Adolescent + Psych Flashcards
average age of first intercourse
16.5
Age of consent
Exceptions
16 years old
Exceptions:
● 14-15 years can consent to sex with someone up to 5
years older
● 12-13 years can consent to sex with someone up to 2 years older
● Must not be in a position of authority (teacher, coach, clergy etc.)
- 18years for exploitative sex
- Prostitution
- Pornography
LARCs failure rate
- 2% hormonal
0. 9%
When is return to fertility after IUD removal
1 month
How long after IUD insertion is there increased risk of STI and PID
1 week
WHO - contraindications to OCP
Hypertension (uncontrolled) Migraine w aura VTE Known thrombogenic mutations 2 or more RF for arterial CVD (smoking, DM, htn) Smoking >35yo Known ischemic heart disease Hx stroke Complicated valvular heart disease Breast cancer Cirrhosis Hepatocellular adenoma or malignant hepatoma
Starting OCP
type and dose
Combined OCP
30-35mcg estrogen
Depo provera - dose and frequency
Medroxyprogesterone Acetate (150mg im q12 weeks)
What type of birth control can cause weight gain
Depo provera
Side effects of depo provera
Irregular bleeding
Amennorhhea
Weight gain
Reduced bone mineral density. should get concurrent Calcium and Vit D
Emergency contraception options
Ulipristal Acetate “Ella”
- 30 mg x1, req Rx
- Up to 120 hours after unprotected sex
- Does not reduce efficacy over time
Plan B (progesterone only)
- 0.75 levonorgestrel x2 q12h
- best within 3 days but up to 5days
Copper IUD
- first line but limited access
- insert within 5-7 days, remove next period
Anorexia Nervosa
A. Restriction of energy intake relative to requirements, leading to a SIGNIFICANTLY LOW BODY WEIGHT in the context of age, sex, developmental trajectory, and physical health.
B. Intense FEAR OF GAINING WEIGHT or of becoming fat or PERSISTANT BEHAVIOUR that interferes with weight gain, even though at a significantly 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
Bulimia Nervosa
A. BINGE EATING
- Eating an excessive amount of food
- Sense of lack of control during binge episode
B. Recurrent inappropriate BEHAVIOURS TO COMPENSATE for binge episode (purging, laxative use, fasting, excessive exercise, insulin omission, others…)
C. Episodes occur on average 1/wk for 3 months
D. Self-evaluation is unduly influenced by weight and shape
E. Does not meet criteria for anorexia nervosa
ARFID
Eating or feeding disturbance associated with failure to meet nutritional needs AND 1 of the following
● Weight loss or growth failure
● Nutritional deficiency
● Dependence on enteral feeds or all liquid nutrition
● Marked interference with psychosocial functioning
● No evidence of body image disturbance
● No medical illness to explain the symptoms
Indications for hospitalization for ED
● Impaired/Arrested Growth and Development
- Severe malnutrition
- Weight ≤ 75 - 80% average body weight for age, sex, and height
● Fluid and Metabolic Abnormalities
- Dehydration
- Electrolyte disturbances
● Cardiac Abnormalities
- Arrhythmia/bradycardia HR <50 bpm daytime; <45 bpm at night
- Hypotension (<80/50 mm Hg)
- Hypothermia (body temperature <35.5 C)
- Orthostatic changes in HR (>20 bpm) or BP (>10 mm Hg)
● Behavioural
- Acute food refusal/uncontrolled bingeing/purging
- Suicidal ideation
Chlamydia - treatment
Azithromycin – 1 gm po x 1
Doxycycline 100mg PO bid x 7 days
Gonorrhea - treatment
(treat for chlamydia too)
● Option 1: Ceftriaxone 250 IM x 1, PLUS azithromycin 1 gram po
● Option 2: Cefixime (Suprax) 800 mg po x 1 PLUS azithromycin 1 gram po
PID
- diagnosis
Lower abdominal pain PLUS either
● Adnexal tenderness
● Uterine tenderness
● Cervical motion tenderness
● Increased specificity if also have ● fever >38.3 ● discharge ● WBC on microscopy ● elevated ESR or CRP ● positive testing for GC or chlamydia
PID
- complications if not treated
● Ectopic pregnancy
● Chronic pain
● Infertility
PID
- treatment
Ceftriaxone 250 mg IM in a single dose
PLUS
Doxycycline 100 mg PO bid for 14 days
Teen with unilateral painless breast mass
Fibroadenoma
Top three substances used by adolescents
Alcohol > high energy drinks > cannabis
What do you have to do before and after giving emergency contraception
nothing before
arrange followup after
What are the contraindications to nicotine replacement
none!
not even smoking or ED
Tasks of adolescences
- 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
PCOS - dx
- Abnormal uterine bleeding pattern
(abN for age or persistent for 1-2y) - Evidence of hyperandrogenism
(elevated testo, mod-severe hirsutism, mod-severe acne vulgaris)
When can you become sexually active after starting treatment for chlamydia
7 days
concerning substance in energy drinks
guarana
Mechanism of action for OCP
- Thickening of cervical mucus, blocks sperm penetration, progestin
- Inhibition of ovulation by inhibiting LH surge
- Endometrial changes
- Slowed tubal motility- progestin
Side effects of estrogen
- Breakthrough bleeding
- Breast tenderness
- Headaches
- Nausea
- Hypertension
- Thromboembolism
- Drug interactions (P450)
- Slight increased risk of cervical dysplasia (>5 yrs of use)
Girl vomited 90 minutes after Plan B. What do you do?
Reassure (after 60 minutes is ok)
Signs of bulimia
- Russell’s sign (calluses on dorsum of hand)
- Dental enamel erosion
- Parotid gland enlargement
- Edema
- Fluctuating weight (healthy/overweight)
Cardiac complications of ED
+ what would you see on ECG
• 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
Refeeding syndrome
Main issue: hypophosphatemia
Also see K, Mg, Glucose, Vitamins decrease
Risk factors for refeeding syndrome
– Low weight (< 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
how to refeed to prevent refeeding syndrome
• slow refeeding
– Start ≤ 1500 cal/day (or at intake patient reports) – Increase by 250 kcal/day
– QD-BID electrolytes until stable
• Supplement phosphorus early
– Oral generally sufficient
– IV replacement if critically low or symptomatic
• Careful use of IVF
Treatment of AN
Family based therapy
Parental education
- 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
Female Athlete Triad
- Amenorrhea
- Decreased BMD
- Disordered eating
Gential lesions ddx
- Herpes
- HPV
- Molluscum
- Primary syphilis (chancre)
- Chancroid (Haemophilus ducreyi)
- ‘Pearly papules’
Bacterial vaginosis
- key features
- treatment
- not STI
- fishy odör vag d/c
- vag pH >4.5
- clue cells
+ WHITE CELLS
tx: metronidazole
Candidiasis
- key features
- RF
- treatment
- not STI
- abx use
- steroids/immunecomp/poor DM
- clumpy d/c
- vag pH <4.5
+ WHITE CELLS
tx:
– Intravaginal OTC azole cream (clotrimazole)
– Fluconazole 150 mg OD x 1 dose (not in pregnancy)
Trichomoniasis
- key features
- treatment
- STI
- d/c, ithc, dysuria
- white, yellow frothy d.c
- strawberry cervix
- vag pH >4.5
- protozoa
+ WHITE CELLS
tx
- metronidazole
How to tell conversion d/o from somatization
conversions : not bothered by the sx
Kid with Hx substance abuse. Needs medication for ADHD. What is is BEST option?
Vyvanse
What is the best way to prevent people with disabilities from suffering sexual abuse?
Better sexual education
Substance use disorder
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
Risk factors for substance abuse in youth
Street involved Concurrent mental health disorder Gay, lesbian, bisexual or transgendered FHx Substance abuse Family Dysfunction
HPV vaccine
- what types of HPV
- what kind of vaccines
- what does it vaccinate against
HPV 6, 11, 16, &18
Recombinant quadrivalent
cervical cancer and genital warts
HPV vaccine
- who gets it, what age
- dosing schedule
Everyone
age 9-13: 2 doses, 6 mo apart
age 14 gets 2 doses, 15 gets 3
>14 yo or immunocomp: 3 doses
Irreversible consequences of AN
osteoporosis
Risk factors for substance abuse among youth
- Street involved
- Concurrent mental health d/o
- LGBTQ
- FHx substance abuse
- Family dysfunction
most likely bug in recurrent urethritis in male
chlamydia
Other: Gonorrhea (2nd most common) Trichomoniasis Mycoplasma genitalium HSV
First line for primary dysmenorrhea
second line
NSAIDS
second line
OCP
Contraindications to IUD
Pregnancy
Significantly distorted uterine anatomy
Unexplained vaginal bleeding concerning for pregnancy or pelvic malignancy
Gestational trophoblastic disease with persistently elevated beta-human chorionic gonadotropin levels
Ongoing pelvic infection
Excessive menstrual bleeding in an adolescent is most likely associated with:
excess estrogen
decreased estrogen
excess progesterone
excess estrogen (unopposed estrogen)
How many pregnancies end in abortion in teenagers
just over 50%
Pediculosis Pubis
treatment
Pruritus, excoriation, sky-blue macules;inner thigh or lower abdomen
1% permethrin
signs of recent marijuana use
Elation/Euporia (desired effect) Impairment of short term memory Poor performance on tasks requiring sustained energy (eg driving) Poor judgement Decreased coordination Distortion of time perception Visual hallucinations Increased appetite Conjunctival injection
Ddx for ADHD
Psychosocial issues Fragile X OCD Tourettes Thyroid disorder Meds
Rispiridone - SE
Extrapyramidal symptoms (e.g., restlessness and dyskinesias)- Diabetes (Type II) Hyperprolactinemia Seizures Sedation Neuroleptic malignant syndrome Tardive dyskinesia Cardiovascular effects (prolonged QT)
Investigations for new diagnosis of ASD
HEARING, fragile X, ADOS
microarray
Concern for ADHD
- what should be done
Behavior rating scale (SNAP, Conner, etc...) by parent and teacher Report card Vision testing Hearing testing Psychoeducational testing
Bulimia blood work
Na, K, Cl, pH, HCO3, CO2
Na – Normal or increased secondary to dehydration
K – low (aldosterone increased secondary to volume loss & alkalosis can cause temporary hypokalemia K loss in the urine)
Cl – low secondary to vomiting
pH – high given H+ loss with vomiting
HCO3 – high
CO2 – normal (? High secondary to compensation)
Management after providing EC
Always arrange follow-up:
Ensure not pregnant (should bleed within 3 weeks)
Encourage condom use/regular contraception
Discuss emergency contraception as part of routine contraceptive counseling
For sexually active youth – consider giving prescription for them to keep
Mgmt of ODD
1) Parent training
2) CBT
Cannabis withdrawal syndrome
symptoms
–2/5 Psychological = irritable, anxiety, depression, sleep disturbance, appetite change
–1/6 Physical = abdo pain, shaking, fever, chills, HA, sweating
Long term risks of cannabis
Cannabis dependence
Cannabinoid hyperemesis syndrome
Increased risk of psychosis or anxiety/depression
Functional and structural changes to brain
Increased risk of MVA (short-term, i.e. when high?)
Cognitive decline
Diminished school performance and lifetime achievement
Misuse of EtOH or other substances
Initiation of tobacco smoking
What medication is
- plan b
- ella
levonorgestrel
ulipristal acetate
Tourette Syndrome
- dx criteria
2+ motor tics AND 1+ verbal tic, though not necessarily at same time
Tics occuring for >1 year
Tics begin before 18 years of age
Symptoms can’t be explained by drugs, or another medical condition
OCD
- dx
1) Presence of obsessions, compulsions, or both
2) They are time-consuming (>1 hour/day), or cause significant distress/impairment in function
3) Symptoms are not due to an illness or drug
4) Symptoms are not better explained by another mental illness
Serotonin Syndrome
- dx
Have taken a serotinergic med + one of:
- Spontaneous clonus
- Inducible clonus PLUS agitation or diaphoresis
- Ocular clonus PLUS agitation or diaphoresis
- Tremor PLUS hyperreflexia
- Hypertonia PLUS temperature above 38°C PLUS ocular clonus or inducible clonus
Serotonin Syndrome
- mgmt
- stop agent
- Supportive care aimed at normalization of vital signs
- Sedation with benzodiazepines
- cyproheptadine
- propranolol
Neuroleptic malignant syndrome
- rispiridone
- muscle rigidity
- hyporeactivity/bradyreflexia
Neuroleptic Malignant Syndrome
-mgmt
- stop agent
- bromocriptine
- dantrolene
What are obsessions
Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
The individual attempts to ignore or suppress such thoughts, urges or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
What are compulsions
Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
Pt treated with prozac for 2 years. What is the chance of recurrence of depression once she is taken off this medication?
~50%
Cannabis use disorder
functional impairments: reduced academic performance, truancy, reduced participation and interest in extracurricular activities, withdrawal from their usual peer groups and conflict with famil
Cannabis withdrawal syndrome
> /=2/5 psychological symptoms
—irritability, anxiety, depressed mood, sleep disturbance, appetite changes
> /= 1/6 physical symptoms
—abdominal pain, shaking, fever, chills, headache, diaphoresis
after cessation of heavy cannabis use
