Adolescent Medicine Flashcards
What are the diagnostic criteria for Adjustment Disorder
DSM 5 Criteria for Adjustment Disorders
A. The development of emotional or behavioural symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor
B. These symptoms or behaviours are clinically significant as evidenced by one or both of the following:
1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account to the external context and the cultural factors that might influence symptom severity and presentation 2. Significant impairment in social, occupational, or other important areas of functioning
C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a pre-existing mental disorder
D. The symptoms do not represent normal bereavement
Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months
What are some reasons (as per CPS) that early detection of pregnancy may be delayed?
- Many deny the possibility of pregnancy even to themselves
- Complex social situations may make it difficult to openly address the prospect of pregnancy
- Normal menstrual irregularities or early adolescence can mask pregnancy
- Blood hCG can be detected 6 days post conception
- Urine hCG 10-14 days post conception
What termination options are available to teens re: pregnancy?
• Physician has a responsibility to refer adolescent if not comfortable managing
“At the patient’s request, the physician should indicate alternative sources for referral and there should be no delay in the provision of abortion services” - JOGC 2012
• Medical abortion - methotrexate and misoprostol
○ Limited evidence about its use in the adolescent population
• Surgical abortion - risks include uterine perforation, bleed and infection (low)
• Should provide
○ Information about the procedures
○ Anticipatory guidance about emotional responses
○ Referral to appropriate medical and surgical services
Follow up after the first 48 hours - screen for complications, emotions, contraception
What are 4 risk factors for developing alcohol abuse?
Family: Low supervision, poor parent teen communication, conflict, severe/inconsistent discipline, parent with alcohol/drug problem
Individual: Poor impulse control, emotional instability, thrill seeking, behaviour problem, perceived risk of drinking low, drinking onset <14yo
EtOH + caffeine: Allows more EtOH to be consumed (less sedation)
What questions can you ask to screen for alcohol abuse?
CRAFFT Questionnaire:
○ Have you ever ridden in aCar driven by someone (including yourself) who was high or had been using alcohol or drugs?
○ Do you ever use alcohol or drugs toRelax, feel better about yourself or fit in?
○ Do you ever use alcohol or drugs while you are by yourself (Alone)?
○ Do you everForget things you did while using alcohol or drugs?
○ Do your Family orFriends ever tell you that you should cut down on your drinking or drug use?
○ Have you ever gotten intoTrouble while you were using alcohol or drugs?
What are 3 principles in managing substance/alcohol abuse?
○ Individual or group counseling
○ Offer mental health services
○ Understand that drug abuse recovery may involve multiple relapses
○ Regular attendance in post-treatment groups
○ Counsel parents if parental use
What are the contraindications to starting OCPs?
ABSOLUTE CONTRAINDICATIONS
• < 6 weeks postpartum if breastfeeding
• smoker over the age of 35 (≥ 15 cigarettes per day)
• hypertension (systolic ≥ 160mm Hg or diastolic ≥ 100mm Hg)
• current or past history of venous thromboembolism (VTE)
• ischemic heart disease
• history of cerebrovascular accident
• complicated valvular heart disease (pulmonary hypertension, atrial fibrillation, history of subacute bacterial endocarditis)
• migraine headache with focal neurological symptoms
• breast cancer (current)
• diabetes with retinopathy/nephropathy/neuropathy
• severe cirrhosis
• liver tumour (adenoma or hepatoma)
RELATIVE CONTRAINDICATIONS
• smoker over the age of 35 (< 15 cigarettes per day)
• adequately controlled hypertension
• hypertension (systolic 140–159mm Hg, diastolic 90–99mm Hg)
• migraine headache over the age of 35
• currently symptomatic gallbladder disease
• mild cirrhosis
• history of combined OC-related cholestasis
users of medications that may interfere with combined OC metabolism
How do progestin-only methods work?
• MOA: Thicken cervical mucous :. Block sperm entry (within 2d of starting)
○ Atrophic endometrium :. Amenorrhea OR less blood loss
○ (Implants/injectable suppress ovulation)
• Counseling:
○ Bleeding irregularities for 3-6mo
○ Pills less reliable at inhibiting ovulation & typical failure rate of 9%
○ “Moderately effective” (Tier 2) contraceptive
If >3h late, need backup method
What are some potential side effects of progestin-only methods?
- Spotting is the most common side effect
- Amenorrhea
- Potential decreased bone mineral density
- Weight Gain
- Delayed return of fertility
- Worsening acne
What is the DSM-V diagnostic criteria for Anorexia Nervosa?
1) Restriction of energy intake relative to requirements leading to significantly low body weight in context of age, developmental trajectory, and physical health
a. Significantly low weight: weight that is less than minimally normal or for children and adolescents
2) Intense fear of gaining weight or becoming fat OR persistent behaviour that interferes with weight gain, even though at a significantly low weight
3) Disturbance in the way 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
Indications for hospitalization of ED patients
- HR < 50 beats/min
- Cardiac rhythm disturbances
- BP < 80/50 mm Hg
- Postural hypotension resulting in a >10 mm Hg drop or a >25 beats/min increase
- Electrolyte abnormalities: hypokalemia, hypophosphatemia
- Hypoglycemia
- Dehydration
- Body temperature < 36.1°C (97°F)
- <80% healthy body weight
- Hepatic, cardiac, or renal compromise
PSYCHIATRIC
- Suicidal intent and plan
- Very poor motivation to recover (in family and patient)
- Preoccupation with ego-syntonic thoughts
- Coexisting psychiatricdisorders
MISCELLANEOUS
- Requires supervision after meals and while using the restroom
- Failed day treatment
What are some potential causes for gynecomastia?
- Medications: spironolactone, androgens, estrogens, certain ACEi, ketoconazole
- OTC products: tea tree oil, lavender oil, soy products
- Illicit substances: marijuana, opioids
- Genetic conditions: klinefelter’s syndrome
- Neoplasms: germ cell tumours
- Idiopathic: familial, weight gain
Treatment options for gynecomastia?
- Watch/wait - familial
- Weight loss
- Surgery
- Symptomatic treatment i.e. chest binders
- Anti-estrogens for severe or very tender cases (must start within first 12 months)
What are some acute adverse effects in Marijuana use?
- Anxiety and panic, especially in naïve users
- Psychotic symptoms (at high doses)/hallucinations – can get flashback of them with stress/fever
- MVC
- Impaired short-term memory, loss of critical judgment, decreased coordination, distortion of time perception
- For synthetic marijuana, toxicity with ++ sympathomimetic: N/V, tachy, HTN, hyperthermia, confusion, ++anxiety, ++sweating, agitation, aggression, dysphoria, hallucinations, seizure, rhabdo, dystonia, unresponsive, confusion, myocardial ischemia
What symptoms are seen in acute withdrawal syndrome related to marijuana use?
• Withdrawal syndrome (24-48h after stopping): malaise, irritability, agitation, insomnia, drug craving, shaking, diaphoresis, night sweats, GI disturbance (in heavy users)
→ start 24-48h → peak 4d → resolve 10-14d
What are chronic adverse effects seen in marijuana use?
- Cannabis dependence syndrome (1 in 10 users)
- Chronic bronchitis and impaired respiratory function (sinusitis, pharyngitis, bronchitis, asthma) in regular smokers
- Psychotic symptoms and disorders in heavy users, especially those with a personal or fmhx
- Impaired educational attainment in adolescents who are regular users
- Subtle cognitive impairment in those who are daily users for 10 yr or more
- > Anxiety/depression, learning problems, truancy, poor job performance, hyperemesis
- ?Amotivational syndrome (lose interest in age-appropriate behaviours; not proven)
Which contraceptive method is considered first line by CPS?
• Long-acting reversible contraceptives i.e. IUD
What are examples of each tier of contraceptive method?
- First tier - IUD, copper IUD, subdermal progestin implant
- Second tier - OCP, vaginal ring, hormonal patches
- Third tier - condoms (male/female), withdrawal, cycle tracking, sponge, spermacides, diaphragms
What counselling should be provided around Emergency Contraceptive methods?
- Work best when used as soon as possible after sexual contact (within 72 hours), but can be used up to 120 hours after
- Copper IUD can be inserted as late as 7 days after sexual contact
- All women should have STI screening done
- All women should have a follow up pregnancy test if their period is >1 week late from expected date or if it is unusual in any way
