Adolescent Medicine Flashcards
What are the 4 tasks of adolescence?
Achieving independence from parents
Adopting peer codes and lifestyles
Assigning increased importance to body image and acceptance of one’s body image
Establishing sexual, vocational, and moral identities
What is the differential diagnosis of gynecomastia in an adolescent male?
- Normal (50%, resolves within 2 years)
- Drugs (steroids, TCA, exogenous hormones, spironolactone, H2 histamine receptor blockers- cimetidine, antiretrovirals, chemotherapy, ETOH, marijuana)
- Endocrinopathies (hypogonadism, AIS, Klinefelter, CAH)
- Underlying malignancy (pituitary, thyroid, adrenal gland, testicular tumours)
How can you conclude that gynecomastia is just pubertal gynecomastia?
Signs of puberty
Tender
<2 cm
Lasts <2 years
Not using any medications associated with gynecomastia
Normal testicular exam
No evidence of renal, hepatic, thyroid, or endocrine disease
What is the age of consent for sex in Canada?
16 years
What are the close age exceptions for sex in Canada?
12 or 13 years can consent with someone within 2 years
14 - 15 years can consent to sex with someone within 5 years older
Must not be in position of trust or authority
What is the age of consent for exploitative sex (prostitution, pornography, position of trust/authority)?
18 years
What are the contraception failure rates for: Chance Withdrawal Condoms Diaphragm OCP Depo-provera IUD
Chance 85% Withdrawal 18% Condoms 15% Diaphragm 16% OCP 8% Depo-provera 3% IUD 0.5% (0.9% for copper, 0.2% for hormonal)
What are absolute contraindications for OCPs?
Pregnancy
Breastfeeding <6 weeks post partum (clotting risk)
Serious cardiovascular disease:
Current DVT, PE, complicated valvular heart disease, past or present MI or cerebrovascular disease
APL-Abs (or lupus and unknown APLA status)
Uncontrolled hypertension (SBP>160, DBP >100)
Active liver disease or history of liver tumours
Cholestatic jaundice
Thrombophilic conditions
Migraine with neurologic symptoms (aura)
Current breast cancer
Major surgery with prolonged immobilization
Undiagnosed uterine bleeding (r/o pregnancy, cancer)
What are relative contraindications for OCPs?
Hypertension
Breastfeeding <6 months post partum
Certain hyperlipidemias
Past breast cancer, disease free>5 years
Medications: ritonavir-boosted protease inhibitors, anticonvulsants, rifampin
Diabetes with vascular disease or >20 years
Certain liver disease (symptomatic gall bladder disease, acute hepatitis)
What do you need to do before giving emergency contraception?
Nothing
Pregnancy test not required
When do you start screening for cervical cancer?
21 years of age
What is the most solid breast mass in an adolescent girl?
Fibroadenoma
What is the diagnosis?
http://www.dbmhresource.org/klinefelter.html
Klinefelters
What is a differential for breast masses in adolescent females?
Fibrocystic changes
Fibroadenoma
Phyllodes tumor (rare tumour, usually present with large painless breast mass)
Intraductal papilloma (benign tumour, can be associated with bloody nipple discharge)
Mammary duct ectasia (nipple discharge, blue mass under nipple)
Montgomery tubercles (obstruction of periareolar glands, subareolar mass, drainage of brownish fluid)
Breast infection
Breast trauma
Breast cancer
What history and physical exam features are consistent with fibrocystic changes?
Painful before menses
Improvement with menses
Generally upper outer quadrants of breast
What are history and physical exam features consistent with fibroadenoma?
Asymptomatic Rubbery Well-circumscribed Mobile Non-tender
What history and physical exam features are consistent with breast cancer?
Hard, irregular, fixed mass Nipple/skin retraction Skin edema Nipple discharge Axillary/supraclavicular LAD
What are the cognitive and moral stages of adolescence?
Early (10-13): concrete operations, unable to perceive long-term outcome, conventional morality
Middle (14-16): emergence of abstract thought, can perceive future implications, but may not apply to decision-making
Late (17-20): future-oriented
What are the stages of identity formation of adolescence?
Early (10-13): pre-occupied with changing body, self conscious of appearance
Middle (14-16): stereotypical adolescent, concern with attractiveness
Late (17-20): more stable body image
What are the stages of family relationships in adolescence?
Early (10-13): Need for privacy
Middle (14-16): Conflicts over control and independence
Late (17-20): Emotional and physical separation from family
What are the stages of peer relationships in adolescence?
Early (10-13): Same-sex peers
Middle (14-16): Pre-occupation with peer culture
Late (17-20): Peer groups recede in importance; intimacy and commitment take precedence
What are the stages of peer relationships in adolescence?
Early (10-13): Same-sex peers
Middle (14-16): Pre-occupation with peer culture
Late (17-20): Peer groups recede in importance; intimacy and commitment take precedence
What are the sexual stages of adolescence?
Early (10-13): interest in sexual anatomy, anxiety about genital changes, limited dating/intimacy
Middle (14-16): initiation of relationships and sexual activity, questions of sexual orientation
Late (17-20): consolidation of sexual identity, focus on intimacy and formation of stable relationships, planning for future and commitment
At what SMR stage do you typically see menses?
SMR 4
How many cm do you grow after menarche?
2-5 cm
When is peak height velocity in males vs females?
Mid to early puberty
At what SMR stage do you see peak height velocity in boys vs girls?
SMR 4 vs. SMR 2
What is the mechanism of action of OCPs?
Progesterone
- Thickening of cervical mucus, blocks sperm penetration, thins endometrium
- Slowed tubal mobility
- Endometrial changes
Estrogen
-Inhibition of ovulation by inhibiting LH surge
What are the estrogen-related side effects of OCP?
Breakthrough bleeding Breast tenderness Bloating Headaches Nausea Hypertension Thromboembolism Drug interactions (P450) Slight increased risk of cervical dysplasia (>5 yrs of use)
What are the benefits of OCP?
Decrease dysmenorrhea
Decrease menorrhagia
Reduce anemia
Improvement in acne, hirsutism (Ortho Tri Cyclen, Yaz)
Reduce risk of ovarian, endometrial cancer
May help w/ ovarian cysts
Decrease benign breast disease
How often is Depot IM given?
150 mg IM in deltoid or gluteus maximus q12 weeks
What are the benefits of Depot IM?
Convenient, low maintenance
What are the side effects of Depot IM?
Irregular bleeding, amenorrhea
Weight gain***
Mood changes
Decreased bone density (Caution if steroids, eating disorders, chronic renal failure)
-Consider BMD
Delays return to fertility- average 10 months!!
How should you counsel women on Depot about risk of osteopenia?
Adequate calcium intake
Exercise
After 2 years-re-counsel about BMD risks and offer alternatives
In what group of people is the transdermal contraceptive patch less effective?
Obese (Wt >90kg)
How long can you keep a copper IUD in?
5 or 10 years
How does copper IUD work?
Copper ions interfere w/ sperm motility, transport, capacitation
Cause sperm head-tail disconnection
How long can you keep a mirena (levonorgestrel) IUD in?
5 years
How does mirena IUD work?
Renders cervical mucus impenetrable to sperm
Produces atrophic endometrium
Slows tubal motility
Ovulation NOT consistently suppressed
What are contraindications to IUD?
Pregnancy/suspected pregnancy
PID (current or w/in last 3 mo)
Acute/purulent cervicitis
Pelvic TB
Puerperal/ post abortion sepsis
Undiagnosed vaginal bleeding (suspicious for serious condition)
Distorted uterine cavity
Malignancy of genital tract (cervical, endometrial, gestational trophoblastic disease)
Wilson disease (for copper IUD)
Uterine cavity < 6cm or >9 cm on sounding
What are complications of Mirena IUD?
Infection: increased only in 1st 20 days after insertion
Bleeding irregularities: typically 3-6 mo, subsequent amenorrhea or oligomenorrhea in 15-30% of users
IUS expulsion (first 1-2 yrs ~4%)
Perforation (1/1000)
Pain at insertion
Ovarian cysts
Progestin effects
CANNOT be used as emergency contraception
What are complications of copper IUD?
Same infection risk as Mirena Increased menstrual bleeding by up to 65%, cramping IUD expulsion (first year rates 2-8%) Perforation or embedment Pain at insertion
What are indications for emergency contraception?
Unprotected intercourse –Sexual Assault –Coitus Interruptus Ejaculation onto genitals Condom breakage or slippage Improper use of prescribed contraceptive –Forgotten pills, late for Depo, etc.
What are two options for emergency contraception
Yuzpe method: 2 large doses of COCs (100ug estrogen and 100mg progestin-Ovral) 12 hours apart
Plan B (1.5 mg Levonorgestrel)
What is the advantage of Plan B over Yuzpe?
More effective
Less side effects (N+V)
What percentage of women who have taken Plan B should have menstrual bleeding within 3 weeks?
98%
Does plan B interrupt an existing pregnancy?
NO
Will not interrupt a pregnancy that has already implanted in the uterine lining
During what time period is Plan B effective?
Best within 72hr, but may use for up to 120 hrs
Within what time period is copper IUD effective for emergency contraception?
5-7 days
How does Plan B work?
Suppresses or delays the LH peak, delaying or inhibiting ovulation
Disrupts follicular development
Interferes w/ maturation of the corpus luteum
What are contraindications to Plan B?***
Current pregnancy
Hypersensitivity to component of product
Undiagnosed abnormal genital bleeding (r/o pregnancy before giving Plan B)
What type of contraceptive should you use in thromboembolic disease?
Progestin only
What type of contraceptive should you avoid in epilepsy?
Avoid triphasic and ultra low pills in combination with anticonvulsants
What type of contraceptive should you consider in GI disease with malabsorption?
Non-oral methods
Can you use hormonal contraceptive in diabetes?
Yes if no vascular disease
What type of contraceptive should you use in SLE?
Combined OCP if no anti-cardiolipid Ab and thrombosis
What type of contraceptive should you use in patients on hemodialysis?
Progestin only
What type of contraceptive should you use in sickle cell?
DMPA-reduces acute sickle cell crisis by 70%
What drugs interact with OCPs?
Rifampicin Rifabutin Phenytoin Carbamazepine Topiramate Barbiturates Fosamprenavir
What are the the DSM V criteria for Bulimia Nervosa?
- Recurrent episodes of binge eating
- Recurrent inappropriate compensatory behaviours in order to prevent weight gain
- Binge eating and inappropriate compensatory behaviours both occur, on average, once a week for 3 months
- Self-evaluation unduly influenced by body weight and shape
- Disturbance not exclusively during episode of AN
Name 5 clinical signs suggestive of BN?
- Russell’s sign (calluses on dorsum of hand)
- Dental enamel erosion
- Parotid gland enlargement
- Edema
- Fluctuating weight (healthy/overweight)
What are the DSM V criteria for Binge Eating Disorder?
- Recurrent episodes of binge eating (more and out of control – same as with BN)
- Binge-eating episodes associated with at least 3 of:
i) Eating more rapidly than normal
ii) Eating until feeling uncomfortably full
iii) Eating large amounts of food when not feeling physically hungry
iv) Eating alone out of embarrassment at volume eating - Feeling disgusted with oneself, guilty, or depressed after eating
- Marked distress regarding binge eating present
- Binge eating occurs on average at least 1x/wk x 3 months
- No compensatory behaviours, no BN or AN
What are the DSM V criteria for Avoidant/Restrictive Food Intake Disorder (ARFID)?
- Eating/feeding disturbance manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one or more of following:
- Significant weight loss or in children, failure to gain
- Significant nutritional deficiency
- Dependence on enteral feeding/oral nutritional supplements
- Marked interference with psychosocial functioning
- Disturbance not better explained by lack of available food or an associated culturally sanctioned practice
- Eating disturbance does not occur exclusively during the course of AN or BN, and no evidence of disturbance in way body weight or shape experienced
- Not attributable to concurrent medical condition and not better explained by another mental disorder. When occurring in context of another condition, severity of eating disturbance exceeds that routinely associated with the condition
What are the medical complications of eating disorder?
Temperature
-Hypothermia (T<36.0), esp while sleeping
Cardiovascular
Refeeding Syndrome
Fluids/Electrolytes
Osteopenia
Impaired linear Growth
Endocrine
GI
Neurologic
What are the cardiac complications of eating disorders?
•Electrocardiographic –Sinus bradycardia –Prolonged QTc •Orthostatic changes •Hypotension •Poor myocardial contractility •Mitral valve prolapse •Reduced LV thickness and mass •Silent pericardial effusion •Congestive failure (aggressive fluid rehydration ) •Cardiomyopathy - ipecac abuse
Admission criteria for anorexia nervosa
•Weight ≤75%-80% expected •Dehydration •Electrolyte disturbance •Cardiac dysrhythmia •Physiologic instability –HR<50, BP<80/50, T<36, extreme orthostatic changes (HR change >35 bpm, BP change > 20 mmHg) •Acute food refusal •Uncontrollable binging and purging •Suicidal ideation
How quickly does QTc correct with refeeding?
3 days
What are risk factors for refeeding syndrome
–Low weight (less than 70% of IBW)
–Rapid weight loss
–Low levels of phosphate, potassium or magnesium prior to refeeding
–Limited nutritional intake for 5-10 days preceding refeeding
What are the clinical features of refeeding syndrome?
- Low PO4, K, Mg
- Cardiovascular collapse (1st week)
- Delirium (2nd week)
Why do you get hypophosphatemia in refeeding syndrome?
Total body depletion of PO4
Shift into intracellular space with refeeding
How do you treat refeeding syndrome?
Slow feeding (start <1500 kcal/day, or at intake patient reports and increase 250 kcal/day)
Monitor electrolytes BID/OD
Oral phosphate supplementation (IV if critically low or symptomatic)
Are patients with AN at increased risk of morbidity/mortality from bacterial infections in AN?
YES
–Unable to mount and sustain immunologic response
–No/little febrile response
Name three GI complications of Anorexia nervosa
Delayed gastric emptying
Slowed GI motility
–Causes bloating, early satiety, and constipation with refeeding
–Improves with refeeding (takes several weeks)
Constipation
SMA syndrome
–life-threatening
–Compression of 3rd portion of duodenum by abdominal aorta & overlying superior mesenteric artery
–Due to lack of retroperitoneal fat cushions duodenum
What are the GI complications of bingeing and purging?
–Gastric dilation and rupture –Esophageal rupture –Rectal prolapse –Mallory-Weiss tear –GERD
Why do patients with AN get osteoporosis?
–Poor nutrition (protein, Vit. D, calcium)
–Amenorrhea (low estrogen)
–High cortisol
–Low IGF-1
Why do patients with AN have impaired linear growth?
GH resistance
What are risk factors for osteopenia in EDs?
- Low weight or absence of weight gain for prolonged period of time
- Early onset of amenorrhea
- Long duration of amenorrhea
- Low protein intake
- Low calcium intake
- Smoking
How do you treat osteopenia in AN?
Primary treatment is weight restoration to a level where menses resumes •Additional treatments: –Calcium 1300 mg/day –Vitamin D 600 IU/day (1000 IU?) –Cautious weight-bearing exercise? –Do not use OCP!
What are the endocrine complications of AN?
- Amenorrhea (due to hypothalamic suppresion)
- Decreased peripheral conversion of t4 to t3 (sick euthyroid)
- High cortisol
What are the hematologic complications of AN?
- Anemia
- Leukopenia
- Thrombocytopenia
What is the initial medical management of ED?
•ABCs
•Cardiac monitor if unstable
•Warming blanket prn
•Electrolyte replacement and regular monitoring if necessary
•Cautious use of iv fluids
•Feeding:
–Start slow if at risk for refeeding syndrome
–Liquid nutrition supplement (e.g. Resource, Ensure, etc.) may be easiest in acute setting
What type of therapy is recommended for EDs?
Family based therapy
List 6 things you should educate parents with EDs about (from CPS)
- Not their fault
- AN a serious condition that probably would not improve without treatment
- Be angry at ED but not at child
- Parent must take charge of child’s eating, exercise, and weight gain
- Supervise 3 meals, 2-3 snacks daily
- Weight restoration first, thoughts/attitudes take longer
What does gram stain for gonorrhea show?
Intracellular gram negative diplococci
What is the most specific test for gonorrhea?
Culture
–Most specific
–Allows for susceptibility testing
–Use for legal cases (abuse/assault)
What is the most sensitive test for gonorrhea?
NAAT
What are the complications of gonorrhea in females?
PID Infertility Ectopic pregnancy Chronic pelvic pain Perihepatitis (Fitzhugh Curtis Syndrome) Reactive arthritis (more common with chlamydia) Disseminated GC infection (DGI)
What are the complications of gonorrhea in males?
Epididymo-orchitis
Reactive arthritis
Infertility (rare)
DGI
How do you treat gonorrhea?
Cefixime (Suprax) 800 mg po single dose OR Ceftriaxone 250mg IM single dose
+
Azithromycin 1gm PO single dose OR
Doxycycline 100mg PO bid x 7 days
Pen allergy: Spectinomycin 2 g IM single dose or Azithromycin 2g po single dose
What percentage of chlamydial infections are asymptomatic?
Most are asymptomatic!
40% - 70% of infections are asymptomatic (50% of males, 70% of females)
What are the complications of chlamydial infection?
Sequelae similar to GC (except DGI!)
How do you diagnose chlymadial infection?
- NAATs for diagnosis
* Use culture for medico-legal issues
What is the treatment for chlamydia?
Azithromycin 1 gm single dose
or
Doxycycline 100 mg bid x 7d
What follow up tests should you do for GC/chlamydia?
- Test of cure for high risk groups (pre-pubertal, pregnant) or if you think treatment ineffective (non compliance, alternative treatment)
- Repeat testing in 6 months as reinfection rate high
How do you test for cure in GC/chlamydia?
Can repeat culture in 4-5 days
NOTE: NAATs stay positive for 3-4 weeks
What are the signs/symptoms of primary HSV infection?
Blisters or sores in genital area
Local swelling and pain
Inguinal lymphadenopathy, Systemic symptoms (1st infection)
How do you diagnose HSV infection?
Swab or scraping of lesion for viral culture, NAAT or EM
Serology for abs
How is primary HSV defined serologically?
1st episode of genital herpes in patient without antibodies for HSV 1 or 2
How is non primary 1st episode of HSV defined serolgoically?
First outbreak HSV2 in patient with Ab for HSV1)
How do you treat primary genital HSV?
–Acyclovir 400 mg tid x 7-10 days OR Famciclovir 250 mg tid x 5 days OR Valacyclovir 1000 mg bid for 7-10 days –May require oral and/or topical analgesics –Start within 5 days for any benefit -Best to start within 12 hours of first lesion
How do you treat recurrent genital HSV?
Valacyclovir 500mg BID or 1000mg OD for 3 days OR Famciclovir 125mg BID 5 days OR Acyclovir 200mg 5X/day for 5 days
What types of HPV are associated with cervical cancer?
HPV 16, 18
Over what time period do the majority of HPV infections clear?
18 months
How do you treat HPV warts?
Imiquimod (Aldara)
Cryotherapy
Podophyllin/podofilix Trichloroacetic acid
Laser
What serotypes are covered by the HPV vaccine?
Gardasil-HPV types 6,11,16,18
Newer vaccine covers 9 types-16, 18, 31, 33, 45, 52, 58, 6, 11
Who is eligible for the HPV vaccine?
Females 9-45 years and males 9-26, at 0, 2, and 6 months
Ideally given between ages 9-13, prior to onset of sexual activity
What are the guidelines for cervical cancer screening?
Sexually active women starting at 21 years
Every 3 years
What is the differential diagnosis of genital lesions?
Herpes HPV Molluscum Primary syphilis (chancre) Chancroid (Haemophilus ducreyi) ‘Pearly papules’
What are the diagnostic criteria for PID?
•Sexually active females with lower abdominal pain and no other cause for illness PLUS any one of: –Adnexal tenderness –Cervical motion tenderness –Uterine tenderness (DON’T NEED ALL THREE!)
•Additional Criteria Which Increase Specificity of diagnosis:
–Fever (>38.3 po)
–Many WBCs on saline microscopy of vaginal fluid
–Elevated ESR
–Elevated CRP
–Lab documentation of cervical infection with GC or CT
List 5 complications of PID
- Chronic pelvic pain
- Ectopic pregnancy
- Tubal factor infertility
- Perihepatitis (may present with RUQ as 1st sx)
- Tubo-ovarian abscess
What are indications for inpatient management of PID?
–Surgical emergency cannot be excluded (e.g. appy) –Patient pregnant –No response to po –Cannot tolerate po –Severe illness with n/v –Tubo-ovarian abscess
What is the inpatient treatment of PID?
Cefoxitin 2gm IV q6hr + Doxycycline 100mg PO or IV q12 hrs (PO doxy preferred)
–Alternate = Clinda + Gent
Can D/C 24 hours after resolution of symptoms
Need to complete Doxycycline x 14 days total
+/- metronidazole 500 mg PO BID x 14 days
What is the outpatient treatment of PID?
Ceftriaxone 250mg IM x 1 + Doxycycline 100mg PO BID x 14 d
+/- metronidazole 500 mg PO BID x 14 days
What is the infectious ddx of vaginitis?
BV
Candidiasis
Trichomoniasis
What are risk factors for BV?
Sexually active
New sexual partner
IUD use
What are risk factors for candidiasis?
Sexually active Recent antibiotic use Pregnancy Steroids Poorly controlled diabetes Immunocompromised
What are risk factors for trichomonas?
Multiple partners
What are the symptoms/signs of BV?
Vaginal discharge
Fishy odor
50% asymptomatic
White, grey, thing copious d/c
What are the symptoms/signs of candidiasis?
Vaginal discharge Itch External dysuria Superficial dyspareunia 20% asymptomatic White, clumpy d/c Erythema/edema of vagina/vulva
What are the symptoms/signs of trichomonas?
Vaginal discharge Itch Dysuria 10-50% asymptomatic Off white discharge Erythema vulva, cervix Strawberry cervix
What is the vaginal pH in BV, candidiasis, trich?
BV-pH >4.5
Candidiasis-pH<4.5
Trich-pH<4.5
What is the wet mount/gram stain for BV, candidiasis, trich?
BV-clue cells, gram -ve coccobacilli/curved bacilli
Candidiasis-budding yeast, pseudohyphae
Trich-motile flagellated protozoa
Which cause of vaginitis has a positive whiff test?
BV
How do you treat BV?
–Metronidazole 500 mg po BID x 7 d
–Metronidazole gel 0.75% 5 g intravaginally OD x 5 d
How do you treat candidiasis?
–Intravaginal OTC azole cream (clotrimazole)
–Fluconazole 150 mg OD x 1 dose (not in pregnancy)
How do you treat trichomonas?
–Metronidazole 2 g po x 1 dose
What are the DSM V criteria for substance use disorder?
Need 2 of:
- Take substance in larger amounts and over longer time than initially intended
- Express persistent desire to cut down/regulate use but may have multiple unsuccessful attempts
- Spend great deal of time obtaining, using or recovering from substance
- Craving, particularly in environment where drug previously used/obtained
- Recurrent use results in failure to fulfill major role obligations
- Continued use despite persistent or recurrent social/interpersonal problems caused/exacerbated by use
- Give up activities because of use
- Recurrent use in situations in which it is physically hazardous
- Continued use despite knowledge of having a persistent/recurrent problem caused/exacerbated by the substance
- Tolerance
- Withdrawal
What are risk factors for substance use amonst youth
Street involved Mental health disorder Gay, lesbian, bisexual, transgendered Family history of substance abuse Family dysfunction
What are signs and symptoms suggesting adolescent may have substance abuse problem
Home or social life
- Stealing momeny and stealing and selling valuable items
- Withdrawing from usual activities
- Not telling family member where he or she is going
- Having problems with law
School
- Drop in grades, poor academic performance
- Missing/skipping school
- Sleeping in class
- Not doing homework
- Dropping out of sports or other extracurricular activities
- Memory or concentration problems
Emotional
- Unexplainable mood swings and behaviour
- Feeling unhappy or depressed
- Feeling suspicious or anxious
Physical
- Bloodshort eyes
- Prolonged cough, nasal stuffiness
- Persistent tiredness
- Losing/gaining weight
- Change in appetite
What is the CRAFFT screen for substance abuse?
C: Have you ever ridden in a CAR driven by someone impaired?
R: Do you use drugs to RELAX or fit in?
A: Do you use drugs ALONE?
F: Do you ever FORGET things you did while using drugs?
F: Do your family or FRIENDS tell you to cut down?
T: Have you gotten in TROUBLE while using drugs?
2+ positive answers indicate a need for further assessment
What are acute complications of ecstasy?
Hyponatremia (polydipsia)
Seizures
Hyperthermia
Rhabdomyolysis
What are the acute complications of crystal meth?
Chest pain
Hyperthermia
HTN
Tachyarrythmias
What are the acute complications of cocaine?
Chest pain HTN Tachyarrythmias Intracranial bleed Stroke
What are the acute complications of GHB?
Resp depression
Coma
Seizures
What are signs of inhalant abuse?
Odour on breath
Stain, paint, glitter on skin or clothing
Perioral dryness or pyoderma (Huffer’s rash)
Facial, oral/nasal, esophagopharyngeal freezing or burning
Edema of lips, oropharynx, trachea
Neurophysiologic impairment – confusion, moodiness, irritability
Pulmonary toxicity – wheezing, emphysema, dyspnea
Poor hygiene, weight loss, fatigue, nosebleeds, conjunctivitis, muscle weakness, nausea, apathy, poor appetite, GI symptoms, changes in school attendance or psychological/psychiatric changes
What are the long term effects of inhalant use?
Drastic and irreversible neurological effects
–Brainstem dysfunction
–Motor, cognitive and sensory deficits
–Signs may include irritability, tremor, ataxia, nystagmus, slurred speech, decreased visual acuity and deafness
•Cardiomyopathy
•Distal RTA
•Hepatitis
•Dyspnea, emphysema
•Bone marrow toxicity leukemia, aplastic anemia
•Teratogenic
Name 4 causes of death in inhalant abuse
Respiratory arrest from CNS depression
Sudden sniffing death syndrome – likely due to primary cardiac arrhythmia
•inhalants disrupt myocardial electrical propagation (enhanced by hypoxia)
•sensitize heart to adrenaline (death after startle or with vivid hallucinations)
Dangerous behaviour from disinhibition and feeling of invincibility
Aspiration, suffocation
What are strategies to help adolescent transition to adult care?
- See teens without parents
- Adolescent involvement in management of the condition
- Foster personal autonomy and independence
- Educational, vocational and future financial planning
- Provide books, newsletters and magazines that deal with youth issues and youth living with health conditions
- Peer-support
- Family or teen education days
- A formal acknowledgement of ‘graduation’
- Give a transition letter
What is the greatest risk factor for re-attempting suicide?
Homosexuality
Adverse effects of anabolic steroid use
Cardiovascular: Coronary heart disease Cardiomyopathy Erythrocytosis Hemostasis/coagulation abnormalities Dyslipidemia Hypertension
Infection
HIV, hepatitis B and C, MRSA
Unsafe needle practices
Musculoskeletal
Tendon rupture
Neuropsychiatric
Major mood disorders
Aggression, violence
Dependence
Men (reproductive)
Hypogonadism (following withdrawal)
Gynecomastia
Acne
Premature epiphyseal closure (when taken before completion of puberty)
Prostate (potential increased risk for cancer)
Women (reproductive)
Acne
Virilization (hirsutism, deepening of voice, clitoromegaly)
Irregular menses
Hepatic (only with oral 17-alpha-alkylated androgens)
Cholestasis
Peliosis hepatis
Hepatic neoplasms
What is the best contraceptive option for a patient with developmental delay?
84 day OCP
Not IUD because involves procedure with sedation, irregular menses 3-6 months
What is the most dangerous complication of anorexia?
Hypokalemia
When can a patient become sexual active again after being treated for chlamydia?
7 days after patient and their partner treated
What dangerous ingredient is present in energy drinks?
Guarana (plant-based concentrated caffeine)
Why are progestin only pills not frequently used for contraception in adolescents?
Requires strict adherance for efficacy (ovulation is suppressed in only 50% of cycles)
Irregular spotting patterns
What is the first line recommendation for contraceptives for teens?
Mirena IUD
Spot diagnosis: https://pedclerk.bsd.uchicago.edu/sites/pedclerk.uchicago.edu/files/uploads/001-002Adenoma_sebaceum_0.jpg
Adenoma sebaceum (tuberous sclerosis)
What is the peak time for parental conflict in adolescents?
Mid adolescence
What are the clinical features of cannabanoid hyperemesis syndrome?
Cyclic vomiting
Relief with hot shower
When do you repeat dosing in a patient taking Plan B who is vomiting?
If vomit within 60 minutes of dose
What are the DSM V for anorexia nervosa?
- Restriction of energy intake relative to requirements, leading to significantly low body weight in context of age, sex, development
- Intense fear of gaining weight or persistent behaviour that interferes with weight gain
- Disturbance in way in which one’s body weight/shape is experienced, or undue influence of body weight/shape on self-evaluation, or denial of seriousness of current low weight
What bloodwork abnormality do you see in bulimia with parotid gland enlargement?
Elevated amylase
When does the phosphate level nadir in refeeding syndrome?
Day 4
When will most patients with anorexia resume menses?
2kg above when they lost their menses
Within 6 months of achieving 90% IBW
What do most patients with anorexia die of?
1) Suicide
2) Arrythmias
What is the female athlete triad?
Amenorrhea
Decreased BMD
Disordered eating
What is the most common cause of missing school for female adolescent?
Dysmenorrhea
Is delayed sexual behaviour in adolescence is associated with strict parenting?
YES
What is the most common cause of menmetorrhagia in adolescent girls?
VWD
Anovulatory bleeding if just oligomenorrhea
Spot diagnosis: https://d1yboe6750e2cu.cloudfront.net/i/3bdd0a4fc9a9ae29e178b3b1646ef2d9c5eef70a
Clue cells (BV)
What would exclude a diagnosis of PID?
Absence of white cells in cervical discharge
The majority of teen pregnancies end in abortion-T/F
True
What is the best medication for ADHD in a patient with history of substance abuse?
Vyvanse-prodrug
At what SMR stage does menses usually start?
Stage 4
What is the difference between transfer and transition?
Transition is a process
Transfer is a one time event
List 2 indications for doing a workup for gynecomastia
- Lasting >2 years
- Diameter >=2 cm
- Prepubertal boy
Work up for pathologic gynecomastia
TSH Testosterone Estradiol hCG LH Prolactin if galactorrhea
What are the progesterone-related side effects of OCPs?
- Amenorrhea/intermenstrual bleeding
- Headaches
- Breast tenderness
- Increased appetite
- Decreased libido
- Mood changes
- Hypertension
- Acne/oily skin*
- Hirsutism*
- Weight gain
- Possible decrease in bone density
List 3 situations in which you would have to breech confidentiality
Permissive reporting:
1. Risk of imminent serious bodily harm or death to a person/group (imminent risk of suicide or homicide to identified person/group)
Mandatory reporting:
- Suspected child abuse/neglect <16 yo - to CAS (not to police)
- Impaired driving ability (e.g. teen with seizure) - to DMV
- Medical information is subpoenaed - to police/court
