1. ADOLESCENT MEDICINE (HEADSSS)

HEADDSSS

• Home: How are things at home? Who lives at home, age, occupation? How does everyone get along? What do you argue about? Have there been any changes lately? Have you ever run away from home?

• Education / Employment: Name of school, grade level, attendance pattern, amount of school missed, academic performance,favourite/least favourite courses, marks, behaviour at school, current and past jobs

• Activities: What do you do when not at school? For fun? On weekends? Do you feel you have enough friends? Who are your bestfriends? What do you do together? Sports / exercise, extra‐curricularactivities, hobbies, social groups? Do you go out to parties a lot? Howdo you pay for things you do?

• Drugs: Have you ever tried smoking or drinking alcohol? What did you think? What about other drugs? Have you ever tried Marijuana? Ever been drunk? Friends’ use and peer pressure? What age did you start? Frequency? Amount? What do you like/dislike? Why do you use? Use alone? Have you ever gotten into trouble because of using these substances? What would/does your family think if they knew that? What do you think about it?

• Dieting: Do you have concerns about/have you tried to change your weight/shape (dieting/exercise)? Presence of bingeing/purging behaviours, use of diuretics/laxatives. Tell me what you eat/drink in an average day

• Safety: Do you regularly use: seatbelts? Bike helmets? Appropriate gear when snowboarding/skateboarding? Does anyone at home own a gun? Has anyone ever hurt you or touched you in a way that was hurtful or inappropriate? Driving?

• Sexuality: Are you interested in the same sex, opposite sex or both? (DO NOT assume heterosexuality!) Are you dating someone now? Are you having sex? What do you use for contraception/STI prevention? Number of sexual partners /age of first sexual activity/STI history / last pelvic exam in females / ever tested for STIs, HIV? History of pregnancy? Sexual abuse?

• Suicide / Depression: Screen for depression (SIGMECAPS). Does the teen see themselves as generally happy or unhappy? Do they have difficulties with anger? When they feel sad, how do they cope with it? Have they ever thought about killing themselves? How recently? Has the teen had any prior suicide attempts?

1. 1. STIs

• 14yo ♂ comes after having urethral discharge and has had 3 sexual contacts (anal but no oral sex, I think). What should you do? What should you tell the child? What are the 5 tests you would do? (choose from menu)

• Plan: further Hx (S+S, sexual behaviours, RFs)

  • chlamydia

    • female: vag discharge, dysuria, abn vag bleed, lower abdo pain, dyspareunia, +/- fever, +/- conjunctivitis

    • male: urethral discharge, urethral pruritus, dysuria, testicular pain, +/- fever, +/- conjunctivitis

  • gonorrhea

    • female: cervicitis, PID, urethritis, inflm of lower 1/3 of vulva, vag discharge, dysuria, abn vag bleed, lower abdo pain, deep dyspareunia, +/- fever

    • male: urethritis, epididymitis, testicular pain, urethral itch, urethral discharge, +/- fever

    • both: pharyngeal inf, purulent conjunctivitis, disseminated gonococcal inf (arthritis, dermatitis, endocarditis, meningitis)

  • HPV

    • irregular bumps (perianal, introital, penile), +/- abn vag bleed/local irritation/pain, hx of warts

  • RFs: inconsistent barrier contraceptive use, new partner, >2 partners in past yr, prev STIs, vulnerable (sex trade, street youth)

• Disclosure: based on maturity/capacity of child, see about involving parents

• Ix: CBC (leukocytosis, elevated ESR/CRP), U/A, urine culture, swab (urethra ± anal; endocervix - F) for NAAT/culture (chlamydia/gonorrhea), first catch urine for NAAT, hepatitis B, HIV, VDRL

  • HIV: pap smear, +/- HPV DNA

• mgnt:

  • chlamydia - abx (empiric if sx’s suggestive; azithromycin 1g PO single dose OR doxycycline 100 mg PO bid x7d)

    • hospitalization if pregnant, high fever, severe n/v, unable to tolerate PO, concurrent HIV

  • gonorrhea - empiric abx (ceftriaxone 250mg IM single dose AND azithromycin 1g PO single dose)

    • hospitalization same as above

  • HPV - watchful waiting (esp if young), medical (podofilox, topical trichloracetic acid, 5-fluorouracil, immune modulators - imiquimod), surgical (cryotherapy, excision, laser), hospitalization only if child abuse

2. 2. EATING DISORDERS

• Know specific signs for anorexia + bulemia

• Anorexia nervosa (think ↓THY): orthostatic changes (pulse >20 or BP >10), bradycardia, cold extremities + acrocyanosis, hypothermia, delayed puberty, lanugo hair, hair loss, loss of muscle mass and subcutaneous fat, dry skin, brittle nails, yellow skin from high carotene, pedal edema (low albumin), constipation, GERD, delayed gastric emptying, osteoporosis secondary to hypogonadism, ↓BMI

• Bulimia nervosa: rough & scaly skin, erosion of enamel of teeth, Russell’s sign (callouses on knuckles), parotitis, ↑/normal BMI

3. 3. DEPRESSION

• 14yo who is not sleeping well comes to you. What are 5 important questions to ask? What is your DDx?

• BEARS: Bedtime problems, Excessive daytime sleepiness, Awakening during night, Regularity and duration of sleep, Snoring; also Suicide screen

• DDx: behavioural, psychosocial, anxiety/depression, OSA, narcolepsy, chronic disease

• What are 5 RFs for suicide?

• Psychiatric d/o, previous attempts, FHx, abuse/violent exposure, access, EtOH/drugs, stress, adoption, sexual orientation