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Board Review 4/2/2013

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True or False: My March Madness bracket was way off this year A. True B. False C. Um, this is the south we only care about football

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Anorexia and bulemia are fairly rare conditions with a prevalence of 0.5-2% Onset Anorexia: mid-adolescence Bulimia: late-adolescence Majority of patients report body image concerns and disordered eating before adolescence Predisposing factors Family history of eating disorders, obesity, mood disorder Girls with early puberty or obesity (especially if teased) Past history of abuse, often sexual Sports that place an emphasis on thinness

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Recognize risk factors and early signs of an eating disorder and obtain an appropriate history and physical exam to guide management.

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Comorbid mental disorders are present in the majority of patients with an eating disorder. Anorexia Major depression Anxiety disorders OCD Generalized anxiety disorder Social phobia Bulimia Comorbid mood disorders (depression, bipolar disorder) Anxiety disorders Substance abuse disorders MORE high risk behaviors due to impulsivity

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Which of the following is NOT a criteria for the diagnosis of anorexia nervosa? A. An intense fear of gaining weight or becoming fat. B. The absence of 3 consecutive menstrual cycles in a post-menarchal female C. Denial of the seriousness of low body weight D. Refusal to maintain body weight more than 80% expected for height and age E. An undue influence of body weight or shape on self evaluation.

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Restrictive typeno binge or purge behaviors; most common type Binge-eating/purging type Patient regularly engages in binge eating or purging behaviors Vomiting Laxatives/enemas Diuretics

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Inpatient management Multidisciplinary team, including medical specialist, psychiatrist, nutritionist, and social worker Goals Correct malnourishment Promote healthy eating and weight gain pound increase per day Correct electrolytes Rule out psychiatric issues Develop a discharge plan Patient contracts

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Prevent refeeding syndrome Reintroducing food to a patient with anorexia may cause a rapid fall in phosphate, magnesium, and potassium, along with an increasing extracellular volume Hypophosphatemia can lead to Rhabdomyolysis Decreased cardiac motility, cardiomyopathy Respiratory and cardiac failure Edema, hemolysis, ATN, seizures, and delirium Phosphate supplementation DC once stable and appropriate weight gain, often to outpatient facility

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The further patients are from their ideal body weight, the more likely they are to suffer medical complications Most complications are corrected with return to ideal body weight Bone loss due to hypothalamic amenorrhea or low testosterone (males) does NOT automatically return to normal with weight gain

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Establish a treatment team to monitor the patient. Clear guidelines should be given to the patient with clear criteria for re-admission Establish appropriate weight goals -1lb gain per week There are varying levels of outpatient care that can be coordinated with the help of the pediatrician. For BMD loss At least 400-800 IU of vitamin D 1200mg elemental calcium DEXA scan for those with 6 months of amenorrhea NO role for psychopharmacology Outpatient behavioral therapies and family therapies are beneficial

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A 17-year-old girl is brought to the emergency department by her parents because of vomiting. She has no fever, headache, abdominal pain, or diarrhea. She says that over the past 3 years she has periods of time when she vomits and then she is fine for a while. She denies inducing the vomiting. Her periods are regular, and her last one was 2 weeks ago. On physical examination, you note normal vital signs, a body mass index of 28.5, a small subconjunctival hemorrhage on the right eye, and slight enlargement of her parotid glands bilaterally. Laboratory results are fairly normal. Of the following, the MOST likely explanation for these findings is A. Acute pancreatitis B. Bulimia nervosa C. Cyclic vomiting D. Diabetic ketoacidosis E. Ectopic pregnancy

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Patients are often of normal weight or above normal weight and can easily hide their disorder Purging subtype describes an individual who engages regularly in self- induced vomiting or the misuse of laxatives/diuretics/enema Nonpurging subtype describes someone who uses other excessive measures (exercise or fasting) to burn calories

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You are seeing your 18 year old patient with a known history of bulimia. Today, you are concerned that your patient may be doing poorly with her outpatient control, as the parents are noticing more warning signs. Every month you follow the patients electrolytes. Which 2 electrolytes should be closely evaluated to help you decide whether or not to admit your patient to the hospital?? A. Sodium and glucose B. Potassium and bicarbonate C. Sodium and chloride D. Glucose and BUN E. Potassium and chloride

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Outpatient management Team approach Promote hydration, high fiber diet, and moderate exercise Monitor electrolytesPO potassium or IV if severe hypokalemia PPI if reflux Similar bone care as anorexia if amenorrhea! FLUOXETINE has been shown to help reduce symptoms Cognitive behavioral therapy Most patients respond to outpatient management, but some do meet the criteria for hospitalization

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Pediatricians should recognize warning signs for both illnesses and intervene quickly! Anorexia Rapid or severe weight loss Falling of growth percentiles Excessive dieting or exercising Constriction of food choices, calorie counting Excessive concern with weight or body shape Bulimia Weight cycles Excessive concern with weight or shape Trips to bathroom after meals Electrolyte abnormalities Swollen parotic glands or knuckle abrasions

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Nearly 50% recover, 30% show improvement, and 20% have a chronic course Mortality rate up to 5%...worse for anorexia? Prognostic indicators Good Onset before adulthood, especially before 14yo Early, intensive treatment Family support Shorter duration of illness Bad Presence of bingeing and purging Longer duration of illness before treatment Poor family relations Comorbid psychiatric conditions

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Eating disorder NOS: patient with disordered eating who does not meet the criteria for anorexia or bulimia Female Athlete Triad 1) Low energy availability with or without an eating disorder 2) Hypothalamic amenorrhea Low body fat composition that leads to low estrogen and amenorrhea 3) Osteoporosis Treatment is multidisciplinary Increase energy availability Calcium and vitamin D supplements with weight bearing exercises; DEXA scan if fracture or >6mo amenorrhea Protectionmaintain healthy balance between exercise, energy availability, and body weight

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The US has the highest rate of teen pregnancy and births in the industrialized world There are numerous social, economic, educational problems associated with teen pregnancy

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Normal period: Lasts 3-7 days Interval: 21-45 days more commonly 21-35 days Total blood loss: 35-40ml Menorrhagia: large quantity of bleeding > 7 days of bleeding or > 80ml blood loss Metorrhagia: irregular bleeding Menometorrhagia: irregular heavy bleeding

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Due to delay of maturation of negative feedback loop Anovulatory cycles Constantly proliferating endometrium with irregular shedding Diagnosis of exclusion Differential diagnosis Threatened abortion Ectopic pregnancy Bleeding disorder Infection (PID) Endocrinopathy (PCOS, thyroid disorder)

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A 14 yo girl, who has had irregular bleeding since menarche at age 11 years, presents with painless menstrual bleeding of 14 days duration. She is using 8 to 10 pads per day. She is tired and is upset with the number of days of bleeding. The only finding on physical examination is mild pallor. Her heart rate is 82, blood pressure is 120/80, with no postural changes. Labs show a hemoglobin of 9.4 g/dL, normal platelet count, PT, PTT, and von Willebrand panel. Of the following, the MOST appropriate treatment for this girl is A. Iron-rich diet B. A daily dose of oral progesterone pills C. Combined oral contraceptive pills and iron supplementation D. Gynecologic referral for surgical treatment E. Tracking with a menstrual calendar and follow-up appointment in 3 months

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Evaluation: UPT, CBC with retic, TSH Must screen for anemia/iron deficiency Other labs based on differential diagnosis Treatment: Surgical intervention is RARELY necessary Depends on severity of anemia Admit if severe Treat any anemia with iron replacement Goal: stabilize endometrium Estrogens for initial hemostasis Progestins for endometrial stability Most cases: treat with combination OCP GnRH analogs for prophylactic (not acute) treatment

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A 15 yo girl presents for treatment of menstrual cramps. She had menarche 3 years ago and over the last year she began having pain with her cycle. The pain is worse on the first day and she occassionally misses school due to the pain. Of the following, which is the BEST initial treatment? A. Acetaminophen B. Calcium channel blocker C. Combined OCP D. Omega-3 fatty acids E. Ibuprofen

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Pain associated with menstrual cycle Primary(functional): occurs in absence of pelvic disease Pain in lower abdomen, back, thighs Caused by prostaglandin E2 and F2a secretion Treatment: 1 st line: NSAIDS If no help after 2-3 cycles, consider next step 2 nd line: OCP If no help after 3-6 months, reconsider secondary causes Secondary: due to pathologic process IUD, PID, endometriosis, pregnancy

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Inflammation of the cervix Caused by Chlamydia trachomatis Neisseria gonorrhoeae Trichomonas vaginalis HSV Signs/Symptoms: Vaginal discharge, itching, irregular bleeding, dyspareunia, friability of cervix Lower abdominal pain or cervial/adenexal tenderness suggest PID

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Evaluation NAATs for gonorrhea or chlamydia Wet prep, HIV, syphilis Treat based on test results unless unsure of follow-up High risk adolescents should be screened for GC and chlamydia every 6 months Multiple sexual partners, prior history of STI Treatment Gonorrhea: Ceftriaxone 250mg IM x1 (125mg for