Adolescent Medicine and Sexual Health Flashcards
For which STIs should sexually active girls be screened annually?
Chlamydia trachomatis and Neisseria gonorrhoeae
The U.S. Preventive Services Task Force recommends annual screening for both Chlamydia and gonorrhea in sexually active women 24 years of age and younger. The data is insufficient to make strong recommendations in males, but if a male presents with high-risk sexual contact history, it makes clinical sense to screen him as well.
A sexually active 17-year-old girl presents with:
- Right upper quadrant abdominal pain
- Vaginal discharge
- Fever
- She started her menses today.
What is the most likely diagnosis?
Perihepatitis (Fitz-Hugh-Curtis Syndrome)
Perihepatitis is due to Neisseria gonorrhoeae, Chlamydia trachomatis, and/or a mixed polymicrobial infection. It is a complication of pelvic inflammatory disease in ∼ 10% of cases. The inflammatory process is thought to ascend from the fallopian (uterine) tubes along the paracolic gutters to the right upper quadrant. There are minimal, if any, abnormalities of liver function tests. Diagnostic laparoscopic findings include purulent and fibrinous inflammation of the hepatic capsule.
A 16-year-old girl presents with:
- Homogenous, white vaginal discharge
- On wet mount microscopy, you see epithelial cells that appear granular and stippled with ragged borders.
- pH of vaginal fluid is > 4.5
- A fishy odor occurs when 10% potassium hydroxide (KOH) is placed on the vaginal discharge smear.
What is the most likely diagnosis?
Bacterial Vaginosis (BV)
The microscopic findings described are “clue cells”, which are the single most reliable predictor of BV. BV is a clinical syndrome due to the replacement of the normal vaginal flora (Lactobacillus) with anaerobes (Prevotellaand Mobiluncus), Gardnerella vaginalis, and Mycoplasma hominis. Although not a true vaginitis (in that it is not characterized by an inflammatory response of the vaginal mucosa), it is the most common cause of abnormal vaginal discharge.
What is the #1 cause of adolescent morbidity and mortality?
Motor Vehicle Accidents
Motor vehicle (automobile and motorcycle) accidents are #1. Homicides are #2.
A 15-year-old boy presents with:
- A left-sided mass that feels like a “bag of worms”
- The mass increases with Valsalva
- What is the most likely diagnosis?
Varicoceles
They are dilated scrotal veins and are usually idiopathic but can be secondary to intraabdominal masses, Hepatosplenomegaly, and other disorders. Surgery is necessary if the testicle has become hypotrophic on that side; so watch for loss of testicular volume (> 2 mL difference between the two testicles) or if the testicle fails to grow during puberty.
A 15-year-old boy presents with:
- A painless ulcer on his dorsal penis that is “punched out” with clean-appearing, sharp, firm, slightly elevated borders
- Bilateral regional lymphadenopathy
What is the most likely diagnosis?
Primary Syphilis
This is a classic description of a chancre, and it most likely is primary syphilis. Test him with a VDRL or RPR and then send specific antitreponemal tests to confirm. Treat primary syphilis (chancre) with benzathine penicillin G, 2.4 million units IM × 1 dose (if he weighs < 48 kg, dose with 50,000 units/kg IM).
A 17-year-old girl presents with:
- Bilateral painless parotid gland swelling
- Loss of tooth enamel
- Metabolic alkalosis
What is the most likely diagnosis?
Bulimia Nervosa (BN)
BN occurs in 1–4% of girls but <1% of boys. Patients with BN have recurrent episodes of binge eating during which they have feelings that they “lack control” of their eating behavior. They regularly resort to self-induced vomiting, use diuretics and/or laxatives, fast, and overexercise to prevent weight gain. They have a persistent concern with their body shape/weight.
What is the organism responsible for chancroid?
Haemophilus ducreyi
It is a painful genital ulcer disease with unilateral inguinal lymphadenopathy.
A 15-year-old girl presents with dysmenorrhea. What is the likely mechanism for her pain?
Prostaglandin Production
It causes vasoconstriction and muscular contractions. Cyclooxygenase inhibitors like ibuprofen or naproxen work well to inhibit the symptoms. If the pain does not respond to ibuprofen and naproxen, then the pain is likely due to the lipoxygenase pathway instead. Oral contraceptives are helpful as well in reducing or eliminating dysmenorrhea.
A 16-year-old girl presents with:
- Diffuse, frothy, malodorous yellow-green vaginal discharge
- Dysuria
- Pruritus
- Vulvular irritation
- A “strawberry” cervix is seen.
What is the most likely diagnosis?
Trichomoniasis
Trichomoniasis due to Trichomonas vaginalis is classically asymptomatic in men but more commonly symptomatic in women. The “strawberry cervix” with the malodorous vaginal discharge, dysuria, and pruritus is a classic presentation. Treatment is metronidazole 2 g × 1 dose, or tinidazole 2 g × 1 dose, or metronidazole 500 mg 2×/day for 7 days. Treat women at any stage of pregnancy with metronidazole 2 g × 1 dose. Treat sexual partners.
A 16-year-old girl presents with:
- Diffuse, frothy, malodorous yellow-green vaginal discharge
- Dysuria
- Pruritis
- Vulvular irritation
- A “strawberry” cervix is seen
What is the most likely diagnosis?
Trichomoniasis
Due to Trichomonas vaginalis is classically asymptomatic in men but more commonly symptomatic in women. Treatment is metronidazole 2 g x 1 dose, or tinidazole 2 g x 1 dose.
What is the most common reason for secondary amenorrhea?
Pregnancy
It can also be an etiology for primary amenorrhea.
An adolescent boy presents with:
- Dizziness
- Dilated pupils
- Says he “sees smells” and “hears colors”
- Delusions that he is someone else
What illicit drug did he likely take?
LSD (Lysergic Acid Diethylamide)
It is a potent hallucinogen. Classically somatic symptoms (dizziness, dilated pupils, flushing) are 1st, followed by perceptual changes (e.g., “seeing smells” or “hearing colors”). Finally, psychic effects (delusional ideation, body distortion, psychosis) occur.
A pregnant teen presents in active labor. You note that she has active genital warts. She and her baby have no other issues.
Which type of delivery should she have?
Vaginal Delivery
Do not get genital warts confused with genital herpes. Mothers with active genital herpes lesions at the time of delivery require C-section. Genital warts at the time of delivery do not require C-section, although you still worry about possible complications in the newborn (e.g., laryngeal papillomatosis).
A 15-year-old boy presents with:
- A nodule above and posterior to the right testes
- There is no change with Valsalva
- The nodule transilluminates
What is the most likely diagnosis?
Spermatocele
It is a retention cyst of the epididymis containing spermatozoa and is located in the efferent ductal system. It presents as a nodule above and posterior to the testes. Spermatoceles do not affect fertility and do not usually require therapy.
A 15-year-old boy presents with a nontender fluid-filled mass in his right tunica vaginalis. What is the most likely diagnosis?
Hydrocele
Hydroceles are nontender and fluid-filled masses that collect between the parietal and visceral layers of the tunica vaginalis. You can evaluate with an ultrasound (particularly if associated with a hernia or testicular mass). Transillumination is also useful. Generally no treatment is necessary.
An 18-year-old college freshman presents with:
- Painless swelling of his left testicle that he noticed while washing himself
- You feel an irregularly shaped firm mass that does not transilluminate.
What is the best diagnostic test to perform at this point?
Complete Orchiectomy
Complete Orchiectomy with a peritoneal lymph node dissection is the best method of staging and diagnosis for presumed testicular cancer. Do not do a transscrotal CT-guided biopsy - this will just seed the path that the needle travels back out.
What is the most common organism to cause mastitis in an adolescent girl?
Staphylococcus aureus
Treat with antibiotics, heat, and analgesia.
What is the first sign of sexual development for girls?
Onset of Breast Budding
In most females, the onset of breast budding (thelarche) is the first physical sign of puberty. In the U.S., puberty occurs in Caucasian girls at a mean age of 10.0–10.4 years (range of 7.8–11.6 years of age) and for African American girls at a mean age of 8.9–9.5 years (range of 6.1–10.1 years of age). Puberty for girls generally lasts an average of 4 years (range of 1.5–8 years).
A 17-year-old girl presents with:
- Amenorrhea
- Galactorrhea
- Pregnancy test is negative
What is the most likely diagnosis?
Prolactinoma
It is rare in adolescence, but, if it occurs, it will present with amenorrhea and galactorrhea. Most prolactinomas are microadenomas and will not have symptoms of headache, etc.
What Body Mass Index (BMI) is considered to be the definition of obesity?
_> 95th Percentile
Obesity is defined as having a BMI > 95th percentile or having a BMI between the 85th and 95th percentile and one of the following: family history of premature heart disease, obesity, HTN, or DM; HTN themselves; cholesterol > 200 mg/dL; increase of _> 2 points in BMI in 12 months; or the adolescent is concerned about his/her weight.
What is the first sign of sexual development in boys?
Testicular Enlargement
Male sexual development generally begins at an average age of 11.6 years (range of 9.5–13.5 years of age), with the first physical sign of puberty being testicular enlargement. Onset of puberty occurs, on average, 6 months earlier for African American boys than for Caucasian boys. For boys, puberty usually lasts an average of 3 years (range of 2–5 years).
A 15-year-old boy presents with:
- Gradual pain at the upper pole of the left testis
- On exam, you feel a tender, pea-sized swelling at the upper pole of the testis, and a bluish hue is visible through the scrotum.
What is the most likely diagnosis?
Torsion of the Testicular Appendage
It affects the appendix testis or appendix epididymis. Pain can be sudden or gradual. Treat with analgesics and antiinflammatories. The torsion will resolve spontaneously in 2-12 days without surgery.
A 14-year-old girl presents with:
- Anxiety about the way her body looks
- Absence of 3 consecutive menstrual cycles
- Intense fear of becoming obese
- BMI < 5%
Anorexia Nervosa
Girls outnumber boys by 10:1, and anorexia Nervosa occurs in 1/100 girls.
A 15-year-old boy presents with:
- Acute onset of severe pain and swelling of his left testicle and inguinal area
- Nausea/vomiting
- Exam shows a diffusely swollen and tender left testicle and an absent cremasteric reflex.
What is the likely diagnosis?
Torsion of the Spermatic Cord
It is a surgical emergency! Urologic evaluation should be immediate.
A sexually active 17-year-old girl presents with:
- Right upper quadrant abdominal pain
- Vaginal discharge
- Fever
- She started her menses today
What is the most likely diagnosis?
Fitz-Hugh-Curtis Syndrome (Perihepatitis)
It is due to disseminated gonorrhea and is quite common, especially on Boards! Look out for disseminated gonococcal infection with tenosynovitis, dermatitis, and monoarticular arthritis (knee especially). Blood cultures can be positive but always do cervical and rectal cultures as well. Disseminated disease is treated with IV ceftriaxone.
Diethylstillbestrol (DES) was used in the 1960s and 70s and was associated with what type of cancer in the female offspring?
Clear Cell Adenocarcinoma
It can present with vaginal bleeding. Be on the lookout on Boards for this presentation in a girl born to a mom who took this drug during her pregnancy.
A teen with anorexia Nervosa is admitted and is placed on observed meals. Besides potassium and magnesium, what other electrolyte abnormality are you most concerned about with refeeding her?
Hypophosphatemia
This is classic for the refeeding syndrome. The body has been so poor in energy that refeeding overwhelms conversion of ADP to ATP and results in severe hypophosphatemia as phosphorus stores are depleted. Hypokalemia and hypomagnesemia also occur.
A 16-year-old girl presents with PID and will require inpatient therapy. She has anaphylaxis to cephalosporins. What 2 antibiotics should be used for her therapy?
Clindamycin and Gentamicin
Clindamycin 900 mg IV q 8 hours, plus gentamicin-loading dose of 2 mg/kg IV/IM, followed by a maintenance dose of 1.5 mg/kg q 8 hours.
A pregnant patient presents with signs and symptoms of secondary syphilis. She has anaphylaxis to penicillin. What is the best appropriate therapy?
Desensitize Her; Treat with Penicillin
Pregnant women with syphilis must be treated with IM penicillin. Other therapies are not as effective; also, doxycycline is contraindicated in pregnancy. If she is penicillin-allergy, the next step is to desensitize her and then proceed with penicillin therapy in appropriate doses depending on her stage of syphilis.
An adolescent with known history of substance abuse is arrested on a drunk driving charge and placed in jail. It has been about 6 hours since he has been held in the jail. He is now having noticeable yawning. What is one of the illicit drug categories that he likely uses?
Opiates (Heroin)
Opiate withdrawal occurs about 8 hours after the last exposure. One of the first signs is yawning. Then lacrimation, mydriasis, insomnia, “goose flesh,” diarrhea, and systolic hypertension occur. Diazepam is helpful for the withdrawal symptoms, but the patient should be managed in a professional setting.
A sexually active 16-year-old boy presents with:
- Urethral discharge
- Gram stain shows 10 WBCs/hpf with no organisms seen
What is the most likely diagnosis?
Chlamydia trachomatis Infection
Treatment is either azithromycin 1 g x 1 dose or doxycycline 100 mg bid x 7 days.
