Adolescent Medicine Flashcards
What is the age of consent in Canada?
Age of consent = 16 yrs
Close age exceptions:
- 14 - 15 yrs can consent to sex with someone up to 5 yrs older
- 12 -13 can consent to sex with someone up to 2 yrs older
- must not be in position of authority (teacher, coach)
What is the failure rate of:
Long acting reversible contraception, Depo-Provera, Pill/Ring/Patch
LARC - 0.2%
Pill/Patch/Ring - 9%
Depo-Provera - 6%
What are the benefits of OCPs
- low failure rate
- easier periods (shorter, less dysmenorrhea, predictable)
- easy to use
- improvement in acne
- few side effects (no weight gain, no acne)
What are the mild and serious side effects of OCPs
Mild:
- breast tenderness
- breakthrough bleeding
- nausea
- headache
Serious side effects:
-thrombosis: increase risk with smoking and age, increased risk with migraine with aura and migraine with focal neurologic signs
What to do if a patient on OCPs has:
1) Frequent breakthrough
2) Nausea
3) Headache
Frequent breakthrough - increase the estrogen
Nausea - lower the estrogen
Headache - use a monophasic pill, lower estrogen
What drug class interacts with OCPs
Anticonvulsants
- mean decrease efficacy of OC
- valproate is not affected
- use higher dose of pill
What are non-contraceptive benefits of OCPs
reduction in the following:
- blood loss, anemia
- PMS, dysmenorrhea
- acne, hirsutism
- certain cancers (endometrial, ovarian)
- ovarian cysts
- PID and future ectopic pregnancies
- benign breast disease (fibrocystic disease, fibroadenomas)
What is the #1 contraceptive type recommended by AAP
Long acting reversible contraception
Mirena IUD
- 99% effective
- lasts 5 yrs
- increased spotting for 3 - 6 months possible
- Progesterone only
- No increased risk PID
Jaydess IUD
- 3 yrs
- smaller
What are the side effects of Depo-Provera
-irregular bleeding for 3 - 12 months
-amenorrhea
-weight gain ( 4 - 15 lbs)
-Reduced bone density (steroids, eating disorders, chronic renal failure, anti-epileptic meds)
depression
-should prescribe concurrent Ca and Vit D
When is Depo-provera a good choice
- can’t reliably take pills
- estrogen is contraindicated (Depo has no risk of thrombosis)
- want amenorrhea
What are indications for emergency contraception?
- unprotected intercourse
- contraception failure
- near intercourse (ejaculation on genitals)
What is the contraceptive Ella
- type of emergency contraceptive
- selective progesterone receptor modulatory
- take once, need prescription
- up to 120 hours
- does not reduce efficacy over time
What are the side effects of Plan B
- progesterone only
- Nausea 23%
- vomiting 6%
What are the symptoms of Chlamydia?
Incubation:
-7 - 21 days
Common symptoms:
- none (60 - 80%)
- dysuria
- vaginal discharge
- abdo pain
- vaginal spotting (especially after sex)
Systemic symptoms (rare)
- joints
- eyes
What is the treatment for Chlamydia
Azithro - 1g po x 1 dose (treatment of choice in teens)
other 7 day regimens
- doxycycline
- erythromycin
- tetracycline
What are the symptoms of Gonorrhea
-less common than Chlamydia
Incubation
-3 - 5 days
Common symptoms:
- none (75 - 90%)
- discharge
- dysuria
- abdo pain
Systemic symptoms (rare)
- joints
- pharynx
- rectum
- eye
What is the treatment for Gonorrhea
**Have to treat for Chlamydia as well if Gonorrhea +
Option 1 : Ceftriaxone IM x 1 plus Azithro 1 g PO
Option 2: Cefixime PO x 1 plus Azithro 1 gm PO
What is the most common STI?
HPV
Quadrivalent vaccine offered to all females 9 - 26
What is the sequelea if PID untreated
- Ectopic pregnancy
- Chronic pain
- Infertility
How do you diagnosis PID?
Lower abdo pain PLUS either
- adnexal tenderness
- uterine tenderness
- cervical motion tenderness
(need to do a pelvic exam + bimanual to dx)
Increased specificity if also have
- fever > 38.3C
- discharge
- WBC on microscopy
- elevated ESR or CRP
- positive testing for GC or chlamydia
What is the treatment for PID? Outpatient
Ceftriaxone IM on a single dose PLUS Doxycycline PO BID x 14 days
-consider flagyl
When should you consider admission to hospital for PID
- concerns re adherence
- pregnancy
- failure to respond to oral txt
- severe illness, vomiting or high fever
- Tubo-Ovarian abscess
- HIV
Cefoxitin IV q6H Pluse Doxy IV or PO every 12 hours
How early does Brest develop precede:
Adrenarche
Menarche
Thelarche precedes adrenarche by 6 months and menarche by 2 yrs
What are common features of Mastalgia
- common complaint early in puberty
- benign, improves with time
- may be better or worse with OCP
- usually cyclical worsening prior to menses
- exam to r/o mass, infection
- advise tight fitting bra
- management - supportive and NSAIDS prn
What are the most common causes of Breast masses
- **benign fibroadenomas
- fibrocystic disease
other causes:
-trauma, abscess, lymph node
-less than 1% malignant
What is the difference between a Fibroadenoma and Fibrocystic disease
Fibroadenoma - solitary, painless, mobile no change with menstrual cycle
Fibrocystic disease - cystic mass (es), tenderness, worse prior to menses
Which province has an age of consent and what age?
-there is no formal age of consent in any province except Quebec (14 yrs)
What is the second most common cause of death in teenagers
Suicide
-90% associated with psychiatric diagnosis
Who is at risk for suicide? (9)
- males
- access to firearms
- past suicide attempt
- exposure/family hx
- bullies/being bullied
- substance abuse
- bipolar disorder
- intent/plan/means
- sexual minority youth
What is the difference between substance Abuse and Dependence
Abuse: adverse consequences related to use:
- missing school
- unplanned sexual activity
- conflict with parents
- negative health consequences
Dependence
-tolerance - increased amount for deisred effect
withdrawal - withdrawal effects when substance discontinued
-drug or related substance is taken to relieve or avoid withdrawal symptoms
What are common risk behaviours? (7)
- defiance of family rules
- truancy
- sexual experimentation
- smoking
- not using seat belts, bike helmets
- shoplifting, bullying
- substance use
-risk behaviours cluster - if you have one you probably have others
How do you approach risk reduction
- reduce the complications of risky behaviours
- may or may not include abstinence from the behaviour
- doesn’t label a behaviour as good or bad
- discuss the negative consequences of a behaviour and work to reduce the consequences
- takes into account normal adolescent development and decision making
Causes of abnormal uterine bleeding?
- immature hypothalamic pituitary - ovarian axis
- weight changes, disordered eating or excessive exercise
- endocrinologic causes (Thyroid disease, PCOS)
- complication of pregnancy (threatened abortion, postpartum or postabortal endometritis)
- infection: cervicitis, condyloma, PID
- trauma: sexual assault
- vaginal foreign body
- hematologic causes: vWD, plt function disorder
- medications: estrogen, progestin
- anatomic: partial obstruction of vagina or uterus causing asynchronous bleeding, cervical or endometrial polyps or myomas, hemangioma
- systemic disease
What are factors that impact adherence? (3)
- Age - teens less adherent
- psychosocial risk (unstable family, mental illness, learning or attentional problems)
- chronic conditions (illness less immediate or noticeable)
How can you improve adherence? (7)
- simplify
- once daily dosing
- long acting meds
- no treatment during school day
- take into account sleeping in on weekends and sleepovers with friends
- meds should not be associated with eating or not eating
- minimize side effects
Patient-physician relationship
- continuity of care
- friendly clinic space and staff
- time spent with their MD
- direct conversations about adherence
- be on time
- after school appointments
- their MD takes personal interest
How do you dx ARFID?
Avoidant/restrictive food intake disorder:
1) Eating or feeding disturbance associated with failure to meet nutritional needs and 1 of the following:
- weight loss or growth failure
- nutritional deficiencies
- dependence on enteral feeds or all liquid nutrition
- marked interference with psychosocial functioning
- no evidence of body image disturbance
- no medical illness to explain symptoms
What is the diagnosis of AN
A. restriction of energy intake relative to relative to requirements, leading to a significant low body weight in the context of age, ex, developmental trajectory and physical health
B. Intense fear of gaining weight or becoming fat or persistent behaviour that interferes with weight gain, even though at a significant low weight
C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight
How does DSM - 5 AN differ from previous
- the word “refusal” has been removed
- there is no specific weight criteria
- amenorrhea not necessary
How do you define Bulimia Nervosa
A. binge eating
- eating excessive amounts of food
- sense of lack of control during binge episodes
B. recurrent inappropriate behaviours to compensate for binge episodes (purging, laxative use, fasting, excessive exercise, insulin omission)
C. Episodes occur average 1/wk x 3 months
D. Self-evaluation is unduly influenced by weight and shape
E. does not meet criteria for AN
What’s the difference between Binge Eating Disorder and Bulimia Nervosa
-no compensatory mechanisms
What are the indications for hospitalization in AN
- Impaired growth and development
- severe malnutrition: weight 75 - 80% average body weight for age, sex and height
- arrested growth development - Fluid and Metabolic Abnormalities
- dehydration
- lyte disturbances - Cardiac abnormalities
- arrythmias
- severe brady HR < 50 daytime, < 45 at night
- hypotension (< 80/50)
- hypothermia (< 35.5C)
- orthostatic changes in HR (>20) or BP (> 10)
Behavioural
- acute food refusal
- uncontrollable bingeing and purging
- acute psychiatric emergencies
- comorbid dx
Severe effects of AN on organ systems?
1) Heart
- VT, prolong QTC, sinus bradycardia, low voltage
2) GI
- constipation, delayed gastric emptying, SMA syndrome, increased liver enzymes, pancreatitis
3) Interruption of Puberty
4) Affect on growth
5) Osteoporosis
6) Brain and cognitive changes
Physical signs of cannabis intoxication
- tachycardia
- increased BP or orthostatic hypotension
- increased RR
- conjunctival injection
- dry mouth
- increased appetite
- nystagmus
- ataxia
- slurred speech
- bronchospasm
Effects on sexual development
- small testes
- gynecomastia
