PBR Flashcards
What is the normal age range for pubertal development?
9-13yo for both boys and girls
How long does it take to go from Tanner stage 2-5?
5 years
True or False.
Adolescent peak height velocity has more to do with Tanner stage than age.
TRUE
I have no pubic hair, a childlike penis and my testicles are < 2.5ml. What is my SMR?
1
I have fine pubic hair and wrinkles on my scrotum. What is my SMR?
2
I have coarse, curly pubic hair and my scrotum and penis have grown. What is my SMR?
3
I have dense, curly pubic hair and a full size penis, what distinguishes me between SMR 4 and 5.
SMR 5 has adult size scrotum, penis and testicles and hair is also on inner thigh.
I have fine hair along my labia and breast buds. What is my SMR?
2
I am flat chested and have no pubic hair. What is my SMR?
1, unless I am a supermodel waif who has been waxed.
My breasts go beyond the areola and my pubic hair is coarse and curly. What is my SMR?
3
My SMR is 4. What is my pubic hair and breast situation?
Pubic hair is dense, coarse and curly but not extending to thigh. Breasts have a secondary mound and papilla now.
My SMR is 5.What is my pubic hair and breast situation?
Hair extends to inner thigh. Areola is no longer a separate projection from the breast.
What is classified as delayed puberty?
No development by 14 for a boy and 13 for a girl.
What is the pre-puberty height velocity?
What is the pre-adolescent height velocity?
5-6 cm/year
9-10 cm/year
When does growth spurt begin?
At breast development for girls and at testicular enlargement for boys.
A 13yo girl is found to have an elevated alkaline phosphatase on routine screen. What is your next step?
Reassurance.
What is bone age vs. chronological age in constitutional growth delay?
Bone age < Chronological age. The bones catch up later
True or False.
Boys reach SMR 4 prior to peak height velocity.
TRUE
True or False.
HCT increases with growth spurt.
True.
What is the sequence of male pubertal development?
Testicular growth then pubarche then penile growth then peak height velocity
Ball then bat then height.
What is the most common cause of delayed puberty in boys?
Constitutional delay
At what age is pubertal development considered too early? What is normal onset?
Age 9 is too early. Age 10-11 is normal
When do boys develop axillary hair?
After SMR 5.
A boy has pubic hair development and penis enlargement but no testicular gland enlargement. What does this mean?
Androgen stimulation is coming from outside the gonadal area.
What is the difference in pubic hair development between boys and girls?
Pubarche occurs 1 year after testicular growth in boys vs. girls where it occurs parallel to breast development.
A 13yo complains of breast development with milk from his breasts. He is otherwise healthy but does smoke marijuana. What do you advise?
Stop the marijuana.
What is the sequence of puberty in girls?
Breast bud then Pubarche then Peak Height Velocity then Menarche
What is too early puberty for girls?
Younger than 8yo is too early.
What is the first sign of puberty in girls? What age does it occur? By when should it occur?
Thelarche (breast tissue development). Usually occurs at age 11, but should occur by age 13.
Which hormone(s) are responisible for breast and pubic hair development in girls?
Estrogen for breast and Androgen for pubic hair
How long after thelarche do you expect menarche?
2 years
In which SMR does a girl have peak height velocity?
SMR 3 or 4.
How far from adult height are girls at menarche?
2 inches.
An 11yo girl who is in SMR 2 has bloody vaginal discharge. What do you do?
Look for vaginal foreign body, such as toilet paper.
True or False.
If thelarche occurs without pubarche, think androgen insensitivity.
TRUE
True or False.
If Pubarche occurs without thelarche, think excess androgen/low estrogen.
TRUE
A 3yo has developed breast buds. Her mother is very worried. What is your response?
This is okay, as long as there is no further development and there is no pubarche. This may be due to obesity.
Which of the following kids is undergoing precocious puberty? Pick all that apply.
A) A 9yo girl who has started menarche with breasts and pubic hair.
B) A 10 yo boy who has developed pubic hair and genitals.
C) A 7yo with thelarche and pubarche but no menarche
D) A 9yo with thelarche and pubarche but no menarche
E) A 7yo girl with thelarche but no pubarche and no menarche
A) yes B) no C) yes D) no E) no
What is premature pubarche without thelarche due to?
Adrenal androgen production
Which hormone is responsible for axillary hair and acne?
Androgen
You evaluating a girl for precocious puberty and note that she also has visual field defects. What is the likely cause of precocious puberty?
CNS lesion…pituitary
You are evaluating a boy for precocious puberty and not acne, facial hair and muscle bulk. What is the cause?
Excess androgen from outside of the gonads.
A prominant labia minora or a change in vaginal color is due to which hormone?
estrogen
A girl has premature breast development. What is your test of choice?
Ovarian ultrasound
A boy has premature pubarche what is your test of choice?
Adrenal ultrasound
How do you differentiate peripheral vs. central causes of precocious puberty?
LH, FSH and adrenal steroids and MRI.
What is the most likely reason not to use contraception?
Desire for pregnancy
True or false.
50% of all pregnancies occur within 6 months of first time experiencing intercourse and 20% occur in 1st month.
TRUE
What are absolute contraindications to OCP?
Breast Cancer CAD or Cerebrovascular Disease Hepatic Disease Elevated Lipids Pregnancy
Of the following patients who would you not give OCPs to? A) A sickle cell patient B) A epilepsy patient C) A girl whose mother has breast cancer D) A girl with lymphoma E) A girl with hyperlipidemia
E.
How often do you screen for HPV?
If Sexually active, every year.
If not sexually active, start at age 18 then repeat every 3 years.
When do you start workup for amenorrhea?
No period by age 16
No thelarche or pubarche or menarche by age 14.
No period for 3 months in a 6 month span.
What are the expected Lab findings in PCOS?
LH:FSH ratio > 2.5 and elevated androgen level.
What is the treatment for PCOS?
OCP, weight loss, and anti-androgen medications like spironolactone
A 13yo girl presents with amenorrhea, your partner saw her and dismissed her 6 months ago without doing a pelvic exam, but you notice she does not have any pubic hair despite having developed breasts. What is the likely problem?
Androgen insensitivity
An amenorrheic 13yo girl has breast buds but no pubic hair. What should be your next step?
Karyotype for Turner’s syndrome
A 15yo marathon runner has not had a period in 6 months. What do you expect on her labs? What is she also at risk for?
Low estradiol. Osteoperosis and Anorexia nervosa.
Does resumption of menses reduce the risk of osteoperosis in a girl with stress induced amenorrhea?
yes
What is the pathophysiology of primary dysmenorrhea? How do you treat it?
Excess prostaglandins. Treat with NSAIDs
True or False.
Primary dysmenorrhea is a significant cause of school absence.
TRUE
True or False.
Exercise, healthy diet and tylenol may help in reducing primary dysmenorrhea.
False.
How do you distinguish endometriosis from primary dysmenorrhea?
Endometriosis pain occurs any time in cycle, not just during menses.
A teenager presents with recurrent nightmares, fear of being alone, diminished appetite, and diminished interest in school. She is otherwise healthy but was raped on campus last year and has been depressed since then. What is her diagnosis?
PTSD
What is the leading cause of death among teenagers?
Accidents (MVA)
Homicide
Suicide
Which of the following is not a requirement to diagnose anorexia nervosa?
A) Distorted body perception
B) Poor caloric intake
C) Intense fear of weight gain
D) Weight below 15% expected
E) Absence of 3 consecutive menstrual cycles.
B.
Which of the following is required to diagnose anorexia nervosa? A) Depression B) Excess exercise C) Poor caloric intake D) Distorted body perception E) Diuretic abuse
D.
Which is not an indication for inpatient admission in a patient with bulemia nervosa? A) Failure of outpatient treatment B) Dehydration C) ECG abnormalities D) K+ of 3.0 E) Suicide ideation
D
How do you distinguish achalasia from bulemia?
Achalasia is involuntary
What is the metabolic risk in refeeding an anorexic or bulemic patient?
Hypophosphatemia
What is the most prevalent STD among teens?
HPV
What is the most common bacterial STD?
Chlamydia
True or False.
Genital warts caused by the HPV is the most prevalent STD.
False. Even though HPV is most transmitted STD, genital warts are not.
A young mother is devastated that her daughter has been diagnosed with gardenerella vaginalis and thinks her 12yo daughter has been sexually active. The girl swears she has not been. How do you explain the infection?
This is BV. It can be passed non-sexually even from toilet seats and door knobs.
You do a pelvic exam on a 15yo sexually active woman. You quickly note a fishy odor on applying KOH to the smear. In addition, you note clue cells on the smear. What is your diagnosis?
BV
True or False.
Males do not get trichomoniasis.
False. They can get it, but are asymptomatic usually.
A 15yo girl complains of vaginal itching and burning along with dyspareunia. On exam you not a frothy yellow discharge with a strawberry cervix. What do you expect on wet mount?
Flagellated organisms.
What is the treatment for trichomoniasis? Do you need to treat the partner?
Treat with 2 grams metronidazole. Treat the partner too.
True or false.
Gonorrhea is usually asymptomatic.
True.
What is the major complication of untreated GC in men and in women?
Men can lead to severe epididymitis. Women can get peri-hepatitis, AKA Fitz-Hugh Curtis.
What are symptoms of disseminated gonococcal infection?
Rash, arthritis, possible meningitis and endocarditis.
What is the treatment for genital herpes ulcers?
7 days po acyclovir.
An asymptomatic sexually active 15yo has now changed her sexual partner since her last exam. What is the most appropriate study at this time?
Urine PCR for chamydia and gonorrhea.
What are the diagnostic criteria for PID?
Lower abdominal or Pelvic pain AND EITHER
Uterine or Adenexal tenderness
OR
Cervical motion tenderness.
Which of the following tests are required when doing a pelvic exam and drawing blood for PID evaluation? A) Chlamydia culture B) GC culture C) Pap smear D) Vaginal swab for Trichomoniasis E) Vaginal swab for BV F) RPR G) HIV
All of them. And you must counsel on the HPV vaccine.
What is the outpatient treatment regimen for PID?
Azithromycin 1gram x 1 and Ceftriaxone 250mg IM x 1
What do you do if pain persists despite outpatient treatment?
Do U/S to look for TOA and admit.
When do you expect resolution of RUQ pain upon treatment of Fitz-Hugh Curtis?
Within 2 days.
A 15yo girl comes in with fever, RUQ pain that radiates to her shoulder, and nausea. Her abdominal ultrasound is normal. She is otherwise healthy and her only medication is an OCP. What is your next step? A) ERCP B) Abdominal CT C) Pelvic exam D) Surgical consult E) Serum amylase and lipase
C.
Which of the following require parental informed consent? A) Life threatening emergency B) Medical Care during pregnancy C) Blood Donation D) Substance Abuse Treatment E) STD treatment F) HIV testing G) Sexual assault management H) Any care for an emancipated minor
C.
? Whats inside? Serous edemal fluid :)
? Vaguely demarcated area of edema found
in presenting part of the scalp
? Associated with:
o Molding of head
o Overriding of parietal bones
? Features: o External to periosteum o Crosses suture lines and midline o Overlying skin with petechiae or purpura
? No specific treatment
? Resolves in 48-72 hrs
Caput Succedaneum
Whats inside? Blood :)
? Subperiosteal collection of blood
? Associated with: o Rupture of capillaries traversing from skull to periosteum o Difficult labor and delivery ? Features: o No extension across suture lines o Parietal bones involved mostly o Overlying scalp not discolored o More apparent after several hours or days
? No therapy for uncomplicated lesions
? Most common complication:
Hyperbilirubinemia
cephalhematoma
Collection of blood beneath the aponeurosis
? May extend from eyes to nape
? Firm fluctuant mass increasing in size after
birth
? Mechanism of injury: rupture of emissary
vein
? Severe anemia and hypovolemic shock
? Volume replacement and blood products
? Resolves over 2-3 wks
? High morbidity and mortality
Subgaleal Hemorrhage
Uncommon in neonates because: o Skull bones are less mineralized thus are compressible o Bones separated by membranous sutures (allows molding)
? Features: o Associated with forceps delivery o Most fractures are linear ? This is good because they do not require treatment o Depressed fractures are rare o Entirely asymptomatic unless with associated intracranial injury
skull fractures
Diagnosed by X-ray
? For linear fractures ? No treatment
? For depressed fractures with neurological
signs? immediate surgical intervention
skull fractures
Most serious brain lesion in the neonatal
period
? Major cause of death
? Incidence increases with decrease in
birthweight & AOG
? Results from trauma, asphyxia or primary
hemorrhagic disorder
Periventricular- interventricular hemorrhage
Bleeding site: subependymal germinal matrix o Area where future neurons & glial cells will migrate from o Very vascular o Very thick in young/preterm babies
Periventricular- interventricular hemorrhage
Predisposing factors: hypoxic-ischemic
injury, pneumothorax, hypovolemia,
hypotension
? 80-90% occur w/in the first 2 postnatal days
? Clinical manifestations: apnea, lethargy, poor
muscle tone, convulsions and bulging
fontanel
Periventricular- interventricular hemorrhage
Diagnosis: cranial US
? Complications: periventrucular
leukomalacia (PVL), posthemorrhagic
hydrocephalus
Periventricular- interventricular hemorrhage
- Principal ischemic brain lesion of premature
infants - Necrosis of periventricular white matter
- Anterior and posterior periventricular regions
most commonly affected - Dx by US: see cystic changes
- MRI more sensitive or evaluating extent
periventrucular
leukomalacia (PVL)
Major complication of severe IVH
- Progressive ventricular dilatation
- Plugging of arachnoid villi by intraventricular
blood clots
- Cranial US: procedure of choice for dx
- Clinical signs: enlarging head circ, apnea,
lethargy, bulging fontanel or widely split sutures
- 3-5% will require shunt insertion
Posthemorrhagic Hydrocephalus
? Etiology: a. Peripheral paralysis? compression of peripheral part of facial nerve b. Central paralysis ? contralateral CNS injury ? Paralysis may not be apparent at birth ? Type and distribution of paralysis depends on etiology ? No specific therapy ? Most resolve spontaneously
facial nerve palsy
Very common finding
? Bright red patches on bulbar conjunctiva
? Noted in both difficult and easy delivery
? Treatment: reassure parents
? Blood absorbed within 1-2 wks
Subconjunctival hemorrhage
Most frequently fractured bone ? Found in difficult delivery of shoulders ? Greenstick type fracture commonly ? Usually asymptomatic ? Decreased movement of arm on affected side ? Crepitus on palpation ? Irregularities along clavicle ? Callus formation at 7-10 days ? X-ray/radiographs confirm diagnosis ? Therapy is directed at minimizing pain
Clavicle fracture
Paralysis of muscles of the extremities ? Follows mechanical trauma to the brachial plexus (spinal roots of the 5 the cervical to 1st thoracic nerves)
brachial palsy
Most common o Injury to 5-6 th cervical nerves o Arm is adducted and internally rotated, forearm pronated, wrist flexed o Absent Moro on affected side o Suspect when arms are extended because normally they should be flexed o Tx: partial immobilization and proper positioning (to prevent contractures & minimize pain) o Good prognosis arm is extended
Erb-Duchenne/ Upper Arm Paralysis
o Injury: 8 th cervical and 1st thoracic roots o Extremely rare o Paralyzed hand o No grasp reflex o Horner Syndrome (ptosis, miosis, enopthalmos) o Relatively poor prognosis
Klumpkes/ Lower Arm Paralysis
Avulsion of 3rd ,4th ,and 5 th cervical roots which supply phrenic nerve ? Occurs in difficult breech delivery ? Apparent respiratory distress ? X-ray shows elevation of affected hemidiaphragm
Phrenic nerve palsy/ Diaphragmatic paralysis
Affected side cannot contract so it
remains elevated (more than 1
vertebral space)
? Dx: Real time sonography (to rule out
congenital diaphragmatic hernia)
? Spontaneous and complete recovery
Phrenic nerve palsy/ Diaphragmatic paralysis
Uncommon
? Suspected in any newborn with pallor,
irritability and abdominal distension without
evidence of external blood loss
? Liver =most frequently injured abdominal
organ
? Spleen rupture, adrenal hemorrhage, kidney
injuries rare
INTRAABDOMINAL ORGAN INJURIES
- Evidence of fetal distress and all of the following:
1. Profound acidemia (pH5 minutes
3. Evidence of neurological sequelae (seizures, coma,
hypotonia)
4. Multisystem organ failure (CV, GI, hematolog
Criteria for Diagnosis of Perinatal Asphyxia
- Impairment of maternal oxygenation
- Dec blood flow from mother to placenta
- Dec blood flow from placenta to fetus
- Impaired gas exchange across the placenta
- Inc fetal oxygen requirement
Factors That Increase the Risk of Perinatal Asphyxia
Conditions that Predispose to Perinatal Asphyxia
Maternal, Obstetric, Fetal, or Intrapartum?
Hypertension DM CVD Infectious disease Renal disease Drug addiction Anemia/ isoimmunization Age 40
Maternal
Conditions that Predispose to Perinatal Asphyxia
Maternal, Obstetric, Fetal, or Intrapartum?
Abruptio Cord prolapse Placenta previa PROM Hydramnios Multiple gestation
Obstetric
Conditions that Predispose to Perinatal Asphyxia
Maternal, Obstetric, Fetal, or Intrapartum?
Abnormal presentation Precipitous delivery Prolonged labor Difficult assisted delivery Chorio - amnionitis Use of general anesthesia
Intrapartum
Conditions that Predispose to Perinatal Asphyxia
Maternal, Obstetric, Fetal, or Intrapartum?
Prematurity SGA IUGR Post-term gestation Congenital malformation Abnormal heart rate pattern or deceleration
Fetal
An abnormal neurobehavioral state in which the
predominant pathogenic mechanism is impaired
cerebral blood flow
- 20-30% mortality
- 30-50% of survivors develop permanent
neurodevelopmental abnormalities (cerebral palsy;
mental retardation)
Hypoxic-Ischemic Encephalopathy (HIE)
vesicles measure
<5 mm in diameter
bullae measure
> 5 mm in diameter
contain edematous or lymphatic fluid, serum proteins, antigen-antibody complexes, and soluble inflammatory mediators.
Vesicular, bullous, and pustular rash
Infectious Causes in Children (Viruses)
Varicella-zoster virus (wild and vaccine strains)Herpes simplex virus 1, 2; Coxsackievirus A4, A5, A7-10, A16 and B1-3, B5 Echovirus 4, 6, 9, 11, 17, 19, 33 and Enteroviruses 7,2
Infectious Causes in Children (Bacteria)
S. aureus (impetigo, SSS), S. pyogenes (blistering distal dactylitis, ecthyma,erysipelas, impetigo, SSS), Reiters disease
Noninfectious Causes of Vesicles and Bullae In Children, Neonates and Infants
Drug reactions , Stevens-Johnson syndrome , Arthropod bites (Cimex spp. [bedbug], S.scabiei) Contact dermatitis , SLE, Thermal injury, Toxic epidermal necrolysis (Lyell disease)
Primary infection Common highly contagious disease
In normal immunocompetent children,
systemic symptoms usually mild,
serious complications unusual
Varicella (Chicken Pox )
Adults and in children with CMI deficiencies:
constitutional symptoms more severe, eruptions
extensive, occasionally complicated by
pneumonia
Varicella (Chicken Pox )
Mode of transmission: respiratory route or direct
contact with skin lesions of varicella/herpes
zoster patients
Incubation period: 10 21 days
Varicella (Chicken Pox)
characterized by short or absent prodromal period
Prodromal symptoms: fever, malaise, anorexia,
headache, and occasionally abdominal pain for
24-48 hours before appearance of rash.
varicella Chicken pox
Vesicles with irregular margin of erythema that
resemble dewdrops on a rose petal
Varicella Chicken pox
Most striking manifestation of lesion: rapidity of
progression from macule to papule to vesicle with clouding and umbilication within 24 to 48 hours and ends in crusting
Varicella (Chicken Pox)
Lesions appear in crops, generally involve
trunk, scalp, face and extremities
distribution typically central spread peripherally
rash more profuse on the proximal parts of the extremities (upper arms and thighs)
Varicella Chicken Pox
Mild illness with few vesicles Full-blown Varicella syndrome Completely asymptomatic Severe disease with complications in neonates, adults & immunocompromised (Disseminated/Progressive Varicella)
Primary VZV Infection clinical spectrum
Occur in ~ 5% of otherwise healthy subjects
Skin infections
Can cause scarring
Risk of septicemia
Pneumonia
Primary viral or secondary bacterial
Rare in children, more common in adults especially smokers and immunocompromised
Complications of Varicella Chicken Pox
Encephalitis/meningitis Hepatitis Glomerulonephritis Thrombocytopenia Arthritis Reyes syndrome aspirin
Other complications of Varicella Chicken Pox
associated with fever and mild constitutional symptoms
Papulovesicular eruptions
Rapid progression of macules to papules to vesicles and finally to crusts
Appearance of lesions simultaneously in one anatomic area
Predominant central distribution of lesions including the scalp
Eventual crusting of all skin lesions
Clinical Diagnosis
Risk Factors for Progressive Varicella
Malignancy Corticosteroid therapy Pregnant Immunodeficiency Newborns Adolescents and Adults
Neonatal Syndromes resulting from Maternal Varicella
- Congenital defects secondary to intrauterine VZV infection
- Neonatal Chickenpox
- Zoster in infants
Most of the stigmata are due to virus induced injury to the nervous system Cicatricial skin lesions- dermatomal Ocular abnormalities Cataracts Chorioretinitis Horners syndrome Microphthalmia Nystagmus Hypoplastic limbs Cortical atrophy or mental retardation Early death
Congenital (fetal) Varicella Syndrome
17% chance of acute
infection, 31% untreated case mortality rate
5 days before
delivery to 2 days
after delivery
20 days until 6 days
before delivery
Serologic evidence or minimal symptoms of chickenpox
May develop Herpes zoster during infancy
2nd and 3rd trimester up
to 21 days before
delivery
Congenital Varicella Syndrome (2% risk)
1st trimester
Mild disease, or Severe Systemic Infection Fever Poor feeding Pneumonia Vomiting and respiratory distress Mortality 30%
Neonatal Varicella
Varicella zoster virus (VZV) establishes latent infection
in dorsal root ganglia and reactivate
Rare in children younger than 10 years
Incidence higher among children with prior VZV
infection in utero or during the first year of life and
esp. immunocompromised
Herpes Zoster (Shingles)
Tx for Neonatal Varicella
VZIG and Acyclovir
Tx for Herpes zoster:
Acyclovir (oral) 20 mg/k/dose max 800 tid to shorten the course (optional)
Primary varicella:
Option of no treatment in a healthy child unless with complications then treatment with IV acyclovir at 500mg/m2 or 10 mg/k/dose every 8 hours for 7 days
Prevention
Varicella vaccine live attenuated vaccine given in 2 doses ( 12-18 months and at 4-6 yrs)
? Varicella vaccine within 3 to 5 days from exposure
? VZIG within 96 hours from exposure (recommended for immunocompromised children, pregnant women, and exposed newborns)
? Pooled IVIG within 96 hours from exposure
Post Exposure Prophylaxis Options
Family Alphaherpesviridae subfamily herpesvirus
hominis
Herpes Simplex
associated chiefly
with infections of the mouth, lips, eyes and central
nervous system (above the waist)
HSV 1
associated with
genital and neonatal infections
HSV 2
HSV-2, the site of latency is the
sacral ganglia
Viral infection begins at a cutaneous portal of entry such as oral cavity, genital mucosa, conjunctiva or breaks in keratinized epithelia.
HSV
? Various stimuli precipitate recurrent infection:
? manipulation of nerve roots,
? direct trauma to the ganglia,
? exposure to UV light,
? hormonal changes e.g. menses,
? administration of immunosuppressive agents
? and significant intercurrent infection
HSV
