Adolescent Primary Care - Exam 1 Flashcards
1
Q
Puberty is defined as the development of __________ and the biologic process that ultimately leads to _________.
A
secondary sexual characteristics; fertility
2
Q
The hormonal regulatory systems in the (4) undergo major changes between the prepubertal and adult states
A
hypothalamus, pituitary, gonads, adrenal glands
3
Q
However, even though the timing and progression of adolescent development varies, the _______ is orderly
A
sequence of events
4
Q
________ refers to the psychosocial and emotional transition from childhood to adulthood and is influenced by social, genetic, and environmental aspects
A
Adolescence
5
Q
of tanner stages
A
5
6
Q
First non-visible physical change pf puberty
A
increase in ovary size
7
Q
First visible physical change of puberty
A
breast budding (thelarche)
8
Q
Thelarche
A
onset of breast budding
9
Q
Menarche
A
onset of menses
10
Q
Adrenarche
A
onset of pubic hair
11
Q
Average range for thelarche
A
8-13 yo (av. 10.3)
12
Q
Most females will experience breast budding ______ months before pubic hair and _________ years before menarche
A
6 months before pubic hair; 2-2.5 years before menarche
13
Q
Typically females have completed their linear growth spurt by age….
A
15yo
14
Q
Final height is determined by the amount of bone growth at the …
A
epiphyses of the long bones
15
Q
Breast budding (thelarche) begins as a result of _______ secretion
A
estradiol
16
Q
Average range for menarche
A
9-15 yo (av. 12.5)
17
Q
Body fat is an important mediator for the onset of menstruation and regular ovulatory cycles. An average of ____% of body fat is needed for menarche, and about ___% is needed to initiate and maintain regular ovulatory cycles.
A
17%; 22%
18
Q
First visible sign of puberty for males
A
testicular enlargement
19
Q
Average age of testicular growth for males
A
11.5 yo
20
Q
Growth of the testes occurs about _____ months before adrenarche for males
A
6 months
21
Q
If testicular enlargement does not precede other changes, the provider should consider whether the adolescent is….
A
taking exogenous anabolic steroids
22
Q
Once puberty begins, the ______ testis generally hangs lower.
A
left
23
Q
Most males finish linear growth by age…
A
17yo
24
Q
Between ________% of males experience gynecomastia, a transient benign unilateral or bilateral enlargement of breast tissue. Gynecomastia generally lasts _______ and resolves completely by late puberty in nearly all cases.
A
50% and 75%; 12 to 18 months
25
the process of psychosocial, emotional, and cognitive development in adolescents is a transition that is (2)
continual; typically smooth
26
disruptive family conflict is vs. is not the norm
is not
27
In adolescence, the quality of thinking changes from concrete to ....
formal operational
28
Type of thinking characterized by the use of propositional thinking and abstract reasoning
formal operational
29
teenagers acquire increasing sophistication in abstract thought after they are _______ years old
14 yo
30
As “mandatory reporters,” primary health care providers are required by law to report information that ....
puts the child or others in danger (i.e., physical or sexual abuse)
31
Some states require reporting teen sexual activity, even if consensual, if an age difference of _____ years or more exists between the two
3 years
32
Testicular growth can be directly assessed by palpation of the testes in the scrotum and comparison of their size with a standardized _________
orchidometer
33
HEEADSSS is a screener for....
risk taking behavior
34
What does HEEADSSS stand for
Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicidality, Safety
35
The biologic process that ultimately leads to fertility
puberty
36
(3) axes facilitating puberty
1) hypothalmic-pituitary-adrenal
2) hypothalmic-pituitary-gonadal
3) growth hormone
37
Screener for classifying stages of secondary sexual characteristics
Sexual maturity rating (SMR; aka Tanner stages)
38
Average length of puberty
1.5-8 years (av. 4)
39
Precocious puberty would describe onset of breast budding or pubic hair before age....
8yo in females; 10yo in males
40
Explain to parents at the ____yo visit that you will begin to speak privately with the adolescent at the next year's visit
11yo
41
Parental consent is needed to see any patient under the age of...
18yo (exceptions: emergencies, adoptive parents, emancipated minor, mature minor, abuse)
42
If an adolescent needs STI testing/contraceptives but does not want their parents to receive the itemized insurance bill, where should you send them?
public health department (free services)
43
How often/who should you screen for hypertension
everyone, annually
44
How often/who should you plot height and weight on the growth curve
everyone, annually
45
>___% percentile is considered obesity for adolescents
95%
46
AAP guidelines recommend screening lipids at ages ...
10yo and 20yo
47
How often/who should you screen for tuberculosis
at-risk, annually
48
How often/who should you screen for substance use
everyone, annually
49
Screening tool for substance abuse in adolescents
CRAFFT
50
What does CRAFFT stand for
Car, Relax, Alone, Forget, Friends/Family, Trouble
51
How often/who should you screen for depression
Ages 11-21, annually
52
Screener for depression in adolescents
PHQ2
53
Who should you do a pelvic exam with
sexually active or >20 yo, if requested, or if there are symptoms (pain, discharge, AUB)
54
Guidelines to check for up to date immunization schedules
ACIP (advisory committee on immunization practices)
55
What does Tdap/Dtap cover?
tetanus, diphtheria, acellular pertussis
56
Tdap vaccine schedule
initiate age 11, Td booster Q10 years
57
Meningococcal vaccine schedule
initiate age 11, booster age 16
58
2-dose HPV vaccine schedule
initiate age 11 (range 9-14) with 2 doses 6 months apart
59
3-dose HPV vaccine schedule
if age 15 or older at initiation, 3 doses at 0, 1-2 months later, and 6 months later
60
Number of HPV vaccine doses depends on....
age at initial vaccination
61
HPV vaccine is most effective if given when
before onset of sexual contact (younger patients achieve a better immune response)
62
HPV subtypes that most commonly cause cancer
16, 18
63
HPV subtypes that commonly cause genital warts
6, 11
64
The strongest motivator to vaccinate is ______, and the primary obstacle is _________
provider recommendation; lack of knowledge
65
The leading causes of illness and death among adolescents are largely....
preventable
66
Leading cause of death in developing countries (2)
road injuries, HIV/AIDS
67
Leading cause of death in developed countries (1)
mental health disorders, especially depression
68
(3) leading causes of death for adolescents ages 15-19yo
accidents, suicide, homicide
69
The proportion of adolescents who have ever had sex is trending.....
down (green)
70
The proportion of adolescents who have had 4 or more sexual partners is trending.....
down (green)
71
The proportion of adolescents who are currently sexually active is trending.....
down (green)
72
The proportion of adolescents who used a condom during last intercourse is trending.....
down (red) [but the STI lecture says increased]
73
The proportion of adolescents who used effective hormonal birth control and a condom is trending....
stable (yellow)
74
The proportion of adolescents who ever used or injected illicit drugs is trending....
down (green)
75
The proportion of adolescents who experienced depression and suicidality is trending....
up (red)
76
___% of adolescents who report being in excellent, very good, or good health
98%
77
High school enrollment is trending _____ while dropout rates are trending _______
up; down (green)
78
College enrollment is trending ....
up (green)
79
Poverty rate is trending....
stable (yellow)
80
% of adolescents who live in poverty
17.8%
81
Leading cause of death in adolescents ages 10-24 in the US
Motor vehicle accidents (18% mortality, 23-40% involved alcohol)
82
Second leading cause of death in adolescents ages 10-24 in the US
suicide (more deadly for males, more attempts for females)
83
Third leading cause of death in adolescents ages 10-24 in the US
homicide (82% from firearms, mostly males)
84
Exercise levels for adolescents are trending....
stable (yellow)
85
Sedentary activity (3 or more hours per day of television?) is trending....
down (green)
86
Obesity rates are trending.....
up (red; tripled)
87
% of adolescents who are overweight or obese in US in 2017
31%
88
(3) worrisome trends that are increasing in adolescents
hearing impairment, excess UV exposure, e-cig use
89
% of adolescents with a chronic condition
30%
90
Sensitivity of urine vs. cervical NAAT for chlamydia or gonorhrea
```
urine = 81% sensitive
cervix = 85% sensitive
```
91
How often/who should you screen for chlamydia and gonorrhea
sexually active people, annually
92
Who should you screen for syphilis
MSM, pregnant
93
How can you test for urethritis
UA with microscopy, urine GC/CT probe, urine or urethral culture
94
CDC recommended regimens for treatment of uncomplicated genital chlaymdia
Azithromycin 1g PO single dose (preferred); doxycycline 100mg PO BID x7 days
95
Clinical presentation of chlamydia-related urethritis in males
asymptomatic (>50%), or discharge (mucoid or clear) and dysuria
96
When you see urethritis in people and you don't know the underlying diagnosis yet, treat empirically for....
chlamydia/gonorrhea
97
Dx: Swollen, painful testicles with pain that goes away when you lift the scrotum
epididymitis
98
Epididymitis is usually caused by.... (2)
chlamydia/gonorrhea
99
Clinical presentation of chlamydia-related cervicitis in females
asymptomatic (70-80%), or mucopurulent endocervical discharge and edematous cervical ectopy with erythema and friability
100
Clinical presentation of chlamydia-related urethritis in females
asymptomatic, or dysuria, urinary frequency, and pyuria
101
Dx: Elevated liver enzymes, RUQ pain, NAAT positive for chlamydia
Fitz High Curtis Syndrome
102
Dx: Joint pain, hand pain, elbow pain, NAAT positive for chlamydia
Reactive arthritis
103
Treatment for LGV (lymphogranuloma venereum) lymphadenopathy
doxycycline 100mg BID x21 days
104
LGV (lymphogranuloma venereum) lymphadenopathy is caused by long-term infection with....
chlamydia
105
Classic presentation of gonorrhea-related urethritis in males
purulent white discharge from penis
106
Treatment regimen for gonorrea
Ceftriaxone 250mg IM one time AND azithromycin 1g PO one time (or doxycycline 100mg PO BID x7 days)
107
When should you re-test after treatment of gonorrhea/chlamydia
test of reinfection at 2-3 months after therapy
108
A gonorrhea/chlamydia NAAT will take at least ______ to become negative after resolution
4 weeks
109
50% of the time, if someone has a bartholin gland abscess they also have...
gonorrhea
110
Treatment for disseminated gonorrhea
hospitalization for IV antibiotics
111
Dx: Triad of tenosynovitis, dermatitis, and polyarthralgias + purulent arthritis with skin lesions, suspect....
disseminated gonorrhea
112
Treatment for disseminated gonorrhea
ceftriazone 1g QD and step down to cefixime PO x 7 days
113
How do you diagnose suspected disseminated gonorrhea
blood cultures, culture of the mucosal surfaces, NAAT urethral swab, tap the infected joint for culture
114
Adnexal tenderness is the most sensitive sign for....
acute salpingitis/PID
115
The CDC recommends treatment for suspected PID for ANY sexually active adolescent who presents with...
lower abdominal/pelvic pain AND
- CMT, or....
- adnexal tenderness, or...
- uterine tenderness
116
Treatment regimen for PID
ceftriaxone 250mg IM single dose AND doxycycline 100mg PO BID x14 days AND consider metronidazole 500mg PO BID x 14 days
117
How soon should you reassess after starting treatment for PID
within 72 hours (some need hospitalization)
118
Condyloma lata is caused by....
syphilis
119
Condyloma accuminata is caused by....
HPV
120
Treatment for pediculosis pubis
permethrin 1% cream
121
Main differences between a herpes vs. syphilis lesion (2)
herpes lesions are painful and multiple; and syphilis usually is not painful and solitary lesion
122
Are antibodies present at primary infection of HSV?
No, they are not present when symptoms appear but should be present upon later recurrence of symptoms
123
Clinical presentation of primary HSV infection
malaise, fever, burning with urination, herpes lesions on erythematous base that are more severe or bilateral. There may be vaginal or urethral discharge and or tender inguinal adenopathy
124
Lesion progression in HSV
papules > vesicles > pustules > ulcers > crusts > healed
125
How long does primary HSV infection typically last without treatment
2-4 weeks
126
Gold standard for diagnosis of herpes, though not often used in practice
viral culture (unroof a lesion for swab)
127
Treatment for primary genital HSV infection
7-10 day course of: Acyclovir 400mg TID, famicyclovir 250mg TID, or valacyclovir 1000mg BID
128
Benefits to antiviral therapy for HSV first episode
Compared with untreated disease, oral antiviral therapy decreases the duration and severity of disease by days to weeks (particularly among those with primary infection) with minimal adverse drug effects. It appears to reduce viral shedding (transmissability). However, treating the first episode of genital HSV does not eradicate latent virus
129
Preferred regimen for HSV suppressive therapy
valacyclovir 500 mg once daily
130
Most genital HPV infections are.... (3)
transient, asymptomatic, no clinical consequences
131
(2) low risk HPV types that cause genital warts
6, 11
132
(2) high risk HPV types that can cause cancer
16, 18
133
(5) ways HPV infection can present
asymptomatic; genital warts; cervical cell abnormalities; anogenital cancers; recurrent respiratory papillomatosis
134
Dx: genital warts with cauliflower-like appearance that are skin-colored, pink, or hyperpigmented
condyloma acuminata (HPV)
135
Diagnosis of HPV-related genital warts is usually a ______ diagnosis
clinical (visual inspection; biopsy can be used when diagnosis is uncertain, patient is immunocompromised, or persistent symptoms after treatment)
136
Treatment options for HPV genital warts
podophyllotoxin 0.15-0.5% solution at home every other day for 2-3 weeks; imiquimod 5% 3x weekly overnight; or in-office treatment with TCA acid or podophyllin
137
Dx: genital warts with smooth, rounded, moist surface
secondary syphilis
138
Dx: genital warts with central dimple, sparing the mucosal surfaces
molloscum contagiosum
139
Dx: Solitary, painless, indurated ulcer with clean base to genital area. On physical exam, found to have rubbery, painless, bilateral inguinal lymphadenopathy
primary syphilis
140
Primary syphilis will heal without treatment in ______ weeks
1-6 weeks
141
Secondary syphilis symptoms occur how long after primary infection
3-6 weeks
142
Most common manifestation of secondary syphilis
mucocutaneous lesions
143
Manifestations of secondary syphilis
rash (75-100%); lymphadenopathy (50-86%); malaise; mucous patches; condyloma lata; alopecia
144
Secondary syphilis is ALWAYS treated with ______: if they are allergic, go to hospital for densensitization
penicillin
145
Classic rash for secondary syphilis
palmar/plantar rash (nickle and dime rash of the hands and feet)
146
(3) types of NON-treponemal tests for syphilis
RPR, VDRL, TRUST (results are in titer form, positive or negative)
147
(3) types of treponemal tests for syphilis (diagnostic)
FTA-ABS, MHA-TP, TP-IgG (based on antibody response)
148
Diagnostic test of choice at VUMC for syphilis diagnosis
TP-IgG (treponemal IgG)
149
Treatment regimen of choice for syphilis
benzathine penicillin G 2.4 million units IM in a single dose
150
Dx: Pt presents with palmar/plantar nickle and dime rash, and tests positive for syphilis. You treat with penicillin in office. They return the next morning with fever, malaise, n/v. You suspect.....
jarisch-herxheimer reaction (occurs within 24 hours of treatment, is not an allergic reaction, will be self-limited)
151
According to ACOG, the initial reproductive health visit should take place between the ages of....
13-15yo
152
Psychiatric illness with the highest mortality rate in adolescents
anorexia nervosa
153
(3) DSM-5 criteria for anorexia nervosa (must meet all 3)
restriction of energy intake relative to requirements leading to significantly low weight; intense fear of gaining weight; disturbance in body image
154
(2) subtypes of anorexia nervosa
restricting; binging/purging
155
Definition of a binge
consumption of an excessive quantity of food accompanied by a loss of control followed by a feeling of distress
156
(4) DSM-5 criteria for bulimia nervosa
recurrent episodes of binge eating; recurrent compensatory behaviors to prevent weight gain (vomiting, laxatives, fasting, exercise); behaviors that occur at least 1x per week for 3 months; self-evaluation is influenced by body shape and weight
157
Individuals with a primary relative with an eating disorder have a _____x increased risk of developing an eating disorder
6-10x
158
During puberty, body fat levels are expected to ______ for males vs. females
```
males = decrease
females = increase
```
159
Screening tool for eating disorders
SCOFF
160
What does SCOFF screener stand for
Sick (vomit), Control, One stone (15 lbs in 3 months), Fat, Food
161
Abrasions of the proximal knuckles is called....
russel's sign (purging, vomiting)
162
Initial laboratory assessment for suspected eating disorder
CBC, electrolytes, TSH, LFTs, kidney function, beta HCG, UA
163
Metabolic _______ is often seen in eating disorders
metabolic acidosis
164
First line therapy for anorexia
family based therapy
165
First line therapy for bulimia
CBT
166
FDA-approved medication for bulimia
fluoxetine (SSRI; can decrease frequency of binge-purge cycle)
167
Estrogen replacement role in eating disorders
Can restore menses but does not improve bone mineral density
168
Reasons to hospitalize someone with an eating disorder
severe malnutrition (weight < 75% expected), ongoing weight loss despite treatment, dehydration, electrolyte abnormalities, syncope, bradycardia, hypothension (SBP <90), orthostatis, refusing food, uninterrupted binge-purge cycle, hypothermia, hematemesis, suicidality
169
(3) signs of recovery from eating disorder
normalized eating pattern and flexibility; restoration of body weight; resumption of menses
170
Median time to recovery from eating disorder
5 years
171
(3) protective factors conferring better prognosis for an eating disorder
earlier age at onset, shorter duration of symptoms before treatment, strong family relationship
172
(4) factors associated with poorer prognosis for eating disorder
purging behaviors, physical hyperactivity, significant weight loss, disease chronicity
