >4.5
Candida - itch, pain, swelling, redness, dysuria. Curdy discharge. Not common pre-adolescence
Trichomonas - diffuse malodorous yellow-green discharge and vulvar irritation
102
Best test to detect PCOS:
```
hypertension
increased TSH
XO chromosome
increased LH/FSH
increased testosterone
```
e. increased testosterone (not increased LH/FSH)
```
PCOS is a clinical Dx :
Rotterdam : Need 2 of 3
- oligomenorrhea (<8 cycles per year)
- Hyperandrogenism
- PCO on US
```
103
How long after intercourse can you give emergency contraception?
24 hours
72 hours
120 hours
120 hours
but most effective if given within 72 hours
104
According to the WHO, which of the following can receive combined hormonal oral contraceptive pills?
Unexplained vaginal bleeding
Migraine with aura
Liver disease
Malignant hypertension
Unexplained vaginal bleeding
105
A teen in your practice has been on fluoxetine and risperdal.
He presents to your office with hyper-reflexia and tremor and ataxia and 5 or 6 more symptoms. What to do you do?
b) stop fluoxetine
- serotonin syndrome: usually rapid onset, mild symptoms incld increased HR, shivering,
diaphoresis, dilated pupils, myoclonus, hyperreflexia, hypervigilance, insomnia, agitation
o severe symptoms include shock and hyperthermia with metabolic acidosis,
rhabdomyolysis, seizures, renal failure, and DIC
106
63. 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)
107
What are the expected electrolyte changes associated with vomiting, laxative and diuretics:
Na, K, Cl, HCO3, pH
Na - Anything
K - Low in all
Cl - Decreased in vomiting and diuretics (up or down in laxative)
HCO3 - Increased in vomiting and diuretics (up or down in laxative)
pH - Increased (alkalotic) in vomiting and diuretics, (up or down in pH)
108
Anorexic child with HR 30, refusing to eat:
A) List your steps in management
B) What is your plan to feed this child?
a)
- Admit to hospital
- ECG
- Extended Electrolytes, Cr, Urea, LFTs, Albumin, Amylase, glucose
- Correct electrolyte abnormalities
- Initial bedrest
- Consult Eating disorder team
B) Carefully at first with monitoring for re-feeding syndrome.
Start 1500-1800 kcal/day, advance 200-400 kcal q2-4 days.
Aim to increase weight 0.2-0.5 kg/week
Consider NG
109
Side effects of marijuana include all of the following except:
Bronchospasm
conjunctival injection
large testicles
tachycardia
3. large testicles
Actual side effects include: bronchospasm, conjunctival injection, tachycardia
- no longer thought to be associated with gynecomastia
110
What are suicide risk factors for teenagers
- Male (completion)
- Female (Self harm)
- low SES
- LGBT
- parental separation
- hx physical or sexual abuse
- family hx suicide attempts/completions
- bullying
- depression, anxiety, ADHD
- drug and alcohol abuse
- hopelessness
- low self esteem
- impulsivity
- perfectionism
111
List some medications that decrease the effectiveness of oral contraceptives:
```
Rifampin
Oxcarbazepine
Phenytoin
Phenobarb (barbiturates)
Carbamazepine
Topiramate
St John's wort
```
112
A teenager from an indian reserve has just returned from an extended hospitalization because of substance abuse problems. What are 4 factors that you would do to prevent him from drinking again.
- Treat co-morbid psychiatric conditions
- Treat comorbid substance issues
- Family therapy
- Behavioural therapy
- AA
113
What would exclude PID?
a) Negative Chlamydia screening test
b) Negative gonorrhea screening test
c) Cervical wet mount negative for wbc’s
d) Positive pregnancy test
c) Cervical wet mount negative for wbc’s
Laboratory diagnosis:
- Negative laboratory results do not rule out a diagnosis of PID.
- A normal ultrasound study does not rule out a diagnosis of PID.
- Ultrasound may aid in the diagnosis, especially if tubo-ovarian abscess is suspected.
- A STAT beta HCG pregnancy test should be done to exclude ectopic pregnancy from the differential diagnosis
Tx: Cefoxitin 2g IV q6h plus Doxy 100 mg IV or PO q12
114
Child comes to the office because his teacher wants him investigated for disruptive behaviour and is
concerned about ADHD. Parents may have some concerns about his attention but none about his
behaviour.
A) What do you think is the diagnosis?
B) What are 4 things to request to investigate for this diagnosis?
ADHD- possibly inattentive or combined type. Two setting of inattention clear.
B) Additional information:
- ADHD specific questionnaires, parents and teachers
- Report cards
- Hearing + Vision
- Developmental Hx
- Family Hx
115
In an adolescent female, which of the following would be a contraindication for oral contraceptives:
a) undiagnosed vaginal bleeding
b) asthma
c) diabetes mellitus
d) moderate hypertension
e) seizures
d) moderate hypertension
(As in Stage II >160)
DM with nephropathy/ retinopathy/neuropathy would be a contraindication
116
15 year old high school student is being bullied at school because he is a homosexual. His parents tell
you they keep their meds in a locked cabinet after an incident where he took some of their meds.
1. do not tell his parents because he insists that you don’t tell them
2. get more information from the school principal
3. he is at low risk for suicide because the pills are locked away
4. he is at increased risk for suicide because he is a homosexual
b. he is at increased risk for suicide because he is a homosexual
(per CPS disclosure of homosexual orientation is a common precipitating factor for suicide)
117
Photo of female genitalia with labia adhesions: management
a. estrogen cream
b. CPS
c. Ultrasound of abdomen
d. Karyotype
a) Estrogen cream
118
Autism. Risk for recurrence?
- Slightly higher than general population
- Equal to gen population
- 50 % chance because AD
- None, if avoids MMR
y. Slightly higher than general population
Risk Factors for autism:
- FHX: high recurrence risk in siblings (2-19%)
- Closer spacing of pregnancies
- Advanced maternal or paternal age
- Extreme prem birth (< 26 wk GA)
- FHX (+) for LD, psychiatric dx or social disability
119
Normal BMI
Underweight BMI
Overweight BMI
Obese BMI
5-85%ile - Normal
<5% - Underweight
85-95% - Overweight
>95% Obesity
120
A teenage girl presents with a one week history of periumbilical pain, fever of 39.2 degrees. She looks unwell and a blood Cx shows gram negative rods. Which antibiotic will you treat her with:
a. Ciprofloxacin
b. Penicillin
c. Gentamicin
d. Clarithromycin
Gentamicin?
Really - cover for pseudomonas (Ceftazadime, Cefepime, Pip-tazo, Imipenem, or Meropenim)....
Gent is part of the double coverage !! (Gent, Tobra, or Amikcain).
Reminder of some Gram negative rods from up to date:
- Chlamydia (coccobicilli)
- PSEUDOMONAS
- E. coli
- hemophilus
- klebsiella
- campylobacter
```
(Gonorrhea is gram -ve diplococci)
PID Tx:
- Cefoxitin + Doxy or
- Clinda + Gent or
- Cipro + Doxy + Flagyl
```
121
63. What is the most likely finding on physical examination after a girl has been sexually assaulted?
b. normal vaginal exam
| Physical findings specific to previous genital trauma only in 2.5% of abused children.
122
A 10 yo brother of boy with AML, decision for palliative care at home. Brother going out to play with his friends rather than spending time with family. Counsel the parents.
-Feelings are normal, encourage him to have normal routines, acknowledge and validate feelings, involve him as much as he wants in sick sibling's life
Developmentally appropriate language and explain the situation honestly and involve the brother w/ appropriate decisions, while providing support as all members experience emotions in different ways.
123
23. A sexually active adolescent female with sickle cell disease and a history of previous transfusions
presents with an acute history of fever, jaundice and vomiting. She also develops right shoulder pain.
Hbg 79 (prev 89), AST and ALT slightly elevated. Unconjugated bilirubin is increased. What is the
most likely diagnosis?
a) Fitz-Hugh-Curtis
b) cholecystitis
c) hepatitis C
d) HIV
e) vaso-occlusive disease of the liver
b) cholecystitis
Liver enzymes should be normal with Fitz-Hugh-Curtis because it is a perihepatitis (liver capsule, not the liver itself)
Fitz-HIgh-Curtis: complication of PID causing liver CAPSULE inflammation with adhesions (mainly caused by G+C)
124
7 y/o disclosed that her 15 y/o brother has been sexually abusing her for 2 years. On exam, you find a deep cleft in the inferior rim of her hymen. What does this mean?
1. Normal variant
2. She has been sexually abused
3. Diagnostic of previous hymen injury
3. Diagnostic of previous hymen injury
Normal variants:
- any notch or cleft of the hymen (regardless of depth) above 3 + 9 O'Clock
- superficial notches on the hymen at or below the 3 and 9 o'clock
- perianal skin tags
No Expert Consensus:
- notch or cleft at or below 3 and 9 o'clock; may extend to base of hymen but not complete transaction.
125
```
At what age are most children sure of their gender identity?
1- 4
2- 6
3- 8
4- 10
```
??? Age 5-6
126
What is the maximum age of a partner that a 12 year old can consent to have sex with?
What about 14?
What situation can a 16 year old not consent to have sex with someone older
Consent Exemptions
1) 12-13 year olds : less than 2 years older
14-15: less than 5 years older
16: A person in authority or dependency, or activity of exploitation.
127
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
128
You see an 8 year old girl in your office with a history of vaginal bleeding for the past 3 days.
Name 4 diagnoses on your differential.
- Precocious puberty
- Blunt trauma (accidental)
- Penetrating vaginal trauma (child abuse)
- Foreign body
- Urethral prolapse
- Infection (vaginitis): GAS, Shigella in prepubertal girls
- Lichen Sclerosis
- hemangioma
- hypothyroidism
- genital tract malignancy
129
16 y/o breast mass 2X 2cm, firm.
Fibroadenoma
Lipoma
Fibrocystic changes
Fibroadenomas
- most common solid mass seen in adolescent girls - often upper/outer quadrant, 2-3 cm, well circumscribed, rubbery, non-tender
Excision if rapid growth, >5cm or persists into adulthood.
Fibrocystic changes: painful breast tissue before menses, improve during. May be palpable.
130
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
131
What is the treatment of chlamydia?
azithromycin 1g PO x1 dose OR doxycycline 100mg
PO BID x7 days
o doxy and quinolones are contraindicated in pregnant women
- sexual partners of patients with non-gonococcal urethritis should be treated if they have had
sexual contact with the patient within 60 days of symptom onset
- most recent sexual partner should be treated regardless of how long ago that sexual contact was
- patients and their partners should abstain from sex until 7 days after a single-dose regimen
or after completion of a 7 day regimen
132
The EKG finding in anorexia nervosa
1. widened QRS
2. ST elevation
3. R axis deviation
4. tall T wave
r axis deviation
ECG is generally normal except sinus Brady. May have prolonged QTc with hypo.
If there is axil abnormality - it is usually R.
133
159. At what age should screening begin with PAP smear?
25 or 3 years after first sexually active, whatever comes later.
Can consider at 21-24 years
134
Teen boy that confesses to you that he thinks that he may be gay. He is concerned about telling his parents. What things (social/emotional/health) is he as risk for (5 lines)
```
Verbal and physical assault
Depression
Substance misuse
Homelessness
Dropping out of school
Suicidality
Social isolation
Increased risk of STIs
```
135
When would you counsel a teen who took plan B to expect her period to return?
- menses return within 7 days of expected date in 62.5% of patients - CPS statement
o “explain to the adolescent the next period may be early, on time or late”
o should return for a pregnancy test if their next period is more than 1 week late or is
unusual in any way
136
61. The estrogen part of the OCP causes what?
b. salt and water retention (fluid retention)
137
How do you treat PID?
Ceftriaxone 250mg IM x1 dose, doxycycline 100mg po BID x14 days +/- metronidazole 500 po BID x14 days
138
What are 2 signs of imperforate hymen on a physical exam of a neonate?
What are 2 symptoms of imperforate hymen for an adolescent
1) Bulding introitus due to mucucolpos. Lower abdominal midline mass
2. Amenorrhea, cyclic abdominal pain, back pain, pain with dedication, difficulty urination
139
Teenager comes in asking for the morning after pill.
a) What is the latest after intercourse that the pill is effective (1)?
b) What two things will you do for subsequent management (2)?
A) an use up tp 120 hours (5 days), but the sooner the better
B)
start regular contraceptive - Plan B will not cover you for any sex you have after taking it
counsel teen to return if have not had period within 3 weeks: could be pregnant
- Counsel re: safe sex, STI testing
140
Which is true of adolescence:
a) preoccupation with body image in mid adolescence
b) parental conflict peaks in mid adolescence
b. parental conflict peaks in mid adolescence
| early, middle and late changes; physical, cognitive, moral, self-concept, family, peers, sexuality all evolve
141
A mom is worried because her adolescent child is doing poorly in school, is stealing money from her purse, etc.
What are 4 clinical manifestations of cocaine use?
1. Euphoria
2. Psychosis
3. Motor agitation
4. Decreased fatigability
5. Mental alertness
Sympathomimetic → pupillary dilatation, tachycardia, hypertension, hyperthermia
Snorting cocaine → loss of sense smell, nosebleeds and chronic rhinorrhea
Chronic users will have anxiety, irritability and sometimes paranoid psychosis
142
14 year old boy recently has had two weeks of behaviour change. Saying weird things. Staying in his room. Not going to school. No comments on any physical symptoms.
What are four possibilities in your differential diagnosis?
LIst 4 non-psych Dx for psychosis/delerium
```
Depression
Anxiety
OCD
Substance abuse
Brief Psychotic Disorder
Schizophrenia
PTSD
Bipolar
```
```
SLE
Seizures
Encephalitis
Brain tumor
Hyper/hypothyroid
ADEM
IEM!
Wilsons
```
143
```
Teenage girl with mild acne now moderate. Wants to go on birth control but does not want to make things worse?
What do you prescribe?
a. barrier methods
b. progestin only
c. combined ocp
d. Depo-Provera
```
c. Combined OCP
144
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?
Depo-Provera
IUD
84/7 pill
LHRH agonist
c. 84/7 pill - will need to plan periods 3-4 times per year; no major risks
145
You are treating a 17 year old male for Chlamydia urethritis. Which of the following do you tell him regarding when he can resume sexual activity?
a) Once he completes 7 days of treatment
b) Once his partner is treated
c) After 6 days
d) Until retested and found to be negative
a) Once he completes 7 days of treatment
Patients diagnosed with a bacterial STI or trichomonal infection should be advised that they and their partners should abstain from unprotected intercourse until 7 days after treatment of both partners is complete (e.g., 7 days after single-dose therapy).
146
A teenage boy has a history of substance abuse. Which of the following medications is the best choice for the treatment of his ADHD?
a) guanfacine
b) Vyvanse
c) Adderall XR
d) Dextrin XR
b) Vyvanse - a prodrug (and also longer acting as in 10-12 hours)
147
14 year old girl has severe dysmenorrhea and has missed 2-3 days of school with each period.
A) What are three causes of dysmenorrhea (3)?
B) Name two meds (or things you can do) to recommend to her. What medication do you offer?
A) Primary, Endometriosis, Adenomyosis, Ovarian cysts, Silent PID, congenital abnormalities (imperforate hymen, cervical stenosis), pregnancy complication
B) NSAIDS - start at onset of menses, for first few days
OCP
GnRH (if endometriosis)
148
15 year old boy who you have been following for Type 1 diabetes. You are preparing for transition to adult care.
List 5 things you would do to assist with this transition?
- Ensure has a good understanding of his condition
- Involve teen in mangement
- See teen alone for part of appointment
- Give transition letter
- Teach skills of negotiation and communication
- Peer support programs
- Provide resources about youth living with chronic health conditions
- Collaborate with family MD or Adult specialists
- Formal acknowledgement of graduation
149
Patients with anorexia nervosa become osteopenic due to:
a) lack of exercise
b) excessive water intake
c) estrogen deficiency
d) increased LH
e) increased calcium excretion
c) estrogen deficiency
150
17 year old male with history of enthesis related JIA comes to your office. Just had a new baby girl with his girlfriend and would like to quit smoking for her sake. What puts him MOST at risk of not being able to quit
Chronic illness
Male gender
Older adolescent
Parenthood
Chronic Illness
151
What is associated most with adolescents and illicit drug use?
a) treated ADHD
b) decreased school performance
b) decreased school performance
Early warning signs of teen substance abuse:
- change in mood appetite or sleep pattern
- decreased interest in school or school performance
- weight loss
- secretive behaviour about social plans
- valuables (money/jewelry) missing from home
152
Suicidal teen, would not be able to be seen until after the weekend. How would you manage this patient with parents at home without admitting.
List 5 things
- Use crises services and help lines
- Use of ED as necessary
- Ensure home environment is safe (no firearms / meds)
- Make up a safety contract/plan
- Supervision over the weekend
- Ensure follow-up is arranged
- Leverage on teen's identified positive aspects in life
- Identify key trusted individuals
153
14 y.o. female brought in by parents because she was found drunk. List five things that would increase
your concern over her substance abuse.
```
Absenteeism
Social Isolation from friends
Episodes of drinking more than intendended
Risky Drinking (cars!)
Tolerance
Withdrawl
Cravings
Drinking alone
Trouble with the law while intoxicated
Wanting to cut down or friends/family telling her to cut down
```
154
What does CPS recommend for smoking cessation?
- Brief Counselling
- CBT
- Phone or Distance Counselling
- Nicotine Replacement Tx: not a lot of evidence for teens but national guidelines suggest using for regular users >12
- Buproprion - only in some causes (not in AN or Seizures)
- Varenicline - only in some cases, with caution
155
27. Tourette’s syndrome.
a. ) List 3 criteria for diagnosis.
b. ) List 3 associated conditions.
a) 2 motor + 1 vocal tic
- X 1 year minimum (present most days)
- < 18 y.o. at onset
- not due to other dx
b) ADHD, OCD, LD
156
Which of the following laboratory results is very worrisome in an anorexic patient?
Hypokalemia
WBC <1000
Metabolic alkalosis
Low protein
Hypokalemia
