Description 1st peer: Week 7 Discussion Part I Table 1: Amenorrhea Complete the Table Disti ...
Description 1st peer: Week 7 Discussion Part I Table 1: Amenorrhea Complete the Table Distinguish between primary and secondary amenorrhea o Primary amenorrhea: no menstrual period by age 15 or within 3 years of breast development o Secondary amenorrhea: no menstrual period for 3 cycles or absence of periods for at least 6 months in those who previously have had their periods Clinical presentation o SMR IV o Physical signs of eating disorder: anorexia, low pulse, temperature, and blood pressure. Dry skin. o Androgen excess: acne, excess hair on body, male pattern baldness o Hyperinsulinemia: central adiposity, acanthosis nigricans, striae List 3 differentials o Pregnancy o Thyroid disease o Polycystic ovarian syndrome Labs ordered o Pregnancy test o FSH o Estradiol o TSH o T4 o Prolactin o Estradiol o LH o Total and free testosterone o DHEA-S and androstenedione o 17-OH o Pelvic ultrasound o Chromosomal analysis o Pituitary MRI Causes o Pregnancy o Hypogonadotropic conditions: decreased FSH and LH production, low estrogen o Ovarian dysfunction o Structural causes o Hypothalamic or pituitary gland dysfunction o Functional: chronic illnesses, stress, athletics, eating disorders Treatment/Management Based on individual needs. Close monitoring of the patient and her menstrual periods – which should return to a normal frequency of at least every 45 days. Complications Vasomotor symptoms, osteoporotic fractures, endometrial hyperplasia, metabolic and cardiovascular disease, infertility, galactorrhea, hyperandrogenism, psychological effects Table 2: Dermatologic Conditions (Maaks et al., 2020). Common Skin Lesions Description Common Location Treatment/Plan Mongolian Spots Blue or slate gray, irregular, variably sized macules. Presacral or lumbosacral area, upper back, shoulders, extremities. Often covers large area. Transient and will resolve as the child gets older and the skin darkens. Erythema Toxicum Neonatorum Firm, yellow-white papules or pustules with erythematous flare, 1 to 2mm in size. Cheeks, nose, forehead Clears in 2 weeks, completely gone in 4 months Milia, Miliaria, “Prickly Heat” Firm, pearly, white papules Cheeks, nose, forehead Will spontaneously resolve Seborrheic Dermatitis “Cradle Cap” Erythematous, flaky to thick crusts of yellow, greasy scales Scalp, face, behind the ears, neck, trunk, and diaper area Infants: resolves within the 1st year of life, mineral oil may be used. Adolescents: antifungal, anti-inflammatory, keratolytic Café au Lait Spots Tan to light brown macules, oval or irregular in shape, increases in number with age. Anywhere on the skin Monitor, usually no treatment indicated Faun Tail Nevus Posterior midline cutaneous lesion. Excessive hair growth. Represents underlying spinal abnormality Lumbosacral. Posterior midline. Intense pulse light Port Wine Stain (Nevus Flammeus) Purple-red macules, tend to be large. Face, occiput, neck, possibly extremities Pulsed dye lasers, photodynamic therapy Hemangioma (Strawberry Hemangioma) Overgrowth of blood vessels that are either flat, raised, or cavernous. Can be a pale macule, telangiectatic lesion, or bright red nodular papule. Superficial: upper dermis of skin. Deep cavernous: subcutaneous and hypodermal layers. Propranolol. Intralesional and oral steroids. Table 3: Differential Diagnosis Common Childhood Rashes (Maaks et al., 2020). CC: Rash Condition Appearance/Location Treatment Hand Foot mouth disease Vesicular eruptions in the oropharynx, maculopapular rash in the hands and feet. Rash evolves to vesicles especially on the dorsa of hands and soles of feet. Supportive care – rest, hydration, antipyretics Impetigo Nonbullous: 1-2mm erythematous pustules that become vesicles or bullae – leaving moist, honey-colored crusty lesions. Bullous: large, flaccid, thin-wall, superficial, annular or oval pustular blisters – leaving thin varnish-like coating or scale. Common on face, hands, neck, extremities, perineum. Antibiotics: amoxicillin-clavulanate, cephalexin, dicloxacillin, cloxacillin, or clindamycin. Topical antibiotic for milder cases. Measles Enanthem (Koplik spots) on the oral mucosa, opposite the lower molars. Small, irregular, bluish white granules on an erythematous base. Supportive care – rest, hydration, antipyretics Varicella Centripetal rash beginning on scalp, face, or trunk. Leads to teardrop vesicles. Can occur on all mucosal tissues, mouth, pharynx, larynx, trachea, vagina, anus. Supportive care – rest, hydration, antipyretics. Antihistamines or oatmeal baths for itching. Anti-staphylococcal penicillin or cephalosporins for bacterial superinfections. Scarlet Fever Petechiae in mouth. Tongue with papillae. Scarlatina rash exanthema is red, blanches to pressure, papular – leading to coarse skin with sandpaper sensation. Begins on the neck, spreads to trunk and extremities. 10-day course of antibiotics – either penicillin or amoxicillin. Erythromycin for those with PCN allergy. Pediculosis capitis or head lice Lice visualized. Nits are small white oval cases attached to hair shaft and are laid within 4mm of the scalp. Common in the back of the head, nape, behind ears. Pediculicides Molluscum contagiosum Small, firm, pink to flesh-colored discrete papules 1-6mm in size. Papules become umbilicated with cheesy core. Common in face, axillae, antecubital area, trunk, popliteal fossae, crural area, extremities. Curettage, salicylic acid, KOH, Imiquimod, cantharidin, lemon myrtle oil Scabies Curving burrows, especially in webs of fingers, sides of hands, folds of wrist, armpits, elbows, belt line, buttocks, half of foot and heel, palms, soles, scalp, face, posterior auricle, axilla. Permethrin 5% repeated in 1 week. Antihistamine, hydrocortisone, NSAIDs for itching. Clean environment, linens, clothing. Roseola Diffuse, nonpruritic, discrete, rose-colored maculopapular rash, about 2-3mm in diameter. Supportive care – rest, hydration, antipyretics Table 4: Physical Activity and Sports Participation (Maaks et al., 2020). Physical activity recommendations include children and adolescents participating in at least ____ minutes of moderate to vigorous physical activity daily. o 60 minutes What medical conditions would exclude a child from sports participation? o Asthma o Cardiac conditions o Cardiac murmurs o Diabetes mellitus o Hypertension o Seizures o Sickle cell trait o Acute infectious conditions o Infectious mononucleosis o Communicable skin infections o Tinea corporis o Tinea capitis o HSV o Molluscum contagiosum o Furuncles, carbuncles, folliculitis, impetigo, cellulitis, S. aureus o Scabies o HIV and other blood-borne viral pathogens o Exercise-induced dyspnea What are the three entities of the female athlete triad? o Low energy availability with or without a disordered eating pattern o Menstrual dysfunction o Low bone mineral density (osteopenia or osteoporosis) Table 5: Sexually Transmitted Diseases (Maaks et al., 2020). Complete the table. Infection Common Signs & Symptoms Diagnostic Tests Treatment/Follow-up Chlamydia Majority is asymptomatic. Males: dysuria, urethritis, proctitis, pharyngitis. Females: dysuria, vaginal discharge, vaginitis, cervicitis, post-coital bleeding, breakthrough bleeding, dyspareunia, pelvic pain NAAT by urine, vaginal, endocervical, rectal or oropharyngeal swab. Azithromycin 1g PO x 1 dose or Doxycycline 100mg PO bid x 7 days. Retest at 3 months. Gonorrhea Majority is asymptomatic. Males: dysuria, urethritis, proctitis, pharyngitis. Females: dysuria, vaginal discharge, vaginitis, cervicitis, post-coital bleeding, breakthrough bleeding, dyspareunia, pelvic pain. NAAT by urine, vaginal, endocervical, rectal or oropharyngeal swab. Ceftriaxone 250mg IM x 1 dose and azithromycin 1g PO x 1 dose. Retest at 3 months. Trichomoniasis Majority with minimal or no symptoms. Males: urethritis, epididymitis, prostatitis. Females: diffuse, malodorous, or yellow-green discharge with or without vulvar irritation. NAAT testing of vaginal/urethral secretions. Metronidazole 2g PO x 1 dose. Retest at 3 months. Syphilis Primary: painless ulcer or chancre Secondary: skin rash, lymphadenopathy Latent: lacking clinical manifestations Serologic nontreponemal and treponemal tests. Penicillin G Genital Herpes Primary: flu-like illness, multiple and painful vesicles on genital area. Dysuria, tingling, burning or itching sensation. PCR test of herpetic lesion. Initial: Acyclovir 400mg PO tid x 7-10 days or Valacyclovir 1g PO bid x 7-10 days. Recurrent: Acyclovir 800mg bid x 5 days or Valacyclovir 1g PO daily x 5 days. Suppressive: Acyclovir 400mg PO bid or Valacyclovir 1g PO daily. HIV Starts as brief, acute viral syndrome and transitions into chronic illnesses and immunodeficiency. Serologic testing for HIV-1 and HIV-2. Rapid tests available. Antiretrovirals. PrEP for partners. Routine follow-up. Case Scenario - Part 2 Case Scenario 1: Talla is a 16-year-old who has come into the clinic because she has not had a menstrual period in 5 months. She reports she started menstruating at 13 years old. She denies being sexually active. 1) What more should you know about Talla? Last menstrual period Frequency, duration, flow amounts, and regularity of menstrual cycle Medical history: any existing conditions History of extreme weight loss, loss of smell, galactorrhea, headaches, or visual changes Lifestyle: restrictive diets, exercise habits, life stressors Current medications: use of antipsychotics, antidepressants, anticonvulsants, or opiates (associated with hyperprolactinemia) Exposure to chemotherapy or radiation Presence of any eating disorders or high intensity athletic training Family history Sexual history Presence of cyclic pelvic pain History of endometrial or cervical procedures Presence of hyperandrogenemia: male pattern hair growth or loss, excessive acne Presence of autoimmune conditions or other chronic illnesses Uncontrolled diabetes (Nawaz et al., 2024). 2) What diagnostic tests should you order and why? Urine pregnancy test – rule out pregnancy To rule out hypothalamic or pituitary dysfunction: FSH, LH, estradiol To rule our hyperandrogenism: Total testosterone Fasting morning serum 17-hydroxyprogesterone DHEA-S Prolactin – rule out hyperprolactinemia TSH – rule out thyroid causes Pelvic ultrasound CMP, ESR, CRP, CBC – rule out chronic disease such as liver conditions or inflammatory bowel disease (Nawaz et al., 2024). 3) How should you manage this condition? Treatment for amenorrhea depends on the underlying cause or etiology: Gonad disorders: hormone therapy – hormonal contraceptives Outflow tract abnormalities, such as imperforate hymen or cervical stenosis: surgical correction Functional hypothalamic amenorrhea: encourage reversal of contributing factors, such as weight gain, stress reduction, lifestyle changes, dietary changes. Nutrition counseling programs are beneficial as well. Hyperprolactinemia or prolactin-secreting tumor: dopamine agonist cabergoline 2nd peer: Table 1: Amenorrhea Category Primary Amenorrhea Secondary Amenorrhea Definition Absence of menstruation by age 15 in girls with normal secondary sexual characteristics or by age 13 in girls without secondary sexual characteristics. Absence of menstruation for three cycles or six months in women who previously had regular menstrual cycles. Clinical Presentation No menarche, delayed puberty. Absence of menstruation, possibly with other symptoms like weight gain, hair loss, or galactorrhea. Differentials Turner syndrome, Müllerian agenesis, Androgen insensitivity syndrome. Polycystic ovary syndrome (PCOS), Hyperprolactinemia, Thyroid disorders. Labs Ordered Pregnancy test (?-hCG), FSH, LH, Estradiol, Prolactin, Thyroid function tests (TSH, Free T4), Androgen levels (testosterone, DHEA-S). Pregnancy test (?-hCG), FSH, LH, Estradiol, Prolactin, Thyroid function tests (TSH, Free T4), Androgen levels (testosterone, DHEA-S). Causes Genetic/chromosomal abnormalities, Anatomical defects, Endocrine disorders. Pregnancy, PCOS, Hyperprolactinemia, Hypothyroidism, Stress or excessive exercise, Low body weight. Treatment/Management Hormone replacement therapy, Surgery for anatomical issues, Psychological support. Treat underlying cause (e.g., thyroid medication, dopamine agonists for prolactinoma, lifestyle modifications), Hormonal therapy, Weight management. Complications Infertility, Osteoporosis (due to low estrogen levels), Psychological impact (e.g., stress, anxiety). Infertility, Osteoporosis (due to low estrogen levels), Psychological impact (e.g., stress, anxiety). Table 2: Dermatologic Conditions Common Skin Lesions Description Common Location Treatment/Plan Mongolian Spots Bluish-gray patches Lower back, buttocks None, usually fade by age 3-5 Erythema Toxicum Neonatorum Red papules, pustules on an erythematous base Trunk, face, extremities None, self-limiting Milia, Miliaria, “Prickly Heat” Small white or clear papules Face (milia), skin folds (miliaria) None, keep skin cool and dry Seborrheic Dermatitis “Cradle Cap” Greasy, yellowish scales Scalp, face Gentle washing, emollients, mild corticosteroids Café au Lait Spots Light brown macules Anywhere on the body None, monitor for neurofibromatosis Faun Tail Nevus Tuft of hair overlying the spine Lower back None, MRI if spinal dysraphism is suspected Port Wine Stain (Nevus Flammeus) Dark red to purple macules/patches Face, neck, limbs Laser therapy, cosmetic cover-ups Hemangioma (Strawberry Hemangioma) Bright red, raised lesions Anywhere on the body Observation, beta-blockers, laser treatment Table 3: Differential Diagnosis Common Childhood Rashes Condition Appearance/Location Treatment Hand Foot Mouth Disease Vesicles on hands, feet, and oral mucosa Supportive care, hydration, pain relief Impetigo Honey-colored crusted lesions on face and extremities Topical/oral antibiotics (e.g., mupirocin) Measles Koplik spots, maculopapular rash starting on face Supportive care, vitamin A, isolation Varicella Vesicular rash in different stages, starting on trunk Antihistamines, antivirals (if severe), supportive care Scarlet Fever Sandpaper-like rash, strawberry tongue Antibiotics (penicillin or amoxicillin) Pediculosis capitis (Head lice) Itchy scalp, nits on hair shafts Topical pediculicides, combing out nits Molluscum Contagiosum Flesh-colored, umbilicated papules Observation, cryotherapy, topical treatments Scabies Intense itching, burrows in web spaces of fingers Topical permethrin, oral ivermectin Roseola High fever followed by rash on trunk Supportive care, antipyretics Table 4: Physical Activity and Sports Participation Category Details Physical activity recommendations Children and adolescents should participate in at least 60 minutes of moderate to vigorous physical activity daily. Medical Conditions That May Exclude a Child from Sports Participation Medical Conditions Severe asthma or uncontrolled asthma Hypertrophic cardiomyopathy Severe hypertension Active infections (e.g., myocarditis, pericarditis) Recent concussion with ongoing symptoms Severe anemia Certain orthopedic conditions or injuries Three Entities of the Female Athlete Triad Entities Low energy availability (with or without disordered eating) Menstrual dysfunction (e.g., amenorrhea) Low bone mineral density (e.g., osteoporosis) Table 5: Sexually Transmitted Diseases Infection Common Signs & Symptoms Diagnostic Tests Treatment/Follow-up Chlamydia Often asymptomatic, dysuria, pelvic pain, discharge NAAT (nucleic acid amplification test) Azithromycin or doxycycline; retest in 3 months Gonorrhea Purulent discharge, dysuria, pelvic pain NAAT Ceftriaxone plus azithromycin; retest in 3 months Trichomoniasis Frothy green-yellow discharge, itching, burning Wet mount microscopy, NAAT Metronidazole or tinidazole; retest in 3 months Syphilis Primary: chancre; Secondary: rash, mucous patches; Tertiary: gummas, neurologic symptoms RPR or VDRL followed by confirmatory FTA-ABS Penicillin G; follow up with RPR or VDRL titers Genital Herpes Painful vesicles, ulcers, prodromal symptoms (tingling, itching) PCR or viral culture, serologic testing Acyclovir, valacyclovir, or famciclovir; suppressive therapy for recurrent outbreaks HIV Flu-like symptoms, lymphadenopathy, opportunistic infections HIV antibody/antigen test (ELISA) and confirmatory Western blot or PCR Antiretroviral therapy (ART); regular follow-up with CD4 count and viral load monitoring Case Scenario 1: Talla is a 16-year-old who has come into the clinic because she has not had a menstrual period in 5 months. She reports she started menstruating at 13 years old. She denies being sexually active. What more should you know about Talla? What diagnostic tests should you order and why? How should you manage this condition? What More Should You Know About Talla? To better understand Talla's condition, it is essential to gather more information through a detailed history and physical examination. Key areas to explore include her menstrual history, such as previous menstrual cycle patterns, including regularity, duration, and flow, as well as any changes in the pattern before cessation. Additionally, her medical history should be reviewed for any recent illnesses or chronic conditions, significant weight loss or gain, eating habits, and any history of eating disorders. Exercise patterns, particularly excessive physical activity, should also be considered. Family history of menstrual irregularities or endocrine disorders is important, along with psychosocial factors such as stress levels related to school, family, or social pressures. It is also critical to inquire about symptoms of potential underlying causes, including signs of hyperandrogenism (acne, hirsutism), thyroid dysfunction (weight changes, fatigue, temperature intolerance), and hyperprolactinemia (galactorrhea, headaches, vision changes). What Diagnostic Tests Should You Order and Why? Based on Talla's clinical history and physical examination, several diagnostic tests should be considered. A pregnancy test is essential to rule out pregnancy, a common cause of secondary amenorrhea. Blood tests, including a complete blood count (CBC) to check for anemia or other systemic issues, thyroid function tests (TSH, Free T4) to rule out thyroid dysfunction, and a prolactin level to check for hyperprolactinemia, should be conducted. Additionally, measuring follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels can assess ovarian function, while estradiol levels evaluate estrogen status. Testing androgen levels (testosterone, DHEAS) can help check for hyperandrogenism, and fasting glucose and insulin tests can assess for insulin resistance if polycystic ovary syndrome (PCOS) is suspected. Imaging, such as a pelvic ultrasound, can evaluate the ovaries and uterus for structural abnormalities or PCOS. How Should You Manage This Condition? The management of Talla's condition will depend on the underlying cause identified through history, examination, and diagnostic testing. Possible management strategies include lifestyle modifications, such as counseling on a healthy diet and exercise if weight-related issues are identified, and advising on reducing the intensity and frequency of exercise if it is excessive. Medical management may include treating thyroid dysfunction according to the specific disorder diagnosed, using dopamine agonists like bromocriptine or cabergoline for hyperprolactinemia, and managing PCOS with lifestyle changes, hormonal contraceptives to regularize menstruation, and possibly insulin-sensitizing agents like metformin. Providing psychosocial support is also crucial if stress or psychological factors are significant, potentially involving a referral to a counselor or psychologist. Regular follow-up is necessary to monitor response to treatment and any changes in symptoms. Given Talla’s age and the potential for various underlying causes, a sensitive and supportive approach is vital.
