CH 20 primary care of well and sick infant, child, teen part B Flashcards
early adolescent social development
10-13 years
- Concrete thinking/black & white thinking
- progression of sexual identity development, reassessment of body image
- beginning to identify as a person other than parents’ child
-early strong peer identification, early exploration (drugs)
mid adolescence age
14-17 years
- Increased abstract thinking (right and wrong), I’m “bullet proof;”
- growing verbal abilities; identification of law with morality; start of fervent ideology (religious, political)
- strong peer identification, often increased health risk (smoking, alcohol, etc.); early educational and vocational plans
late adolescence ages
18-21 years
Complex abstract thinking, increased impulse control; f
further development of personal identity; further development or rejection of religious and political ideology
Development of social autonomy, increasingly complex intimate relationships, moving towards development of vocational capability
and financial independence
what medically emancipated conditions can adolescents to get help w/o parents?
all 50 states allow:
-Contraception
-Pregnancy
-Sexually transmitted infection
-Substance abuse (<20% of teens report they would get
treatment for STI, family planning, or substance
abuse if parent notification was required_
- Mental health (45% of teens report they would not get treatment for depression if parental notification was required.)
when is confidentiality broken for medically emancipated conditions?
if the PCP believes the teen is in a situation or has a condition that poses significant danger to the teen, family and/or greater society.
what do you have to disclose to guardian and adolescent at the initiation of relationship with PCP?
A policy guaranteeing confidentiality for the teenager should be clearly stated
14 year young woman and 15 boy have sex vs
but if 14 year old woman and 24 year boyfriend
you remain confidentiality! if 14 and 15 boyfriend but if 25 boyfriend =
satutatory rape ! can’t have sex with a minor
James is a 15-year-old who arrives for a well-teen visit with his mother. Prior to the beginning of the visit, his mother pulls you aside and states, “I want him checked for all drugs, but he said he is not using anything and does not want to be tested.” Which of the following is your most appropriate response?
A. “What drugs do you think James is taking?”
B. “I cannot force James to take a drug test.”
C. “Let’s discuss your concerns with James.”
D. “Since you are concerned, I can order the test without James’ consent.”
answer C:
he COULD turn down being tested. but he engages the convo and doesn’t ignore the problem
In which of the following scenarios is parental consent for care required?
A. An 18-year-old female who is seeking a pregnancy termination
B. A 16-year-old female requesting a prescription for oral contraceptives
C. A 15-year-old male requesting testing for sexually transmitted infection
D. A 17-year-old male who requests treatment for contact dermatitis
answer: D
18 year old is old enough to make decision
A 12-year-old boy presents with his mother for a well-child visit. What is the most helpful approach to this visit?
A. Interview and examine the child in the absence of the mother.
B. Interview the child with the mother, asking her to leave for the examination.
C. Ask the child if he wishes his mother to be there for the interview and examination.
D. Ask the mother if she wishes to be included in the interview and examination.
answer C
ask PATIENT!
screening test for adolescent substance abuse
similar to cage questionnaire
CRAFFT questions
-car in a under influence person,
drugs to Relax
drugs Alone?
Forgetful?
Friends tell you to cut down?
Trouble while doing drugs?
In the USA, which of the following is the most common cause of adolescent
death?
A. Suicide
B. Homicide
C. Accidental injury
D. Malignancy
C Accidental injury - COUNSEL about safety!
Tanner stage 1
pre puberty
tanner stage 2
early changes
males: Testes enlarge; scrotal skin reddening with change in texture; sparse growth of long, slightly
pigmented pubic hair at base of penis
female: Breast buds and papilla elevated, downy
pigmented pubic hair along labia majora
tanner stage 3
“middle finger” = ONSET of growth spurts
Male: - “pencil penis” stage (grows longer but not thicker)
-further scrotal enlargement
pubic hair darker, coarser, covers greater area
-pseudomastia (fat under breasts enlarges)
female: breast mount enlargement, darker, coaser, curling public hair on mons, labia major, onset of growth spurt
tanner stage 4
“ring finger” = peak of growth, menarche
male: Increase in penile length and width with
development of glans; further darkening of scrotal
skin; adult‐type pubic hair with no spread to
medial surface of thighs
female: Areola and papilla elevated to form a second
mound above level of rest of breast; adult‐type
pubic hair with no spread to medial surface of
thighs; menarche
tanner stage 5
full adult pubic
recession of areola to mound of breast, extension of pubic hair to medial thigh
once girl get 1st period, they grow for how much longer?
1 year!
but males have longer period of grown during adolescents than females do
most common pubertical alteration in female?
early onset puberty in girls ~ 7-8 years old. idiopathic in majority
- starting periods
can start GnRH agonist analog an option to delay progress, requires specialty evaluation for
treatment.
alteration in puberty female at > 13 years…
no signs of puberty (pubic hairs, budding)…
nutrition (low weight)
hormonal, genetic (turner syndrome [XO], etc)
alterations in males for puberty include?
< 9 years old, early onset puberty is < 40% idiopathic (CNS tumor most often implicated)
> 14 year old late (tanner 1) onset = nutrition, hormonal, genetic etc
You see Sharon for a well-child visit. She is a 12-year-old who is at Tanner stage 2–3 and states unhappily, “I am the shortest girl in my class.” When reviewing her growth chart, you notice she has been consistently between the 10th and 15th percentile for height and weight during her childhood. The rest of her examination is within normal limits. You advise that:
A. She should have an evaluation by a pediatric endocrinology specialist.
B. Her growth spurt will start soon.
C. Due to her age, she is likely near her adult height.
D. X-ray determination of bone age should be obtained.
B. Tanner 2-3 she will start her spurt soon within few inches next few years.
A & D implies something is wrong but nothing is wrong
Physiologic gynecomastia is usually found in which of the following?
A. A 14-year-old male who is at Tanner stage 3
B. A 12-year-old male who is at Tanner stage 2
C. A 17-year-old male who is at Tanner stage 5
D. A 10-year-old male who is at Tanner stage 1
A. seen in 50% of males age 13-14 / tanner 3 thru 4 lasgts 6-24 months
no further eval; reassure it’s normal
fragile X syndrome findings in males vs females
sx’s more prominant in males: Large forehead, ears, prominent jaw, tendency to avoid eye contact. Large testicles (macroorchidism), large body habitus, learning and behavioral differences
ADHD, autism - hyperactivity, developmental disability common
In females: Significantly less common with fewer prominent findings,
usually with less severe developmental issues
what is the most common cause of autism in either gender, in all racial and ethnic groups?
Fragile X syndrome
Klinefelter syndrome
XXY only males affected - extra “X” = more feminine features
SMALL testes, lowtesticular volume, hip and breast enlargement (gynecomastia) INFERTILITY
Mostly developmental issues, language impairment.
Blood testing for carrier state (genetic risk for having a child with
Klinefelter syndrome) or for diagnosis of the condition.
-Antenatal diagnosis possible.
Turner syndrome & findings
XO female (missing X/Y chromosome)
short (>5 ft ),
-usually evident by age 5 years
-wide, webbed neck; broad, shield-shaped chest, absent menses, infertility.
- Often noticeable at birth, narrow, high-arched palate, retrognathia (lower jaw not prominent), low-set ears, edema of and feet.
turner syndrome fetus
high rate of spontaneous pregnancy loss in XO female fetus
You see a Tanner stage 4 14-year-old male who you suspect has Fragile X syndrome because of the notation of all of the following except:
A. Macroorchidism.
B. Large body habitus.
C. History of learning differences.
D. Hip and breast enlargement.
D. XXY male (Klinefelter syndrome)
acne vulgaris patho
-P acnes organism with inflammation
-Follicular epidermal hyperproliferation with subsequent follicle plugging, excess sebum production
Keratolytic and antibacterial agents guide acne vulgaris therapy.
how long does it take acne therapy to work?
all therapies take 6-8 weeks until clinical effect
topical therapy should be used over entire skin region, not SPOT therapy of lesions
topical benzoyl perioxide cream, lotion, MOA and indication
antibacterial, comedolytic effecs
-cheap, OTC
-for mild acne, usu wih keratolytic acne wash with salicyclic 2%
2.5% just as effective as 10% but less irritating
Topical retinoids MOA, indication
-Keratolytic, significant antiinflammatory effect.
- for ALL acne types
- when starting, mild-to-moderate skin irritation, improves over time
- SUNSCREEN! photosensitizing (regardless of skin tone)
- Adapalene (Differin®) gel or cream, tazarotene (Tazorac®), tretinoin (Retin-A®), azelaic acid (Azelex®)
topical retinols brands
Adapalene (Differin®) gel or cream
tazarotene (Tazorac®)
tretinoin (Retin-A®)
azelaic acid (Azelex®)
topical antibiotics for acne
clindamycin
erythromycin
dapsone (sulfa based)
topical antibiotics MOA, indications
antibacterial, anti-inflammatory
- Most effective for mild acne
- often used with comedolytic such as benzoyl peroxide
and/or retinoid
oral antibiotics for acne names
doxycycline,
minocycline
erythromycin,
TMP/SMX
azithromycin (safe for pregnancy; off label use)
oral antibiotics for acne MOA and indications
- Antibacterial, antiinflammatory
- for moderate inflammatory acne, usually when topical
not working - NO protracted/prolonged minocycline use =
hyperpigmentation risk
how long do you leave a pt on oral antibiotics for acne vulgaris treatment?
minimum of 3 months of continuous therapy, then taper off slowly while adding in topical antib
if stop immediately, acne returns.
long term/repeat therapy often needed if acne flares happens again
Combined estrogen-progestin
hormonal contraceptive for acne treatment
MOA & indication
FEMALES ONLY
-Pill, patch or ring form
-Spironolactone
Reduces androgen levels, decreased sebum production
- MOD TO SEVERE acne
- ~ 3 months of continuous use
for significant acne improvement. - if stop, acne usually gradually
returns to pretreatment baseline.
topical anti-androgens (clascoterone [Winlevi®]) MOA , indication
any gender can use this!
reduces androgen levels, decrease sebum production
* Clascoterone 1% cream approved for males and females 12 years and older
Isotretinoin (Accutane) MOA, indication
- MOA not understood
- Cystic (SEVERE) acne that does not respond to other therapies (oral antibiotics, retinoids); derm consult
Isotretinoin (Accutane) therapy
- takes ~ 4–6 months therapy to see final effect
- discontinue when nodule count is reduced by 70%
- repeat course only if needed after 2 months off drug.
monitoring during isotretinoin (Accutane)
box warning!
*monitor for mood destabilization and/or suicidal thoughts even tho mental health risk low
in order to prescribe accutane and pt takes accutane…
have to be registered to prescribe! can refer to derm
* Be properly educated of drug and
adverse reactions (cheilitis, conjunctivitis, hypertriglyceridemia, xerosis (super dry skin), photosensitivity, and potent teratogenicity!
* Females of childbearing age must
use 2 types of highly-effective contraception 1 month before, during, and 1 month
after use of isotretinoin.
iPLEDGE Program is designed to
prevent pregnancies in patients taking isotretinoin by using iPLEDGE prescribers and pharmacies, and
signing iPLEDGE card.
mild acne preferred treatment
-not highly inflammatory
-Topical retinoid alone or add topical antibiotic and/or
benzoyl peroxide
moderate acne preferred treatment
-Oral antibiotic with topical
retinoid to start, once lesions controlled usu within 3 months, can transition to topical antimicrobial with topical retinoid.
- Can consider combined hormonal contraception or
spironolactone (females only) or topical clascoterone (both genders)
severe acne preferred treatment
-Oral antibiotic with topical retinoid. If ineffective, oral
isotretinoin (Accutane®).
-For large, painful cysts = intralesional
corticosteroid injection
with cystic acne, consider if there is ___ use
anabolic (testosterone) steroid use
A 16-year-old male with moderately severe acne returns for a follow-up visit
after initiating an oral antimicrobial plus topical retinoid two weeks prior. He
expresses concern that he has not noticed any improvement. The NP advises:
A. Replace the oral antimicrobial with a topical agent.
B. Replace the topical retinoid with topical salicylic acid.
C. At least 4–6 weeks is needed to observe the full therapeutic effect.
D. Begin assessment for oral isotretinoin.
C.
Indicated for treatment of cystic acne
isotretinoin (Accutane)
Most cost-effective topical antibacterial in mild
acne
benzoyl perioxide
Used as a keratolytic in acne treatment
tretinoin (Retin-A)
Use results in reduction of androgen levels
combined oral contraceptives
Used in moderate-to-severe acne therapy for ≥3
months, usually preceding topical antimicrobial
therapy.
oral antibiotic therapy
Adolescent issues: True or false?
(T/F) Compared to adults age ≥25 years, adolescents tend to drink alcohol less frequently, but they drink considerably more alcohol per occasion of drinking.
true - binge drinking
(T/F) USPSTF recommends depression screening using a validated questionnaire in adolescents (ages 12–18 years).
true
(T/F) In all states, parental notification or consent is NOT required for an adolescent (generally considered to be ages 14 up until 18th birthday) to receive
contraceptive services, prenatal care, or evaluation and treatment for STIs or substance abuse.
true
(T/F) The majority of states require either parental consent or parental notification for teenagers younger than 18 to have a pregnancy termination.
true for TERMINATION but not needed for consent for pregnancy
The most common contraceptive method used by teens is:
A. Male condom.
B. Combined oral contraceptives.
C. DMPA injection (Depo-Provera®).
D. Withdrawal.
A. male condoms - educate male condons as a way of STI reduction but not pregnancy since it has 20% failure rate
When approaching the provision of primary care for LGBTQI+ youth, the NP considers that:
(T/F) The healthcare provider should ask the adolescent how he/she/they selfidentifies/identify.
(T/F) Therapy which attempts to change one’s sexual orientation or gender identity is
inconsistent with current standards of medical care.
(T/F) Because victimized LGBTQI+ youth are at increased risk of depression and
suicidality, providers should screen for these mental health issues and intervene
as appropriate.
(T/F) In adolescents, sexual orientation and gender identity are relatively fixed
constructs.
True- The healthcare provider should ask the adolescent how he/she/they selfidentifies/identify.
True - Therapy which attempts to change one’s sexual orientation or gender identity is inconsistent with current standards of medical care.
True - Screen ALL adolescents!
False - In adolescents, sexual orientation and gender identity are relatively fixed
constructs.
You are seeing 17-year-old Cynthia. As part of the visit, you consider her risk factors for type 2 diabetes mellitus would likely include all of the following except:
A. Obesity.
B. Pacific Islander ancestry.
C. Family history of type 1 diabetes mellitus.
D. Personal history of polycystic ovary syndrome (PCOS).
secondary prevention because screening for type 2 DM
answer: C. DM 1 is autoimmune and not risk factor for DM 2
when to consider screening for DM 2 in children?
Overweight or obese (BMI ≥85th percentile
for age and sex) ages 2 years to 10 years old:
*Plus ≥1 risk factors:
-Family history of T2DM in first- or seconddegree relative
-Race/ethnicity (Native American, African
American, Latino, Asian American, Pacific
Islander)
-Signs of insulin resistance: acanthosis nigricans, hypertension, dyslipidemia, PCOS, small for gestational age at birth
-Maternal history of DM or gestational DM
during the child’s gestation
how to test and how frequent to test for DM 2 in children?
-Initiate testing (A1C, FBS, 2-h oral GTT) at age 10 years or at onset of puberty (Tanner stage
2 for VERY early puberty changes not when period starts), if puberty occurs earlier
-Frequency: Every 3 years, sooner with
symptoms
string of pearls in ovaries
PCOS - insulin resistance
Sam is a 15-year-old with a BMI=40 kg/m2 who presents with a lipid profile that reveals low HDL, elevated triglycerides, and an acceptable A1C. Which of the
following is the recommended treatment option?
A. Oral niacin
B. Oral fibrate therapy
C. Weight loss
D. Oral statin therapy
C. weight loss
high BMI and high trig = insulin resistance
dont’ use niacin anymore
risk factors for lipid screening in children?
only screen if have fam hx of MI, angina, stroke, or sudden cardiac death in 1st or 2nd degree family member < 55 years (male), < 65 female
-parent w/ total chol ≥ 240
-child has diabetes, HTN, BMI ≥ 95th percentile, or smokes cigarettes
approach to screening ages in children WITHOUT risk factors?
Do not screen earlier than 2 years old.
Screen twice: once between 9-11 years and again 17-21
*no screening 12-16 (w/ no risk factors) since puberty decreases the S&S of screening
when can whole milk be given to a child?
after 1 years old