Case 5,6: 16yo WCC Flashcards

Question 1

Q

important components of teenage WCC

Answer

A

HEEADSSS
confidentiality issues
Tanner stages
Acne

Home environment, 
Education and employment
Eating
Activities - peer-related
Drugs
Sexuality
Suicide/depression, Safety from injury and violence

Question 2

Q

diffdx for (young female):

fatigue, less active, poor academic performance, pale

Answer

A

anemia: iron deficiency == bone marrow otherwise normal
anemia: bleeding disorder == more rapid loss of HgB (more SEVERE FATIGUE) ==> (esp. with hx of heavy menstrual periods) menorrhagia
hypothyroidism ==> menorrhagia, shorter menstrual cycles + constipation, weight gain, appetite
depression
adjustment disorder
eating disorder
drug abuse

Question 3

Q

considerations of bleeding disorders

Answer

A

heavy, prolonged menstrual periods
frequent nose bleeds (+/- clots)
easy bruising
piercings that don’t heal for a while
problems with prior surgeries (tonsillectomy, wisdom teeth)
Fhx of trouble with clotting

Question 4

Q

von Willebrand disease

Answer

A

LOW

Hgb
Plts
MCV

PROLONGED

reticulocyte count
bleeding time
PTT (+/-
Factor 8 activity
vWF antigen
vWF activity

NORMAL
- PT

Question 5

Q

Which of the following are more commonly found in children / adolescents v. adults

Answer

A

B. early morning waking

Question 6

Q

what are the best screening tools for depression for children (and for what age groups)

Answer

A

Children’s Depression Inventory (CDI) = 7-17yo
Beck Depression Inventory (BDI) = adolescents
Center for Epidemiologic Studies Depression (CES-D)

“Have you ever felt that life is not worth living?”
“Have you ever felt like you wanted to kill yourself?”

Question 7

Q

Screening questions for eating disorders

Answer

A

Have you tried to lose weight?
Are you unhappy about your weight or appearance?
Do you worry about eating?
Do you feel obsessed with food?
Do you know about anorexia or bulimia?
Has there been anybody with anorexia or bulimia in your family?
Do you know of anybody with anorexia or bulimia?
Have you been exercising a lot more than usual?
Have you been taking laxatives that haven’t been given by a doctor?

FHx

similar eating d/o
other psychiatric illness (suicidal attempts, depression)

Question 8

Q

Key parts of physical exam for a teenager

Answer

A

Skin: Clubbing; atypical nevi, tattoos, piercings, and signs of abuse or self-inflicted injury
Eyes: Jaundice (sclera)
Pallor (often difficult to tell until Hb < 6 g/L)
General well being
Height/weight/BMI plotted on percentile charts, general nutrition and muscle bulk

Question 9

Q

signs of hypothyroidism in an adolescent

What is unique in an adolescent (v. adult)

Answer

A

Cold skin
Slowness
Fatigue
Preferring hot weather to cold
Doing poorly at school
Coarse hair

Question 10

Q

signs & sxs of infectious mononucleosis

Answer

A

extreme fatigue
pharyngitis
lymphadenopathy

Question 11

Q

in adolescent women, what are menses like?

do they produce clots?

Answer

A

light & irregular (esp. in first 2y)

KEY features

cramping
discomfort
NO CLOTS

Question 12

Q

diffdx of depressive sxs in adolescents

Answer

A

mood swings

- adjustment reactions (moving; breakup) == usually short

Question 13

Q

when evaluating a teen for depression, what is the ONE question you always have to ask?

Answer

A

thoughts / hope / plans for suicide +/- hx of self injury,

Question 14

Q

which is more difficult to diagnose : anorexia or bulimia

Answer

A

Both are difficult in early stages ==> severe emaciation, over-excercising, laxative taking

bulimia –> due to lack of weight loss in early stages

==> dental decay (stomach acid); finger trauma

Question 15

Q

signs associated with anorexia (weight loss, failure to gain weight)

what happens in SEVERE cases?

Answer

A

amenorrhea
bradycardia ==> decreased CO +/- postural hypotension

tx == hospitalization (+ therapists) for prevention of worsening condition & nutrition

SEVERE
- electrolyte abnormalities (hypoalbumin, hypoglycemia, hyponatremia, hypoCa, hypoMg)

+/- neurologic changes, increased reflex tone, compromised cardiac fx

Question 16

Q

define: constitutional short stature

Answer

A

individual who is a “late-bloomer” in

puberty, but will attain a normal adult height-just later than his or her peers

Question 17

Q

Tanner Stages: female

Answer

A

8-13yo ==> puberty

1) breast buds = 10-11yo
2) pubic hair = 10-11yo

3) growth spurt = 12yo
4) periods = 12-13yo

adult height = 15yo

Question 18

Q

Tanner Stages: male

Answer

A

10-15yo ==> puberty

1) testicles = 12yo
2) pubic hair = 12yo

3) growth of penis, scrotum = 13-14yo
4) first ejaculation = 13-14yo
5) growth spurt = 14yo

adult height = 17yo

Question 19

Q

von Willebrand Disease genetics

Answer

A

AD with variable penetrance

Type 1 = most common (70%) - not life treatening

Question 20

Q

von Willebrand Disease genetics

sxs

Answer

A

ecchymoses (easy bruising)
epistaxis
menorrhagia
bleeding post-dental, tonsil extractions
gingival bleeds
bruising in non-exposed areas

Question 21

Q

von Willebrand Disease genetics

tx

Answer

A

intranasal / IV demopressin
human plasma-derived / virally inactivated vWF concentrate
symptomatic treatment for menorrhagia = OCPs, levonorgestrel IUD.

Question 22

Q

von Willebrand Disease genetics

tx

Answer

A

1) intranasal / IV demopressin
2) human plasma-derived / virally inactivated vWF concentrate
3) (TRAUMA, SURGERY) = factor 8 concentrate

symptomatic treatment for menorrhagia = OCPs, levonorgestrel IUD.

Question 23

Q

important components of preparticipation evaluation (prior to sports) in teen

Answer

A

CV screening (esp. for HOCM) + FHx
hx of LOC or concussion
hx significant MSK injuries
general health + health-related issues + fitness level for specific sports

Question 24

Q

vasovagal reflex

Answer

A

vasovagal syncope ==> bradycardia and/or peripharl vasodilation

prodromal sxs = dizziness, lightheadedness, sweating, nausea, weakness, visual changes
+/- syncope

Question 25

Q

osgood schlatter disease

cause
tx
prognosis

Answer

A

cause: irritation of growth plate at tibial tuberosity
tx: ice, NSAIDs
prognosis: self-limited growing pain (with finishing growth spurt, once bones stop growing)

Question 26

Q

diffdx chest pain in teenagers

Answer

A

precordial catch syndrome ==> sudden, sporadic (sharp) along LSB, worsened with deep inspiration. resolve spontaneously, worsened with forced deep inspiration. NOT with exercise
costochondritis ==> inflammation along sternal border @ articulations of ribs to sternum; last for h-d
GI == retrosternal, burning, non-radiating, associated with meals (esophageal/gastric irritation ==> OCPs, EtOH, tobacco, iintoxicants, stimulants, cocaine)
asthma-/exercise-induced bronchospasm ==> + cough, wheeze, respiratory distress

Question 27

Q

Key evaluation points in w/up of chest pain in children

Answer

A

fever ==> infectious (pericarditis, pneumonia)
body habitus: genetic d/o assoc. w/ cardiac problems (Marfan’s)
CV: thrill, hyperdynamic precordium, murmurs
chest wall for injury ==> if reproducible pain with palpation ==> MSK

Question 28

Q

signs and sxs of cardiac causes of chest pain

onset:
quality:
duration:
associated sxs:
exam findings:

Answer

A

onset = pain triggered by exertion, stress

quality: pressure, crushing sensation
duration: 10-15min
associated sxs: syncope, palpitations
exam findings: murmur, thrill, hyperdynamic precordium

Question 29

Q

what vaccines should a 16yo who has had all other childhood shots get?

Answer

A

HPV ==> 9-11yo (3 over 6mo)
meningococcal (esp. since going to college soon): MCV4 ==> 11yo (booster at 16y); MenB ==> 16yo (1x)
Tdap ==> 11-12yo (1x)
annual flu

Question 30

Q

Which of the following would NOT be in keeping with hypothyroidism? (Select the ONE best answer.)

A		Cold skin	
B		Sweaty, with palpitations	
C		Rash on legs	
D		Preferring hot weather to cold	
E		Feet edema	
F		Coarse hair

Answer

A

B

sweaty (heat intolerance) ==> hyperthyroidism

hypothyroidism = cold skin, depression, rash on legs, prefer hot weather, feet edema, coarse hair

Question 31

Q

f the depression symptoms below, which ONE is more common in adults than in adolescents?

A Feels down and doesn’t want to do his or her normal activities.
B Wakes early in the morning; has difficulty falling asleep at night.
C Feels sad and often cries over small things.
D Doesn’t want to participate in friends’ activities.
E Thinks about suicide.
F Feels grouchy and flat all the time.

Question 32

Q

which of the following would be the expected progression of clinical, laboratory, and ECG findings as her anorexia became more and more severe?

A Bradycardia, electrolyte imbalances, arrhythmias, circulatory collapse, death
B Proteinuria, hypoglycemia, seizures, circulatory collapse, death
C Hyponatremia, cerebral edema, seizures, circulatory collapse, death
D Hypotension, fracture, fat embolus, myocardial infarction, death
E Proteinuria, pericardial effusion, pericardial tamponade, circulatory collapse, death

Answer

A

1) bradycardia
2) electrolyte imbalances
3) malnutrition issues = hypoalb, hypoGlucose, hypoNa, hypoCa, hypoMg
4) neurologic changes, increased reflex tone, and compromised cardiac function.

Question 33

Q

Which of the following conditions could cause a drop-off in an adolescent’s performance in school?

 Multiple Choice Answer:
A		Hypothyroidism	
B		Death of a close relative	
C		Drug abuse	
D		Depression

Answer

A

all of the above

Question 34

Q

A 15-year-old female comes to the clinic with a chief complaint of feeling tired for one month. She has also been complaining of frequent nosebleeds while at school and bruising easily. When further history is elicited, you find out that menarche was at the age of 9 and her periods have always been heavy and irregular. Her mother and grandmother also have histories of heavy periods and easy bruising. You suspect a bleeding disorder and send off some labs including a CBC, INR, PT, PTT, and a von Willebrand panel to confirm your diagnosis. Your suspicion was correct for the most common type of bleeding disorder. How is this bleeding disorder most commonly inherited?

A Autosomal dominant inheritance
B Autosomal recessive inheritance
C X-linked recessive inheritance
D Mitochondrial inheritance

Answer

A

most common = vwf

A. Autosomal dominant (AD) inheritance is the correct choice. In AD disorders males and females are equally affected within each generation. These include conditions such as von Willebrand’s disease, Marfan syndrome, neurofibromatosis, and Huntington’s disease.

90% == AD
1% == AR

Question 35

Q

A 14-year-old girl presents to your office wondering why she has not had her period yet. Her mother states that she and the patient’s grandmother reached menarche at 13 years of age. The patient is concerned she is behind her friends in terms of development. She is doing well in school and has not had developmental problems in the past. On physical examination, her breasts are elevated without a secondary mound, and curly, coarse pubic hair is present on the labia majora in a triangular shape but does not reach the mons pubis. What Tanner stage would you assign this patient?

A		Tanner Stage I	
B		Tanner Stage II	
C		Tanner Stage III	
D		Tanner Stage IV	
E		Tanner Stage V

Question 36

Q

Female: Tanner stage I

Answer

A

= 10yo
Breasts = no glandular tissue and is prepubertal.

Pubis = no pubic hair at all

Question 37

Q

Female: Tanner stage II

Answer

A

> 10yo
Breasts = breast buds form and the areola begins to widen

Pubis =small amount of long, downy hair with slight pigmentation appears on the labia majora

Question 38

Q

Female: Tanner stage III

Answer

A

13-14yo
Breasts = elevated but do not have the secondary mound

pubis = extends more laterally; does not extend onto the mons pubis

Question 39

Q

Female: Tanner stage IV

Answer

A

15-16yo
Breasts = increased; secondary mound of areola & papilla projecting from contour of rest of breast

pubis = extends across the mons pubis, spares the medial thighs

Question 40

Q

Female: Tanner stage V

Answer

A

16-18yo
breasts = adult size and the areola returns to the contour of the surrounding breast while the central papilla remains projecting

pubis = extends to the medial surface of the thighs.

Question 41

Q

A 16-year-old female presents to clinic complaining of worsening fatigue. Family history is significant for hypothyroidism and heavy periods in the grandmother. Her exam reveals mild tachycardia and oozing around a recent piercing, but is otherwise normal. Labs reveal Hgb 8.5 g/dL, MCV 58, PT 12.5, PTT 44, and low von Willebrand factor activity. Which of the following is the most appropriate treatment for her underlying disorder?

A		Blood transfusion and iron supplementation	
B		Desmopressin	
C		Factor VIII concentrate	
D		Cryoprecipitate	
E		Vitamin K

Answer

A

B

low Hgb, low HCV ==> bleeding

prolonged PTT

low vwF

==> von willebrand
disease

\only use factor 8 concentrate for trauma / major surgery

Question 42

Q

A 10-year-old female comes to the clinic for a well child exam. Her mom asks about puberty and wants to know in what order she should expect to see normal developmental changes in her daughter. Which of the following sequences is correct?

A breast bud -> pubic hair -> menarche -> growth spurt
B pubic hair -> breast bud -> growth spurt -> menarche
C pubic hair -> menarche -> breast bud -> growth spurt
D breast bud -> pubic hair -> growth spurt -> menarche
E pubic hair -> breast bud -> menarche -> growth spurt

Answer

A

D

tits come first

first growth spurt comes before menarche

1) breast buds = 10-11yo
2) pubic hair = 10-11yo

3) growth spurt = 12yo
4) periods = 12-13yo

Question 43

Q

Frank is 16-year-old male brought in by his mother who complains that her son “looks much younger than his age.” She states that until about four years ago, she did not notice much difference between Frank and his friends. However, in the past two years, Frank has become the shortest person in his class. Frank’s mother is concerned that he has a “hormone problem” and wants to know how she can tell if he has begun puberty. What is usually the first sign of puberty in a male?

A		Growth of the penis	
B		Appearance of pubic hair	
C		Testicular enlargement	
D		Growth spurt	
E		First ejaculations

Answer

A

c

t’s go first

1) testicles = 12yo
2) pubic hair = 12yo

3) growth of penis, scrotum = 13-14yo
4) first ejaculation = 13-14yo
5) growth spurt = 14yo

Question 44

Q

How to talk to teens about performance-enhancing drugs

Answer

A

TEENS

1) undesired physical changes and side effects (bad breath, yellow teeth and cost)
2) drug testing for sports
3) examples on consequences via athletes

PRE-TEENS ==> “just say no”

ADULTS ==> long term-consequences (like CV risk, cancer)

Question 45

Q

Male: Tanner stage I

Answer

A

Phallus: small
Testicle: 1.5mL
Scrotum: pale

Pubic hair: none

Question 46

Q

Male: Tanner stage II

Answer

A

Phallus: small
Testicle: 1.6-6mL
Scrotum: reddened, thinner, larger

Pubic hair: fine hair, along base of scrotum and phallus

Question 47

Q

Male: Tanner stage III

Answer

A

Phallus: longer
Testicle: 6-12mL
Scrotum: larger

Pubic hair: moderate, curly, pigmented, coarser hair extending laterally

Question 48

Q

Male: Tanner stage IV

Answer

A

Phallus: longer, thicker
Testicle: 12-20mL
Scrotum: larger, darker

Pubic hair: coarse, curly adult hair, sparing medial surface of thighs

Question 49

Q

Male: Tanner stage V

Answer

A

Phallus: adult size
Testicle: 20mL
Scrotum: adult size

Pubic hair: adult hair, to medial surface of thighs

Question 50

Q

what is the difference between DTaP and Tdap?

Answer

A

DTaP

for =6yo
3-5x more diptheria toxoid

Tdap

for >7yo
booster doses of diphtheria, tetanus toxoid, and acellular pertussis

Question 51

Q

What is the acronym used for asking teens about their drug use?

Answer

A

CRAFFT

3 initial questions

1) Drink any alcohol (more than a few sips)?
2) Smoke any marijuana or hashish?
3) Use anything else to get high?

if no to all ==> ask only “c”
if yes to any ==> ask all CRAFFT

C Have you ever ridden in a CAR driven by someone (including yourself) who was “high”
or had been using alcohol or drugs?

R Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?

A Do you ever use alcohol/drugs while you are by yourself, ALONE?

F Do you ever FORGET things you did while using alcohol or drugs?

F Do your family or FRIENDS ever tell you that you should cut down on your drinking or
drug use?

T Have you gotten into TROUBLE while you were using alcohol or drugs?

Question 52

Q

Specific unique items of teenage physical exam

Answer

A

CV

1) BP
2) brachial & femoral pulses (? coarctation)
3) cardiac auscultation supine & standing ==> further evaluation of “physiologic” murmur if (a) > grade III/IV; (b) any diastolic; (c) any murmur that increases with standing or valsalva

GU (males only)

inguinal hernia (esp. sprinting, weight lifting)
undescended testicle ==> better protective cup for contact sports
demonstrate correct testicular self-exam monthly
Tanner staging for developmental purposes ONLY

MSK (ortho) - symmetry in:

strength
muscle bulk
ROM

Question 53

Q

Are all murmurs in adolescents abnormal?

Answer

A

NO
can have physiologic systolic murmur

but likely Pathological if:

(a) > grade III/IV
(b) any diastolic
(c) any murmur that increases with standing or valsalva

Question 54

Q

what is the one contraindication for contact sports for having one of a pair of organs?

Answer

A

One kidney

but okay if have only one testicle - e.g. d/t cryptorchidism

Question 55

Q

evaluation for syncope

Answer

A

syncope ==> abrupt LOC and postural tone

1) physical exam + VS (orthostatic BP - supine & upright); detailed cardiac & neuro exams
2) EKG ==> arrhythmias (WPW, long QT, HOCM)

if negative ==> likely neurocardiogenic (vasovasal) cuase

Question 56

Q

what is the typical first presenting sx of HOCM?

Answer

A

syncope

==> need EKG, which will be abnormal in 90% of pts with HOCM

Question 57

Q

diffdx of syncope in a teenager

Answer

A

1) vasovagal reflex == most common
2) HOCM
3) pheochromocytoma
4) heat stroke == + very high body temp
5) hypoglycemia == most common in T1DM, + confusion, AMS
6) dehydration == would resolve with hydration

Question 58

Q

red flags in syncope in a teen that point toward cardiac cause

Answer

A

Fhx of seizures, sudden death, MI in family <30yo.
all syncope assoc. with exercise / exertion
prolonged LOC > 5min + chest pain, palpitations (+ abn cardiac exam, hx of cardiac dz

Question 59

Q

syncope v. seizure

Answer

A

seizure

facial cyanosis
aura
frothing at the mouth
tongue biting
slow recovery
postictal drowsiness
prolonged mental status change / confusion
syncope in supine position
convulsion prior to LOC
warm/flushed/cyanotic skin color

SYNCOPE

pale, diaphoresis
murmur ==> cardiac cause

Question 60

Q

does creatine supplementation help athletes perform better

Answer

A

Not enough benefit / safety profile in teens ==> drs don’t recommend it (esp. in those with existing renal dz or risk of renal failure)

Natural sources = meat, fish

theoretically helps brief (<30sec), high intensity exercise

S/E = weight gain (water retention, cramps, heat intolerance, muscle/tendon swelling, predisposed to sprains, increased BUN/Cr/CPK

Question 61

Q

What is the most common cause of chest pain in an adolescent?

A		Asthma	
B		Gastroesophageal reflux disease (GERD)	
C		Musculoskeletal	
D		Myocardial ischemia	
E		Pericarditis

Answer

A

C

1) MSK most common cause of chest pain in kids
2) asthma (+wheeze, SOB)
3) GERD (+acid)

Question 62

Q

S/E of anabolic steroids with long-term use

Answer

A

Immediate: acne, smaller testicles
Labile mood, reckless behavior ==> dopamine, seretonin, opioid
withdrawal sxs

does NOT give the “high” (b/c not rapid release)

Question 63

Q

Which of the following immunizations are routinely administered at the 11-year-old well child visit? (Select all that apply.)

A HPV Human Papilloma Virus
B Meningococcal B
C Meningococcal ACYW Conjugate vaccine
D DTaP (tetanus/diphtheria/acellular pertussis)
E Tdap (tetanus/diphtheria/acellular pertussis)

Answer

A

A, C, E

HPV (at 11-12)
Menin Conjugate (at 11-12, booster at 16yo)
Tdap (at 11yo)

MenB  = at age 16
DTap = at <6yo

Question 64

Q

John is a 17-year-old presenting today for a pre-participation physical exam. During the interview, he reports a low-grade fever, malaise, and headache for one week. In the past few days, his fever has gotten worse and he complains of a sore throat. He denies cough or chest pain. On physical examination, he is found to have a temperature of 101.3° F, and cervical lymphadenopathy and oropharyngeal erythema with exudate are noted. His participation would be most likely affected by which of the following tests?

A		Chest x-ray	
B		CT head/neck	
C		EBV serologies	
D		Throat culture	
E		No further workup

Answer

A

C. suggestive of infectious mononucleosis. These include complaints of low-grade fever and malaise and findings of cervical lymphadenopathy and pharyngeal exudate. If testing is positive, the patient should be restricted from strenuous activity or contact sports during his illness due to the risk of splenic rupture.

Not throat culture –> b/c this is more likely mono (with fatigue & lymphadenopathy)
- if EBV serologies are negative ==> can do antigen test & culture for strep pharyngitis.

Answer 63

A

D. Prolonged QT syndrome can cause syncopal episodes in late childhood or adolescence. QT intervals are elongated on ECG and lead to arrhythmias, like ventricular fibrillation. This condition is often associated with other abnormalities, including severe congenital sensorineural deafness.

would be HOCM if it was on the list

Postural hypotension (volume depletion, skipping meals) == very common cause of dizziness / visual changes in pedatrics

Hypoglycemia = very uncommon in healthy children; usually no chest pain

Answer 64

A

D. syncope with exertion == RED FLAG ==> referral to cardiology

The combination of syncope with exertion and a family history of a young death is concerning for something like hypertrophic cardiomyopathy. Don’t be fooled about heat stroke. That is a positive family history for sudden death in a young person. This patient must be evaluated by cardiology, even if you don’t hear a cardiac murmur!

Answer 65

A

D. The patient is likely dehydrated given the dizziness without loss of consciousness in the setting of poor PO intake, hot weather and exercise. As the symptoms occurred while he was upright, the likely mechanism is vasovagal. His sunken eyes and tachycardia are signs of moderate to severe dehydration. Since this is a clinical diagnosis, fluids should be given with subsequent rechecking of heart rate and blood pressure to confirm the diagnosis.

no syncopal event, no chest pain

Answer 66

A

B

==> precordial catch syndrome = most common cause of chest pain in an adolescent

ECG would be next if you suspected a cardiac abnormality. This would be more likely if the patient described something more like angina, a crushing chest pain or pressure, for longer periods of time rather than a few seconds, and aggravated by exercise.

Answer 67

A

precordial catch syndrome

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Case 5,6: 16yo WCC Flashcards

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