Family Developmental Stages and Child Development Milestones, Exams of Sociology

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Family Theory-be Able To Identify A Aamily Developmental Stage By A Description.Latest Update Family theory: be able to identify a family developmental stage by a description. • Stage 1: Beginning family- Married couple establish home but no children Developmental Tasks: Establishing a satisfying home and marriage relationship and preparing for childbirth • Stage 2: Childbearing Family- From birth of 1st child until that child is 2 ½ years old Developmental Task: Adjusting to increased family size and providing a positive developmental environment • Stage 3: Family with Preschoolers- Oldest child is between 2 ½ and 6 Developmental tasks (DT): coping with demands on energy and attention with less privacy at home • Stage 4: Family with School Children- When oldest child is between ages of 6 and 13 DT: Promoting educational achievement and fitting in with the community of families with school-age children • Stage 5: Family with Teenagers- Oldest child is between ages of 13 and 20 DT: Allowing and helping children to become more independent • Stage 6: Launching Centre- When oldest child leaves family until the youngest leaves home DT: Releasing young adults and accepting new ways of relating to them; maintaining a supportive home base • Stage 7: Empty Nest- From time children are gone till couple retires DT: Renewing and redefining marriage relationship; preparing for retirement years • Stage 8: Aging Family- From retirement till death of the marriage partner DT: Adjusting to retirement; coping with death and living alone. Growth/development: Identify normal vs. abnormal development if given a description of patient behaviors. Define the diagnosis and meaning of Autism. ● Jean Piaget—developmental psychologist; cognitive development theories ● Piaget’s Theory: • Sensorimotor (0-2 years): Development is driven by motor development; coordination of senses with motor response, sensory curiosity. Language used for demands and cataloging. Object permanence developed. • Preoperational (2-7 years): Symbolic thinking, use of proper syntax and grammar to express full concepts. Imagination and intuition are strong, but complex abstract thought still difficult. Conservation developed. Important milestones Age Milestones 1 Newborn ● Vision is highly limited at birth (8-12 inches) ● Fixes on moving objects ● Prefers human face; establishes eye contact around one month of age ● Infant will tend to lay in flexed position; will turn head from side to side ● On horizontal suspension there will be some head sagging, but infant should not be hypotonic ● All primitive reflexes should be present • Moro, grasp, rooting, tonic neck, etc. ● Infant should regain birthweight by 2 weeks and grow 30 g/day until 4 months of age ● (birth weight should double at this point)  If they are premature, you have to correct for that ● Reacts to voice by one month of age—if child is not reacting, think of hearing loss ● Crying peaks around 6 weeks of age (up to 3 hours per day) 1 month old Reacts to voice, establishes eye contact 2 months old ● Infant is able to differentiate among patterns, colors, and consonants, but due to the baby’s yet-limited ability to communicate, this may be difficult to notice ● Infant should be able to track an object horizontally at 180 degrees—can track to midline ● Head lag should be gone and the head and trunk should be held in the same plane on horizontal suspension ● Social smile ● Will listen to voice and make cooing sounds—cooing is vocal development, not language ● Infant should be able to hold head steady while sitting in lap ● Infant should be able to raise head slightly when laying in prone position— TUMMY TIME!! • Increases risk of SIDS if put to bed on stomach 4 months old • Recognizes hand ● Infant becomes noticeably more distracted by surroundings ● Infant explores own body, especially hands and mouth ● Sense of proprioception begins to mature ● Infant will begin to recognize emotions in others and may mirror such emotions (sustained social smile & laughing) ● Object permanence has not yet developed, so peek-a-boo will amuse the infant ● Infant should be able to lift head above plane when held in horizontal suspension 2 18 months old ● Classically, child should be able to build a 4 block tower ● Vocabulary should include at least 10 words and include at least one body part ● Child should be able to run by this point, but it will look bumbly ● Should be able to walk up and down stairs with hands held ● Often will be able to sit on a small, child-sized chair ● Able to kiss parent with a pucker ● Child exhibits self-awareness and may recognize self in mirror ● Should indicate some desires by pointing 2 years old (24 months) ● Basic sentence; possessive (“mine”) ● Classically, child should be able to build a 7 block tower ● Child should be able to scribble or copy a circle ● Child should be able to put a very basic sentence together (“Come here”, “want more”); vocabulary begins to expand rapidly age 2 ● Child should begin to use pronouns and possessives ● Rule of thumb: the number of words a child can put together in a sentence roughly corresponds to his/her age (i.e., two words at age 2, three words at age 3, etc.) ● Should be able to jump in place ● Often able to insert small objects into holes ● Classically, by 2 years old, the child should be able to build a 7 block tower ● Linguistic development allows child to relate recent experiences in very simple expressions • Vocabulary has usually expanded to 50-100 words and will dramatically increase after ● Should be able to properly use spoon ● Should be able to respond to two-step commands ● Engages in parallel play—two children, together, sitting playing togethe 5 2 ½ years old (30 months) ● Uses “I” to refer to self; knows name ● Child should understand the word “I” and “me” and use it to refer to himself or herself ● Should be able to respond with name when asked ● Should be able to make horizontal and vertical lines with crayon ● Birthweight should have quadrupled by age 2 ½ ● Child should be able to properly ascend stairs with alternating feet ● Child should be able to stand on one foot ● Child begins to engage in imaginative play, but may have difficulty distinguishing reality from fantasy • Big problem when it comes to violence on TV; child could think it is normal or may be scared that the violence could happen towards them ● Tantrums peaks at 2 ½ years of age • Child should be able to express themselves through words more but will still continue to have tantrums 3 years old ● Child should know age and sex—unless there are legitimate gender recognition issues ● Speech should be mostly understandable by strangers ● Should be able to count to 3 ● Should be able to recognize at least 3 colors 6 ● Child should be able to descend stairs with alternating feet ● Should be able to properly draw or copy a circle ● Left-or right-handedness is developed ● Should be able to ride a tricycle if trained (remember to use a helmet!!) ● Should be able to help getting dressed ● Washes hands ● Still not able to consider others’ points of view and fairness is viewed in somewhat concrete terms – egocentriscism • Have started to develop an idea of fairness but it is a concrete idea 4 years old ● Child should be able to draw a square ● Should be able to tell a short story or narrative of something that recently happened to him or her ● Should begin to use the past tense ● Thought process is usually magical in nature (i.e., monsters) • Cannot be reasoned with logic and may be scared • Can use magical thought process to “reason” with them—can tell the parent to dress up as a hero and slay all of the monsters ● Child should be able to hop in place ● Overhand throw ● Social interaction and together play should have started ● Control of bowel and bladder has developed, and potty training is likely accomplished by this age • Bed-wetting is normal in girls up to age 4 and in boys up to age 5 • If potty training is unsuccessful, a brief switch back to diapers and trying again later is okay ● Child should begin to show modesty about sexual organs and nudity – self-consciousness begins to develop and they are aware that they are not supposed to show their “private parts” in front of other people 5 years ● Dresses and undresses self ● Inquisitive: asks about meanings of words ● Should be able to communicate in complete sentences that are understood by strangers ● Child should develop a sense of rules, but they are often understood in only concrete terms • While genital self-touching is still considered normal, the child should know when it is not appropriate. Excessive sexualized behavior or acting- out adult sexual acts is a troubling sign and may indicate psychiatric issues or abuse. • Child does not understand figurative speech—“light as a feather” 7 • Does not respond to his or her name by 12 months old • Does not point at objects to show interest (pointing at an airplane flying over) by 14 months old • Does not play “pretend” games (pretending to “feed” a doll) by 18 months old • Avoid eye contact and wants to be alone • Has trouble understanding other people’s feelings or talking about their own feelings • Has delayed speech and language skills (no babbling or gesturing by 12 months old; no single words by 16 months old; no two-word [not echolalic] phrases by 24 months old) • Repeats words or phrases over and over (echolalia) • Gives unrelated answers to questions • Gets upset by minor changes • Has obsessive interests • Flaps their hands, rocks their body, or spins in circles • Has unusual reactions to the way things sound, smell, taste, look, or feel • Fails to meet childhood developmental milestones • Has a sibling with autism • Has loss of any language or social abilities at any age Genetics: be able to recognize the signs of the common genetic disorders. Disorder Physical characteristics Developmental characteristics Cause/ Diagnosis Downs Syndrom e *Most common cause of moderat e MR *associate d with ↑ in maternal age *3 copies of chromoso m e 21 due to non- disjunction Flat face Upward slanted palpebral fissures Small ears Epicanthal fold Simian crease Protruding tongue Short neck Hypotonia, decreased moro reflex Obesity Issues with expressive language Some degree of developmental delay in all, may be high- functioning though Self-help skills delayed Alzheimer’s ▪ usually prenatal testing ▪ 1st trimester: fetal nuchal translucency ▪ 2nd trimester: quad screen or triple marker screen ▪ formal diagnosis is chromosomal analysis Management: ▪ routine care ▪ attend to comorbidite s ▪ peds consult for congenital heart defects ▪ peds opthalmologist consult 10 ▪ thyroid function test Long term considerations : ▪ health maintenance ▪ chart growth on down’s curve ▪ diet counseling ▪ check vision/hearing annually ▪ xray for atlantoaxial subluxation for neck pain or before sports ▪ speech therapy, PT/OT ▪ life expectancy in 50’s ▪ increased early- onset alzheimer’s risk Prader-Willi Narrow temple distance Narrow nasal bridge Narrow upper lip Obesity Light colored in complexion, hair, eyes Insatiable appetite (hyperphasia) If inherited through mother, causes Angelman ▪ short stature ▪ severe MR ▪ spasticity ▪ seizures If inherited through father, causes Prader Willi: ▪ obesity ▪ excess gorging ▪ small hands, feet ▪ hypogonadism ▪ MR Early life: feeding Genetic testing Syndrome difficulties and hypotonia Delayed physical and Chromosome 15- *70% is gene deletion or mutation cognitive development Delayed puberty OCD features in @ 50% deleted or unexpressed Management: ▪ no cure; reduce symptoms ▪ Failure to thrive in neonates-persistent nursing, language therapy, tube feeding ▪ Cryptorchidism ▪ PT ▪ growth hormone therapy ▪ hyperphgia/obesity ▪ Monitor for long term considerations: ○ DM ○ hyperlipidemia ○ sleep apnea ○ genetic counseling 11 in adulthood 12 Syndrome *error is on x chromosome so males are more affected *severity is related to mutation. *error is on x chromosome so males are more affected Elongated face/ forehead High, arched palate scoliosis Macro-orchidism Hyper-extensible joints Short stature Obesity Autism ADHD Anxiety (esp. social) Gross motor delays- r/t hypotonia Fine motor delays Low IQ Speech and language delays Seizures Premature ovarian failure Early menopause diagnose- prenatally or postnatally prenatal test of amniotic fluid postnatal test with blood screen for heart defects. Most common is MVP. Long term: counseling for discipline and behavior modifications work training and special ed social worker normal life expectancy leads to cognitive/intellectua l disability and some psych Fetal Alcohol Syndrome Short palpebral fissure Epicanthal folds Low nasal bridge Flat midface Thin upper lip Smooth philtrum Small eye openings Short nose Microcephaly Growth retardation/restriction -pre and postnatally CNS dysfunction Mental retardation Congenital heart defects Behavioral disturbances ETOH crosses placenta and blood-brain barrier Treatment: intervention before it happens counseling 15 Klinefelter’ s Syndrome Small testes and penis Reduced body hair Gynecomastia Need for testosterone replacement Infertility Extra X chromosome- random (not inherited) Karyotyping to 16 Long legs/ short trunk Learning disabilities Delayed speech and language development Sexual problems ADHD Complications: ▪ enlarged teeth w/thinning surface ▪ ADHD ▪ breast cancer; lung disease ▪ osteoporosis ▪ varicose veins ▪ autoimmune disorders (Lupus, RA, etc) diagnose Treatment: ▪ testosteron e replacemen t ▪ mastectomy Immunizations: Identify contraindications and order correct vaccines in a patient scenario. Recommended and minimum ages and intervals between vaccine doses*† Vaccine and dose number Recommended age for this dose Minimum age for this dose Recommende d interval to next dose Minimum interval to next dose HepB-1 Birth Birth 1--4 months 4 weeks HepB-2 1--2 months 4 weeks 2--17 months 8 weeks HepB-3 6--18 months 24 weeks --- --- DTaP-1 2 months 6 weeks 2 months 4 weeks DTaP-2 4 months 10 weeks 2 months 4 weeks DTaP-3 6 months 14 weeks 6--12 months 6 months**,†† DTaP-4 15--18 months 12 months 3 years 6 months** DTaP-5 4--6 years 4 years --- --- Hib-1 2 months 6 weeks 2 months 4 weeks Hib-2 4 months 10 weeks 2 months 4 weeks Hib-3 6 months 14 weeks 6--9 months 8 weeks Hib-4 12--15 months 12 months --- --- 17 HPV-1 11--12 years 9 years 2 months 4 weeks HPV-2 11--12 years (+2 months) 9 years (+4 weeks) 4 months 12 weeks††††† HPV-3 11--12 years (+6 months) 9 years (+24 weeks) --- --- Rotavirus-1 2 months 6 weeks 2 months 4 weeks Rotavirus-2 4 months 10 weeks 2 months 4 weeks Rotavirus-3 6 months 14 weeks --- --- Herpes zoster ≥60 years 60 years o Hep B (3 doses) 0, 2, and no earlier than 6 months If HBsAg + mother- give dose 1 and HBIG at birth If HBsAg unknown mother- give dose 1 at birth and give HBIG within 7 days if mom is tested + o Rotavirus (2-3 doses) 2, 4, 6 months *Live Attenuated Virus* o DTaP (3 doses & 2 boosters) 2, 4, 6 months, 15 months, 4 years o TDaP (1 dose) 11 years, each pregnancy at >20 weeks gestation, adults >65 if contact with infants; age 7 if catch-up needed (Td booster every 10 years) o Hib (3 doses & 1 booster) 2, 4, 6 months, 12 months o PCV-13 (3 doses & 1 booster) 2, 4, 6 months, 12 months; additionally 23-valent can be given at 2 years for chronic illness o IPV (4 doses) 2, 4, 6 months, 4 years 20 o Influenza annually; first time vaccination 6 months- 35 months get 2 half doses 1 month apart, 36 months- 9 years get 2 full doses 1 month apart Note- FluMist (*Live Attenuated Virus*) o MMR (2 doses) 12 months, 4 years *Live Attenuated Virus* o Varicella (2 doses) 12 months, 4 years *Live Attenuated Virus* o Hep A (2 doses) 1-2 years old, 6 months between doses o Meningococcal (1 dose & booster) 11 & 16 years o HPV (3 doses) 9-26 years (9-12 for best immune response) dose 1-2 min 4 weeks, dose 2-3 min 12 weeks *Remember* Live attenuated viruses must be given together or 28 days apart. MMR, RV, Varicella, Flu mist, PPD If scrambled eggs are tolerated, not a true egg allergy! Vaccinate Contraindications and precautions* to commonly used vaccines Vaccine Contraindications Precautions DTaP Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Encephalopathy (e.g., coma, decreased level of consciousness, or prolonged seizures), not attributable to another identifiable cause, within 7 days of administration of previous dose of DTP or DTaP Progressive neurologic disorder, including infantile spasms, uncontrolled epilepsy, progressive encephalopathy; defer DTaP until neurologic status clarified and stabilized Temperature of ≥105°F (≥40.5°C) within 48 hours after vaccination with a previous dose of DTP or DTaP Collapse or shock-like state (i.e., hypotonic hyporesponsive episode) within 48 hours after receiving a previous dose of 21 DTP/DTaP Seizure ≤3 days after receiving a 22 a previous dose or to a vaccine component Pregnancy Known severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, or long-term immunosuppressive therapy or patients with HIV infection who are severely immunocompromised)§ antibody-containing blood product (specific interval depends on product)** History of thrombocytopenia or thrombocytopenic purpura Need for tuberculin skin testing†† Moderate or severe acute illness with or without fever Hib Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Age <6 weeks Moderate or severe acute illness with or without fever Hepatiti s B Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Infant weight <2,000 gm§§ Moderate or severe acute illness with or without fever Hepatiti s A Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Pregnancy Moderate or severe acute illness with or without fever Varicella Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Known severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, or long-term immunosuppressive therapy or patients with HIV infection who are severely immunocompromised) Pregnancy Recent (≤11 months) receipt of antibody-containing blood product (specific interval depends on product) Moderate or severe acute illness with or without fever Women’s health Women’s/men’s health: Identify a problem based on symptoms. Contrast normal vs abnormal findings. Plan contraception and know contraindications in hormonal therapies. Female: • Amenorrhea- tx of underlying cause (most common is pregnancy) • Bartholin gland cysts or abscesses- tx is antibiotics or surgical procedures • Breast issues- see answer below. • Chronic pelvic pain- many causes, often difficult to diagnose • Dysmenorrhea- supportive, NSAIDS/ birth control • Dyspareunia is often a result of inadequate vaginal lubrication, OTC or prescription lubricative agents can be useful, as well as education about adequate female arousal prior to intercourse. • Benign breast lumps- make up 80% of lumps seen. Risk of cancer correlates with age (younger is less risk, older is more risk- esp. after menopause) 25 • Fibroadenoma- benign lump in patient under 30 years old. Solid tumor, palpable, rounded and mobile. 10% spontaneously resolve. US to see best. Increased risk of breast ca later in life. 26 • Fibrocystic breast changes- affects half of all female patients (may be asymptomatic). Consists of microcysts or large cysts. May be solid or fluid filled. Large cysts need fine needle aspiration to r/o ca. • Papillomas- intraductal growths, can cause discharge (may be bloody). May need a ductogram to diagnose. • Mammary duct ectasia- non-lactation associated periductal mastitis • Mastalgia (breast pain) without physical findings- often cyclic, may be associated with caffeine. Tx is evening primrose oil. • Breast cancer- fixed, nontender, mobile mass, swelling, lymphadenopathy, nipple or skin changes. Need diagnostic mammogram (multi-angle views) o Invasive ductal carcinoma- most common (80%), usually > 55 years old, rare in men o Inflammatory breast cancer- rare, more common in younger women and African Americans. Red, swollen breast- normal mammogram. Dimpled or pitted skin that looks like an orange peel (called peau d’orange) r/t lymphatic blockage. Pregnancy Physiologic Changes: Cardiovascular changes ● Circulating blood volume 40-45% increase ● 43% increase in cardiac output ● 17% increase in resting heart rate ● BP normally decreases ● May see changes in physical examination: ● Heart murmur (flow murmur), larger cardiac silhouette if patient has chest x-ray, left axis deviation on EKG Respiratory changes ● Functional residual lung capacity decreases in response to increase level of diaphragm ● Dyspnea and SOB on exertion is a common complaint ● Pregnant asthmatics should be monitored monthly for asthma GI changes ● Progesterone causes motility to slow in the GI system. ● This may cause GERD and constipation. May need small frequent meals and high fiber. ● Since gallbladder emptying is delayed, the patient may develop gallstones during Genitourinary ● Renal blood flow is increased due to cardiovascular changes. ● Kidneys increase slightly in size. ● GFR increases by 50%. ● Pregnant patients will often complain of frequent urination. ● Kidney function is assessed at each office visit, urine is checked for protein and infection. Hematology 27 ● Nausea and vomiting ● Pain: ectopic or threatened abortion First Trimester Bleeding ● Not normal but VERY common. ● Remember that the cervix becomes more vascular in early pregnancy (Chadwick’s sign). ● Intercourse or infection may cause bleeding of this now vascular tissue. ● Bleeding may also result from polyps. ● Spontaneous abortion. Ectopic Pregnancy ● Fertilized egg grows inside the tube or other extra uterine site. ● The growing tissue causes severe pain in the pelvic area. ● Usually seen between weeks 5-10. ● If diagnosed early, the patient may be treated with Methotrexate to stop the growth of fetal tissue. ● Otherwise, the patient will require surgical removal. Nausea and Vomiting ● Common signs in early pregnancy but patient must be assessed for danger signs. ● Assess for urinary ketones and hydration status. ● Liver enzymes may be elevated, indicating hepatitis. ● The provider also must consider pancreatitis and cholecystitis. ● Patients with no organic cause may improve with Phenergan or Zofran. *REMEMBER: Nausea and vomiting after the first trimester must be investigated! The Second Trimester: Red Flags Just FYI—during the second trimester, estrogen causes growth of blood supply of lots of things— moles, warts, gums. Patients may report bleeding gums—they should see the dentist, but you can reassure them about this. Incompetent Cervix ● An incompetent cervix dilates in response to the growing uterine contents. ● This may lead to premature delivery. ● Signs are bleeding, loss of fluids. ● A common procedure is cerclage—the use of suture to hold the cervical os closed. Emergency: Abruptio Placenta ● Occurs when placenta separates prematurely from the uterus. ● Fetus loses part of blood supply. ● Maternal death may occur from hemorrhage. 30 ● Signs: decreased fetal movement is often the first sign. Bleeding, hemorrhage, dizziness, shock, contractions. Care of the Patient: 2nd Trimester ● Weight management and healthy eating. ● Assessing for fetal heart tones, fundal height, and fetal movement. ● Screening for anemia and gestational diabetes. ● Begin preparation for childbirth and breastfeeding. ● Domestic violence. The Third Trimester: Red Flags and Common Discomforts ● Pre-eclampsia ● Premature labor vs Braxton Hicks (practice contractions) ● Premature rupture of membranes ● Gestational diabetes ● Urinary frequency, as uterus applies pressure to bladder. ● Swelling as the enlarging uterus prevents good venous return from the lower extremities. Pre-eclampsia ● A pregnancy induced endothelial malfunction accompanied by vasospasm. ● Occurs after 20 weeks and up to 6 weeks postpartum. ● The patient will have elevated BP ● Proteinuria of 3+ or greater ● Headache, scotoma (sense of flashing lights) ● May have one or all of the above symptoms. ● Eclampsia means the patient has developed seizures. Premature Rupture of Membranes ● Occurs after 37th week. ● Prior to labor. ● Infection occurs in 40% after 24 hours following rupture. ● Premature preterm rupture occurs from 24-37 weeks of gestation. ● Goal is to safely deliver infant and prevent infection. ● Requires management by OB-Gyn Premature Labor ● Occurs between 20 and 37 weeks. ● Many causes: infection, uterine abnormality, cervical incompetence, hormonal changes from stress, damage to placenta from smoking, drug abuse, hypertension, some medications. ● Fetal fibronectin testing can predict if a woman is likely to have preterm labor. ● Tocolytic agents are drugs prescribed by the ob-gyn to decrease uterine irritability. 31 Gestational Diabetes ● 3-8 % of pregnant women in the US develop gestational DM—most treated with diet. ● About half will progress to Type 2 DM in their lifetime. ● Hyperinsulinemia and rapid weight gain lead to insulin resistance. ● Danger: macrosomia (infant weighing more than 9 lbs, 9 oz), birth injury, hypoglycemia. Care of the Patient: 3rd Trimester ● Preparing for Parenthood ● Screening for infection, Group B strep ● Parenting and childbirth class, birth plans ● Dealing with common discomforts ● Rest periods ● Screening for domestic violence The Breasts: Development, lactation and breast problems Breast development: ● Stage 1-prepubertal “flat” ● Stage 2-Breast bud-there is a small amount of glandular tissue ● Stage 3-Areola enlarges, tissue increased size ● Stage 4-Areola and papilla form a mound above tissue ● Stage 5-Adult appearance of the breast ● You note the changes in nipple and glandular fullness ● The process typically begins after age 8 and lasts around 8 years ● Asymmetrical development is common ● Breasts develop under the influence of rising estrogen levels Stage 4-5 Tanner Staging ● A mound is formed above the breast glandular tissue. ● Many females do not progress from stage 4. ● Menarche typically occurs in this stage—just after a growth spurt ● During the aging process, the breasts develop ptosis—or sagging. This is due to loss of muscle tone and replacement of breast tissue by fat. ● During pregnancy, lobules and alveoli increase in size. ● Due to estrogen, progesterone, and prolactin *Estrogen and progesterone are from the placenta. *Prolactin comes from the adenohypophysis Colostrum ● Thick yellowish milk that is secreted in the first few days after delivery. 32 ● 10% resolve. ● Slightly higher risk of breast cancer in this patient. ● These are best seen with ultrasound. Fibrocystic changes ● Half of all females have these changes, but not all will be symptomatic. Fluid filled, but may be complex cysts—contains solids as well as fluids. ● Large cyst—usually in perimenopausal women. Must have fine needle aspiration to r/o cancer ● Microcysts-can cause premenstrual breast pain. Papillomas-Intraductal growths ● Cause nipple discharge, which is often bloody ● Unclear if associated with development of breast cancers ● Diagnosis of a papilloma may require a procedure in which dye is injected via the nipple into the ducts. This is called a ductogram. Mammary duct ectasia ● Periductal mastitis ● Non lactational ● Peri-areolar inflammation—leading to the affected duct ● May be sterile abscess or infectious process ● Frequently leaves some scarring Mastalgia without physical findings ● Often cyclic, due to premenstrual breast swelling ● Some studies show correlation with low gamma linoleic acid levels ● Unsure if associated with caffeine intake ● Evening primrose oil 500mg bid may be RXd to help improve GLA levels Breast cancers ● Develop in the epithelial cells that line the ducts and the lobules. ● Symptoms vary among women. ● Classic symptoms are fixed mobile masses, which are nontender ● Other symptoms may include swelling, lymphadenopathy, nipple or skin changes. ● Best seen with diagnostic mammograms—mass is viewed from several angles Breast cancer in situ ● In situ (noninvasive) cancers confine themselves to the ducts or lobules and do not spread to the surrounding tissues in the breast or other parts of the body. ● Having ductal or lobal cancer in situ increases the risk of having invasive cancer later in life. 35 Invasive ductal carcinoma ● Most common breast cancer (80%) ● 180,000 women per yr diagnosed in the US ● Can occur at any age but typically after 55. ● Also seen in men rarely. ● Usually detected on mammogram screening. Inflammatory breast cancer ● Rare probably less than 1% of breast cancers. ● Very aggressive and lethal. ● More common in African American women. ● Appears in younger women. ● Presents as red swollen breast—NOT as a lump. ● Warning: “but my mammogram was normal” Hormonal Contraception Varieties ● Pills ● Patch ● Ring ● Shots ● Implants ● IUDs Hormonal Methods: Mechanism of Action ● All hormonal methods affect ovulation and the endometrial lining. ● They also affect the thickness of cervical mucus. ● Hormonal methods change the production of FSH and LH, thereby preventing egg recruitment and release Role of Estrogen ● Decreases FSH ● Prevents release of egg ● Stabilizes the thickness of endometrium, prevents shedding of layer. ● Estrogen is used to balance effects in hormonal contraception but is NOT necessary to prevent pregnancy. ● Estrogen alone is not a contraceptive, though progesterone is Side Effects: Estrogen ● Breast tenderness ● Lactation suppression ● Nausea, vomiting ● Chloasma ● Headaches ● Increased coagulation= DVT, PE ● Increased blood sugar 36 Roles of Progesterone ● Prevents LH surge ● Thickens cervical mucus ● Thins endometriu Side Effects: Progesterone ● Amenorrhea or irregular bleeding ● Weight gain ● Increased appetite ● Mood swings ● Headaches ● Think pregnancy hormone—same side effects!!! Combined Oral Contraceptive ● Contains both estrogens and progestins (synthetic progesterone) ● These are manufactured in many different dosages and strengths. ● It is a real art to learn how to manage the side effects of hormonal contraception! ● Though they are not pills, the patch and the ring are similar preparations Phasics ● Monophasic: means the dose does not vary from pill to pill. All are the same. ● Biphasic: there are two differing doses in the pack ● Triphasic: each week of the pack is a different dosing. ● Biphasic and Triphasics were introduced with the thought of more closely mimicking a female cycle. ● Women will experience symptoms with the dosage changes Patch/Ring ● The Ortho Evra patch is a combined contraceptive which is delivered dermally. ● Worn for 1 week, then discarded. ● Repeat for 3 weeks, then patch free for 1 week. ● Menses will occur during patch free. ● NuvaRing is a flexible plastic ring which is also combined contraceptive. ● Inserted and left in vagina continuously for 3 weeks. ● Then discarded and should have withdrawal bleed Progestin Only Pill (POP) ● Contains no estrogen. ● A little more difficult to use but more suitable for many women. ● Breastfeeding mothers, some headache patients. ● Need to start while bleeding. ● Need to take at same time every day. 37 ● Possibly causes thickening of cervical mucus. 40 ● Completely non hormonal, therefore can be appropriate for women with clotting disorders, heart disease, breast cancers, etc. Non-hormonal Contraception Mechanism of Action: Non-hormonal methods all work to keep sperm and egg from meeting up! Methods include: ● Abstinence ● Outercourse ● Barrier methods ● Periodic abstinence— “rhythm” ● Spermicide ● Coitus interuptus— “pulling out” ● Abstinence and Outercourse ● Abstinence is the most reliable method of contraception! ● Outercourse-sexual activity which precludes any penetration by the penis into the vagina. This is considered by many to be a stressful method of contraception. Periodic Abstinence Practices Standard days: based on the patient’s cycle, fertile days can be identified. Calendars, cycle beads, apps. 2 days: Based on appearance of cervical mucus-no intercourse for 2 days after the appearance of fertile mucus. Lactational amenorrhea : common worldwide in mothers whose infants are completely breastfed until age 6 months. ● Amenorrhea suggests that ovulation has not occurred. ● Symptomatotherma l—the patient monitors her temperature and notes the increase which follows ovulation. She avoids intercourse during this time. ● Spermicide - Available in creams, jellies, suppositories, and films. Most commonly, Nonoxyol-9, which is actually a detergent. ● Gels - most effective of the bunch. ● Damages sperm, rendering them incapable of penetrating egg. ● Commonly used with another product, such as a condom or diaphragm. ● Research suggests that the detergent is too much of an irritant to vaginal epithelial cells ● May lead to vaginitis, UTI. Barrier Methods Male Condom ● Must be applied correctly with room in the receptacle area. ● Otherwise, the ejaculate will burst through—most common cause of condom failure is failure to put on properly. Female Condom ● Flexible rings are present on either end. One end is inserted into the vagina, the penis is 41 inserted through the open end. 42 ● 3x/12 months or 2x/6 months ● Mechanism ● Thinning of urothelium Associated Urinary Issues ● Overactive bladder and urinary incontinence are common in postmenopausal women Sexual Orientation and Vaginal Atrophy ● Don’t assume patients are in heterosexual relationships ● Women of different sexual orientations may experience vaginal dryness Special Population: Postmenopausal Women Who Have Been Celibate ● All women may not be sexually active ● Women who have been sexually inactive (partner or toy) for many years may find intercourse uncomfortable Screening for Vaginal Atrophy ● “Do you ever have a burning sensation when you have sex?” ● “Do you ever have bleeding after sex?” ● “Do you get frequent UTIs?” Physical Exam for Vaginal Atrophy ● Check for frail tissue in vagina and vulva ● Pale, dry skin ● Loss of elasticity, moisture ● Inflammation ● Measure vaginal pH When to Treat Vaginal Atrophy ● Causing distress ● Prior to vulvovaginal surgery ● Pelvic organic prolapse or urinary incontinence (especially in presence of vaginal mesh) Practical Considerations for Treatment of Vaginal Atrophy Advise patients to: ● Avoid harsh perfumed soaps, detergents, and fabric softeners ● Avoid use of soap on inner vulva ● Exercise care with warming and mentholated lubricants and moisturizers ● Wear cotton underwear Non-hormonal Therapy: Lubricants ● Local solutions that temporarily moisturize the vaginal epithelium ● Must be applied at time of intercourse 45 Avoid: ● Oil-and Petroleum-based 46 ● Lubricants, Warming Gels, Menthol Non-hormonal Therapy: Moisturizers ● Gels or creams used regularly to maintain hydration of the vaginal epithelium for long-term relief of vaginal dryness ● Effects last two to three days Not Effective, Not Recommended Therapies for Vaginal Atrophy ● Cooking oils ● Oral phytoestrogens ● Black cohosh ● Vaginal vitamin E ● Omega-3 supplements ● Yogurt Local Estrogen Therapy: Hormone Therapy ● Estring (Ring)-Estradiol- ● Device releases 7.5 mcg/day for 90 days ● Femring (Ring)-Estradiol acetate-Device releases 50-100 mcg/day for 90 days ● Estrace (Cream)-Estradiol-(100 mcg/1 g cream) 2-4 g of cream/day for 1-2 weeks, then 1 g/1-3 times/week ● Premarin (Cream)-Conjugated estrogens-(0.625 mg/1 g cream) 0.5-2 g/day of cream 2x/week or daily for 21 days, off for 7 days ● Vagifem (Tablet)-Estradiol hemihydrate-(10 mcg per tablet) 1 tablet/day for 2 weeks, then 1 tablet twice/week Vaginal Rings ● Two products available in the US ● Used continuously over 90 days ● Well tolerated ● Femring—much higher dose, considered systemic Vaginal Creams ● Two products available in the US ● Contain estradiol or conjugated estrogens ● Varying administration regimens ● Can be messy Vaginal Tablet ● Estradiol vaginal tablets ● Ultra-low dose ● Inserted with an applicator or finger ● Used daily for 2 weeks and then twice weekly 47 ● Primary outcome rate of fatal or non- fatal MI ● E-P arm terminated July 2002 ● E-only arm terminated March 2004 50 Translating Results into Clinical Practice ● Oral hormone therapy is not for cardio protection nor for treating CVD ACOG Guidelines ● Not for prevention of cardiac disease or osteoporosis ● May be appropriate to treat menopause-related symptoms ● Shortest possible duration in smallest effective dose NAMS Guidelines ● Extended use may be acceptable for some women ● Do not use for prevention of stroke, CHD, or osteoporosis ● Use local therapy for vaginal symptoms ● Use for shortest duration possible NPWH Guidelines (NPS IN WOMEN’S HEALTH) ● Women whose QoL is affected are best candidates ● Use lowest dose and shortest duration ● Use local therapy for urogenital symptoms ● Women’s choice about duration should be respected FDA Guidelines ● Effective for treating vasomotor symptoms and vaginal dryness, preventing osteoporosis ● Use topical therapy for vaginal dryness alone ● Use as last resort for osteoporosis prevention alone ● Use lowest dose and shortest duration possible Counseling Patients about HT ● Each woman must weigh risks and benefits in light of her circumstances ● Women must put risks into perspective to make fully informed decision ● Each woman must clarify her purpose and goal for using HT Contraindications to Systemic ET ● Pregnancy ● VTE ● Breast cancer ● Estrogen-sensitive cancers ● Liver disease ● Hypertriglyceridemia Types of HT: Estrogens ● 17 beta-estradiol ● Conjugated equine estrogens (CEE) ● Estrone derivatives Types of HT: Progestogens ● Progesterone 51 ● Progestins 52 ● Black cohosh ● Red clover ● Dong quai ● Soy ● Evening primrose seed oil ● Same contraindications ● Androgens ● Estratest and Estratest HS indicated for vasomotor symptoms if estrogen alone ineffective ● Testosterone has also been used to improve sexual function Not FDA-approved for this use *Patients and providers have been confused about HT as a result of the WHI and HERS data *Understanding study results and limitations helps providers counsel women to make informed decisions about HT *Individualization of therapy is essential for women who decide to use HT Bone Health throughout the Lifespan ● Osteoporosis affects 8 million women and 2 million men in the US today. ● Affects morbidity up to 50%!! ● Nearly half of all white women will have an osteoporotic fracture in her lifetime! Osteoporosis: Definition ● Low bone mass ● Structural deterioration of bone ● Bone becomes “porous” ● Leads to easy fractures ● BMD of 2.5 standard deviations below the norm for healthy people ● Described as T score -2.5 or below Osteopenia: Definition ● Described as BMD T-score between -1 and -2.5 ● Thinning bone Who is at Risk? Menopausal Women ● Small framed women (<127 lbs) ● White or Asian ● Older ● Less physical activity ● Low Vitamin D intake ● Smokers ● History of falls ● History of fractures ● Low calcium intake Osteoporosis: Causes ● Primary Osteoporosis ● Secondary Osteoporosis 55 ● Due to decrease in gonadal hormones because of aging ● Turner’s syndrome 56 ● Any of the inflammatory conditions such as RA ● Steroid use ● Hyperparathyroidism ● Anorexia nervosa ● Low body weight ● Vitamin D deficiency ● Weight loss surgeries Screening ● WHO the FRAX tool: ● Questionaire predicts need for DEXA screening http://osteoed.org/tools.php ● All women over 65 should be screened ● Other people should receive screening as indicated DEXA ● Hip, spine, wrist are sites ● Hip is best predictor of fracture risk ● Dexastands for ‘Dual Energy X- ray Absorptiometry ● Cost about 200-300 dollars. ● Repeat every 3-5 years Bones and Nutritional Needs ● Calcium—need 1200-1500 if post-menopausal. Same in adolescents! ● Vitamin D-jury still out but somewhere around 800 IU daily. ● Remember that peak bone mass occurs somewhere in the late teens to early twenties for females, early 30s for men. Bone health promotion is essential during the childhood and adolescent years. Stop Smoking! ● Why does smoking contribute to osteoporosis? ● Interferes with estrogen metabolism. ● Smokers have less healthy diet. ● Smokers typically have less weight bearing exercise. ● Does smoking interfere with Vitamin D levels? Weight Bearing Exercise ● Stresses—and strengthens the existing bone. ● Improves muscle tone—supports the bone. ● Improves balance—helps to prevent falls. ● Improves endurance—fall prevention. Who needs Meds? ● Patients with osteoporosis. ● Patients with osteopenia and a high risk using FRAX ● People who have sustained a hip or vertebral fracture 57 ○ Squamous intracellular lesions (SIL): abnormal cell changes that may be precancerous. It can be Low grade squamous intracellular lesions (LGSIL) or High grade squamous intracellular lesions (HGSIL). ○ Low grade squamous intracellular lesions (LGSIL): This shows cellular changes of HPV. LGSIL –You should refer or reflex-DNA testing. ○ High grade squamous intracellular lesions (HGSIL): this means that there is moderate & severe dysplasia. ○ HGSIL – You should refer for colposcopy & treatment ○ Squamous cell carcinoma: this is a rare finding in pap smears as this not a diagnostic test. This finding usually indicates involvement of abnormal cervical cells to the surrounding tissue. ▪ Glandular Cell abnormalities: they can be benign, AGCUS or adenocarcinoma. Since you are not sure if is good or bad Always refer! ▪ If you see endometrial cells postmenopausal without hormone replacement therapy (HRT) – Refer, an endometrial biopsy should be performed. ▪ If the patient has atypical glandular cells of undermined significance (AGCUS): you should do a referral. Can my teenage daughter have a pap smear? No, HPV testing is not recommended for routine use with adolescents because they have high rates HPV and these usually resolve without treatment. Sometimes this can lead to burden of unnecessary dx & tx is avoided. What do I do if my teenage daughter had an abnormal Pap smear? If teen has Pap test abnormality > ASC-US, HPV testing may be done What can I do to prevent HPV on my daughter? HPV vaccines such as Gardasil and Cervarix. 60 Garadasil: is a quadrivalant vaccine that is indicated for women ages 9-26 and has also been approved to be use in males as well. This vaccine protects against HPV 16 and 18 (contributes to 75 % of cervical CA) and HPV type 6 & 11 (causes 90% of genital warts diagnosed in women). Cervarix: is a bivalent and protects against HPV type 16 and 18 only. Men’s Health Incontinence: involuntary transient or persistent loss of urine *not considered normal at any age and is not an expected outcome of aging Pathophysiology: Usually the symptom of an underlying bladder or sphincter condition, but it may also be related to an extrinsic problem that can be easily treated Causes: ❖ Impaired mobility, pelvic floor weakness, race and ethnicity ❖ Weight, other comorbidities (asthma, depression, heart disease, or a history of frequent urinary tract infection [UTI]) ❖ Benign prostatic hyperplasia (BPH), medications, and bowel status Incontinence Definitions: ❖ Stress incontinence : Loss of urine associated with activities that increase intra- abdominal pressure ❖ Urge incontinence : Involuntary loss of urine usually preceded by a strong, unexpected urge to void ❖ Mixed incontinence : Urge and stress incontinence together ❖ Overflow incontinence: An involuntary loss of urine associated with incomplete emptying Physical Examination : ❖ Abdominal, genitourinary, pelvic, and rectal components ❖ Neurologic and functional assessment as well as an assessment of the extremities for edema ❖ Medication history (especially that of diuretic use), mental status, mobility, and social evaluations Diagnostics: Urinalysis ❖ Urine culture and sensitivity ❖ BUN Creatinine Serum glucose ❖ Calcium ❖ Urine for cytology Management: Stress Incontinence ❖ Other Diagnostics ❖ PVR ❖ Urodynamic testing ❖ Cystoscopy ❖ Behavioral therapies: timed or double voiding, smoking cessation, weight loss, pelvic muscle exercises with or without a physical therapist, pessary, and bowel management ❖ Medical therapies: alpha-adrenergic agonists, tricyclic antidepressants, estrogen ❖ Surgical therapies: injectables, bladder neck suspensions, slings, artificial sphincters Urge Incontinence ❖ Behavioral therapies: as above with bladder training, scheduled voiding, bladder irritant minimization, and urge suppression 61 ❖ Medical therapies: anticholinergic-antimuscarinics ❖ Surgical therapies: neurosacral modulation, Mixed Incontinence ❖ Combination of therapies for stress and urge incontinence Overflow Incontinence ❖ Behavioral therapies: timed or double voiding clean intermittent catheterization, pessary ❖ Medical therapies: alpha1 blockers, 5α-reductase inhibitors ❖ Surgery to relieve urethral obstruction or stricture or to reduce prolapse Functional or Transient Incontinence ❖ Treatment of underlying cause Prostate Cancer ❖ Most common malignant neoplasm in men Pathophysiology ❖ Adenocarcinoma develops in the acinar glands located in the posterior peripheral zone of the prostate Clinical Presentation ❖ Urinary hesitancy ❖ Urgency ❖ Nocturia Physical Examination ❖ Frequency ❖ Hematuria ❖ Usually asymptomatic in early stages ❖ DRE is used to detect initial physical abnormalities of the prostate gland: ❖ A firm nodule on rectal examination, induration, or a stony, asymmetric prostate is ❖ suggestive of prostate cancer Diagnostics ❖ PSA level combined with DRE ❖ CBC w/diff Management ❖ Monitoring with PSA and DRE ❖ Radiation therapy ❖ Other: needle biopsy ❖ Hormonal therapy ❖ Surgery Complications ❖ Metastatic disease Prostatic Hyperplasia (Benign) BPH Pathophysiology ❖ Prostate gland undergoes its first growth spurt during puberty and attains an average size of 20 g ( ounce) by the age of 20 years ❖ The gland undergoes a second growth spurt during the fifth decade of life ❖ Dihydrotestosterone (DHT) is the main mediator of the growth and secretory function of 62 Physical Examination: ❖ Abdominal and rectal examinations are important components of the physical examination for symptoms related to the prostate. The abdominal examination should exclude bladder distention, and the prostate gland should be examined for size, consistency, and tenderness. Diagnostics: ❖ Laboratory ❖ Midstream urine specimens for culture and sensitivity ❖ CBC and differential Management: ❖ Broad-spectrum antibiotic therapy ❖ If febrile, consider for hospitalization ❖ Blood urea nitrogen ❖ Creatinine ❖ Imaging At discretion of urologist ❖ Intravenous fluoroquinolones such as levofloxacin or ciprofloxacin may be selected for treatment. Intravenous therapy is changed to oral therapy when the patient is afebrile for 24 to 48 hours and able to tolerate oral intake Complications: ❖ A prostatic abscess rarely occurs as a complication of acute bacterial prostatitis except immunocompromised patients. Sexual Dysfunction ❖ Sexual dysfunction can lead to sexual frustration, guilt, loss of self-esteem, and interpersonal problems Pathophysiology: ❖ Involves a combination of biologic, psychological, and sociocultural factors ❖ Several hormones combine to produce sexual desire, and lower levels of them can lower the sex drive ❖ In men and women, sexual desire is linked to levels of androgen, testosterone dehydroepiandrosterone (DHEA) Clinical Presentation: ❖ predisposing factors (e.g., restrictive upbringing, disturbed relationships, traumatic sexual experiences ❖ precipitating factors (e.g., dysfunction in the partner, discord in the relationship, depression or anxiety, comorbid medical conditions) ❖ maintaining factors (e.g., performance anxiety, relationship issues, impaired self-image poor communication) Physical Examination: ❖ Good, thorough sexual function history ❖ Aimed at detecting endocrine, vascular, or neurologic deficits and penile abnormality Diagnostics: ❖ Laboratory ❖ Complete blood count and differential 65 ❖ Fasting serum glucose or hemoglobin A1c (HbA1c) 66 ❖ Serum electrolytes BUN and creatinine ❖ Lipid profile ❖ TSH Prostate-specific antigen Prolactin Morning total serum testosterone level ❖ Luteinizing hormone Management ❖ Determine whether the patient's major issues are psychogenic, relational, or organic (often all three are involved) ❖ If referral to a psychologist, marriage counselor, or sex therapist might be helpful. Complications ❖ destroyed relationships ❖ Lack of self-esteem ❖ Depression Testicular Disorders ❖ Scrotal pain may be a symptom of an underlying pathologic condition of the scrotum or testis. The pain may be described as sharp, dull, aching, uncomfortable, or tender, and it is characterized as mild, moderate, or severe. Pathophysiology: ❖ A varicocele is an abnormal dilation of the pampiniform plexus and spermatic veins in the spermatic cord ❖ The cause of a varicocele has been determined to be a multifactorial process that involves anatomic variations (the left gonadal vein is longer than the right, and the lef testicular vein inserts at an angle into the left renal vein) and incompetent valves with the pampiniform venous plexus, which results in a backflow of blood and venous pooling Clinical Presentation: ❖ Varicocele - enlargement in a testicle that decreases in the supine position; complain of a dull pain, ache, or heaviness in the affected hemiscrotum ❖ Epididymitis - sudden onset of severe pain that may be partially relieved by elevating the scrotum (Prehn sign) ✓ blood in semen ✓ penile discharge ✓ lower abdominal discomfort ✓ groin pain ✓ lump in the testicle ✓ pain with intercourse or ejaculation Orchitis ❖ testicular swelling ❖ fever ❖ concomitant hydrocele ❖ scrotal wall thickening Spermatocele - painless, cystic mass that is separate from the testis and located superior/ inferior to it ❖ Movable ❖ Firm 67 ❖ Skin ulcerations 70 Physical Examination: ❖ Inspection of the scrotum ❖ Scrotal size can change with temperature variations because of the cremaster muscle response. Asymmetry is expected because the left hemiscrotum is normally positioned lower than the right. 30 The skin of each hemiscrotum should be inspected carefully, spreading the rugae between the fingers. Diagnostics: Varicocele Laboratory: ❖ Semen analysis ❖ Testosterone Imaging: ❖ Doppler ultrasound Epididymitis Orchitis Imaging: Doppler ultrasound Testicular Torsion Imaging: Doppler ultrasound Torsion of the Appendix Testis Imaging: Doppler ultrasound Traum a Laboratory: Urinalysis Imaging: Ultrasound Testicular Tumor Laboratory: Serum tumor markers: hCG, AFP, LDH Clinical staging Imaging: Ultrasound CT scans and magnetic resonance imaging Management: ❖ Specialist or surgical consultation is indicated for testicular or scrotal trauma, complicated epididymitis, painless testicular mass, right varicocele, and varicocele in conjunction with infertility. Immediate emergency department referral or surgical consultation is indicated for patients with sudden-onset unilateral scrotal pain, testicular torsion, incarcerated or strangulated hernia, testicular trauma with concern for rupture, and Fournier disease. Complications: ❖ Associated with infertility ❖ produce abnormal semen parameters 71 ❖ testicular atrophy ❖ Leydig cell dysfunction 72 or symptomatic sex partners. Diagnostics: 75 ❖ Urine dipstick ❖ Urine culture ❖ Renal ultrasound – to diagnose structural abnormalities Management: ❖ Specialist referral is indicated for complicated UTIs ❖ Continuous prophylaxis ❖ Postcoital prophylaxis ❖ Prophylaxis should not be initiated until the existing UTI has been eradicated, confirm with negative culture 1 to 2 weeks after treatment. Recommended antibiotics include TMP-SMX, nitrofurantoin, cephalexin, trimethoprim, or a quinolone. Complications: ❖ The most common complication of UTI is pyelonephritis, a bacterial infection of the kidney resulting from ascending, untreated or inadequately treated lower UTI. STDs: Diagnosis and Treatment. “SORES” Primary Syphilis - (painless) *4 stages: primary (chancre), secondary (rash on palms & soles), latent (asymptomatic), tertiary (neuro) *Incubation: 10-90 days (average 3 weeks) Chancre: usually resolves in 1-5 weeks. Chancre is highly infectious when touched. 15-30% of cases go unnoticed by the patient. Secondary Syphilis (the great mimicker) ❖ Represents systemic dissemination of spirochetes ❖ 2-8 weeks after chancre appears Findings: Rash over entire body (hallmark- rash on palmar and plantar surface.) ❖ Mucous patches ❖ Condylomata lata (highly infectious) ❖ Fever, malaise, aches (constitutional symptoms) ❖ S/S resolve in 2-10 weeks. DIAGNOSIS AND TREAT: Early Syphilis Diagnose: ❖ Clinical presentation ❖ darkfield test or serology (serology is typically the method used) Treatment: ❖ Benzathine PCN G 2.4 million units x1 ❖ Primary and Secondary Syphilis: PCN G 2.4 million units IM x1 76 ❖ Latent Syphilis (normal CSF): PCN G 2.4 million units IM weekly x 3 does ❖ Penicillin G is the preferred treatment in ANY stage of syphilis. Bicillin LA is 2nd choice medication. ❖ Penicillin G is the ONLY treatment for pregnant women. Pregnant women with an allergy to PCN will have desensitization with allergist. Jarish-Herxheimer reaction may require hospitalization for pregnant women and may induce labor. Neurosyphillis ❖ Uveitis may be the first symptom, check CSF & HIV blood test ❖ Hospitalize patient to start IV treatment ❖ Treatment: PCN G 3-4 million units IV Q4H for 10-14 ❖ (may see PCN 2.4 plus Probenecid 500mg QID for 14 days) **Report to the health department Genital Herpes Simplex *Primary infection is commonly asymptomatic. *Symptomatic cases when severe or prolonged will have systemic manifestations. *Vesicles cause ulcerations and crusting (painful) *Recurrence is possible Diagnosis: ❖ Culture ❖ Serology (Western Blot) Treatment HSV1: ❖ Acyclovir ❖ Valacyclovir ❖ PCR ❖ HSV1 vs HSV2 ❖ Famciclovir Treatment HSV2 : (all episodes receive treatment, 1st case treatment) ❖ Acyclovir 400mg tid x 7-10days ($8) ❖ Acyclovir 200mg 5x per day x 7-10 days ❖ Valcyclovir 1 gram bid x 7-10 days ❖ Famciclovir 250mg tid x 7-10 days ❖ Suppressive Therapy : (reduces recurrence by 80%) ❖ Acyclovir 400mg BID ❖ Valtrex 500mg or 1gram daily ❖ Famciclovir 250mg BID ❖ Episodic Therapy : ❖ Acyclovir 400 TID x5 days ❖ Valtrex 500mg BID x 5 days ❖ Famciclovir 500 BID x 5 days “DRIPS” Gonorrhea 77 ❖ DX: ❖ Amsel Criteria - must have 3 of the following: ❖ vaginal pH >4.5 ❖ Presence of .20% per HPF of “clue cells” on wet mount examination ❖ Positive amine or “whiff” test ❖ Homogeneous, non-viscous, milky-white discharge adherent to vaginal walls. ❖ TX: (only treat if symptomatic) ❖ Metronidazole 500mg po BID x 7 days ❖ Metronidazole gel 0.75% 1full applicator (5g) intravaginally at bedtime x7d ❖ Clindamycin cream 2% 1 full applicator (5g) intravaginally at bedtime x7 d ❖ Alternative: Tinidazole 2gm po qd x 2 days ❖ Tinidazole 1gm po qd x 5 days ❖ Clindamyacin 300mg po BID x 7 days ❖ Clindamyacin ovules 100g intravaginally once at bedtime x3d Vulvovaginal Candidiasis: ❖ HPV: ❖ Transmitted from skin to skin contact, including fingertip transmission during sex play ❖ Low-risk types (6, 11): Cali-flower shaped warts ❖ High- risk HPV (16,18) infection is associated w/ cervical cancer & other anogenital squamous cell cancers (anal, penile, vulvar, vaginal) ❖ DX : ❖ TX: ❖ clinical exam, cytology, nucleic acid amplification methods (in conjunction w/cytology for high-risk HPV types) ❖ Patient Applied: ❖ imiquimod 3.75% or 5% cream, podofilox 0.5% solution or gel sinecatechins 15% ointment ❖ Provider Administered: ❖ Cryotherapy, trichloroacetic acid or bichloroacetic acid, surgical removal ❖ Vaccine: ❖ Ceravarix HPV 16 and 18 ❖ 0,1, 6 months dosing ❖ Females 10-25years ❖ Gardasil HPV 6,11,16,18 ❖ 0,2,6 months dosing ❖ Females 9-26 years old ❖ Gardasil for males: ❖ initial study 90% efficacy for preventing external lesions caused by HPV types 6,11,16 and 18 in men 16-26y ❖ males 9-26y for prevention of genital warts 80 ❖ Gardasil for Anal Cancer Prevention: ❖ HPV associated with 90% of anal cancer ❖ Males and females 9-26y ❖ Prevention of anal cancer and associated precancerous lesions caused by HPV types 6,11,16,18 Yeast- thick white curdy discharge Dx wet mount (yeast buds), TX clotrimazole, miconazole (*OTC meds are available, but don’t cover every strain*) Hematology: recognize patterns of anemia, causes. Bleeding disorders. • RBC Production Disorders: ■ Production is too low (hypoproliferative) ■ Bone marrow damage: stem cell/marrow damage due to chemo/radiation, drugs, autoimmune disorders, viral infections/TB, congenital disorders, tumors, leukemias, cancer, idiopathic aplastic anemia, chemicals/metals, rheumatoid disorders, congenital disorders (Fanconi anemia, Diamond Black anemia) ■ Drugs include: antibiotics (pcn, sulfa, cephalosporins, streptomycin, amphoteracin B); antidepressives and ftpand(lithium, TCA’s); antiepileptics (dilantin, tegretol, depakote), NSAIDs, antiarrhythmics, antithyroids, diuretics (lasix, thiazides), antiHTN, antiuricemics, antimalarials, hypoglycemics, tranquilizers, platelet inhibitors ■ Fanconi anemia: recessive disorder w severe pancytopenia, high incidence of cancer, multiple physical defects (microcephaly, café au lait); Diamond-Blackfan anemia (physical abnormalitiesw strabismus, growth retardation, finger and rib bony abnormalities) ■ Infection & inflammation that is both acute or chronic (anemia of chronic disease) viral/bacterial-TB, parvo, hepatitis, acute pneumonia, AIDS, collagen-vascular, renal disease, low protein, endocrine disorders-hypothyroidism, rheumatoid disease ■ Iron deficiency anemia: Iron deficiency: low iron will slow RBC production in the marrow (chronic blood loss, low dietary sources, malabsorption) ▪ Most common in adults & kids ▪ Dietary depletion, blood loss (GI/menstrual), malabsorption ▪ Presents with fatigue, short of breath, PICA, palpitations, sometimes no symptoms, cheilosis, soft spoon nails, sore tongue, difficulty swallowing, behavior/learning problems (kids) ▪ Labs: low HGB, low MCV, low MCHC, low iron, low ferritin, high TIBC, low retic ▪ Treatment: Fix bleed/malabsorption, give iron, recheck few months (90-100 days to renew ) ■ Anemia of chronic kidney disease ■ Vitamin B12 deficiency ■ Folate deficiency 81 ▪ Folate is the water soluble B vitamin found in foods; helps in cell division/neural tube/RNA/DNA, RBC production ▪ Found in green leafy foods, citrus foods, dried beans, peas ▪ Folic Acid- synthetic form of folate that is added to foods, supplements ▪ Low due to alcoholism, poor diet, celiac & Crohn’s disease, hemolysis, meds (dilantin, bactrim) ■ Anemia of chronic disease ▪ Extremely variable due to the disease state, age, general health of the patient, comorbidities, medicines, length of illness ▪ Chronic inflammation, renal, liver, pancreas, nutrition, strong predictor of morbidity /mortality later on (even if not severe now) ▪ Some microcytic, MOST normocytic /normochromic or macrocytic/normochromic with B12,folate deficiency ■ Aplastic anemia ▪ Aplastic anemia: failure of bone marrow to produce red and white cells; exposure to chemicals (benzene, glue, insectacide, solvents), gold, chemo, ABX, seizure meds, HIV, EBV, radiation, lupus, RA, pregnancy, Fanconi anemia (inherited). ▪ Presentation: fatigue, hair loss, malaise, palpitations ▪ Treatment: cause, stop med, iron supplements, vit B12 injections ■ Anemia in the elderly ▪ RBC’s do continue to produce in old age; it’s the inflammation, immune system, disease states, environment, thrombotic events, cognitive issues that contribute to anemia ▪ Non-hispanic black men and women elderly suffer anemia 2-3X more than other ethnicities ▪ Higher anemia rates in nursing homes ▪ Microcytic, normocytic, macrocytic depending on cause. ***Much is normocytic/normochromic due to poor reticulocyte regeneration so do Tic count • RBC Destruction Disorders ■ Maturity is abnormal ■ Problems with RBC maturation at the PREcursor stage (nucleus, protein globin chain synthesis, RBC DNA synthesis) or keep maturing to a larger than normal size ■ Can be due to folic acid, vitamin B12 deficiency, hereditary disorders (thalassemias, sickle cell), iron deficiency (immature and hypoproliferative and low HGB carrying ability), sideroblastic anemia (marrow stem cell maturation failure=leukemia) ■ Sickle cell anemia ▪ Sickle cell anemia: Auto-recessive disorder of abnormal hemoglobin (S) shape, blacks, Mediterranean, middle East, 1/500 African Americans (1 in 12 has the TRAIT) ▪ Presentation: joint pain, abdominal pain, spleen, MI, hands, feet, micro- vascular necrosis, swelling, face, bone pain, extremely variable onset, length, 82 ■ Microcytic (MCV <80fL): RBC is too small ▪ Iron deficiency ▪ Thalassemia ▪ Anemia of chronic disease ▪ Sideroblastic anemia ▪ Hemoglobin E disease ■ Macrocytic (MCV >100fL): RBC is too big ▪ Megaloblastic anemia (Vitamin B12 or folate deficiency ▪ Causes due to folate deficiency and B12 deficiency (most common), hypothyroidism, myelodysplasia (bone marrow does not produce blood cells properly/pre-leukemia), pernicious anemia, alcoholism, chemotherapy, pregnancy, malabsorption dz, GI surgery ▪ Presentation varies w disease state: psychosis, mental status, peripheral neuropathy, cerebellar ataxia, sore tongue, weakness, heart & GI, lemon-color skin (bilirubin) ▪ Replace dietary folate, B12, maybe transfusion ■ Normocytic: RBC normal size ▪ Sickle cell disease ▪ Anemia of chronic disease ▪ Aplastic anemia ▪ Hemolytic anemia ▪ Variable causes, many due to hemoglobinopathy, immune causes, hemolytic anemias due to autoimmune disease, abnormal hemoglobin chains (sickle cell and hemmoglobin C), abnormal RBC shape (sphere/sickle), G6PD, various drug therapies. ▪ Presentation may be nothing to palpitations, short of breath, pale, jaundice, icteris, dark urine ▪ Labs: low HGB, normal MCV, normal MCHC, elevated retic count b/c this compensatory mechanism is INTACT. • CBC Review ■ WBC’s (diff: monos, eos, lymphs, etc.) ■ Platelets ■ RBC’s (#, color, volume, shape, age, size) ■ Hgb (how much O2 being carried by RBC) ■ HCT (percent of RBC volume) ■ Reticulocyte count (RBC production..young cells) • RBC for evaluation of anemia ■ MCV (mean cell volume): RBC size; how much the rbc holds; (macrocytosis/microcytosis= increase/decrease in VOLUME/SIZE)*** ■ MCH (mean cell hemoglobin): how much hemoglobin the RBC is holding ■ MCHC (mean cell hemoglobin concentration): overall amount of HGB in the cell/small cell=low value)*** ■ RDW: measures the VARIABILITY or RBC size (some small/ some big). Useful in thalassemia vs iron deficiency determination & iron treatment. ■ Reticulocytes: useful for hemolysis, blood loss, bone marrow activity for RBC production*** 85 ■ Start : HGB!! Low = anemia 86 ■ Next: MCV=size=micro, normal, macro ■ Then :MCHC=concentration of HGB in RBC ▪ Hypochromic=low Hgb concen.=pale color=usually w microcytic (iron defic) ▪ Normochromic=normal Hgb concen.=normal color=BOTH normocytic (check retic count, hemolytic anemia)/macrocytic (Folate & B12 deficiency) ▪ Hyperchromic-high hgb=darker color=macrocytic (sickle cell, spherocytosis) ■ Finally : Retic count=hemolysis, bleeding ■ Helpful: HCT=percentage of RBC’s; is 3 x HGB, acute/chronic bleed/fluid status • Values ■ Iron Level in Anemia ▪ ↑ in hemolytic, megalo blastic, aplastic anemia, thalassemia, leukemia, excess iron therapy, repeated transfusions, drugs (OCP’s, ethanol, estrogens, methotrexate, others) ▪ ↓ in iron deficiency, acute/chronic infections, cancer, nephrotic syndrome, malnutrition, surgery, hypothyroid. ■ Ferritin/TIBC Testing ▪ Serum ferritin is most useful for detecting iron deficiency anemia***** ▪ Detects amount of ferritin readily available; if low, then is iron deficient. ▪ TIBC measures the transerrin protein available in bone marrow. It can be normal in iron deficiency and is NOT a good test ■ Folate/Folic Acid ▪ Folate is the water soluble B vitamin found in foods; helps in cell division/neural tube/RNA/DNA, RBC production ▪ Found in green leafy foods, citrus foods, dried beans, peas ▪ Folic Acid- synthetic form of folate that is added to foods, supplements ▪ ↓ 2⁰ to alcoholism, poor diet, celiac & Crohn’s disease, hemolysis, meds (dilantin, bactrim) ■ Vitamin B12 ■ Water soluble vitamin found in fish, meat, dairy, eggs. Used for protein and DNA, bound to hydrochloric acid in stomach/intrinsic factor for absorption ■ Low level due to malabsorption (Crohn’s/celiac/GI surgery), ETOH, poor diet ■ Pernicious anemia=lack of intrinsic factor/perform schilling test /treat w monthly Vit B12 injections/oral supplements • Bleeding disorders: ■ Von Willebrand ▪ Hereditary bleeding disorder, missing platelet clotting factor, several types of this disease. ▪ Presentation : bleeding gums, abnormal menstrual bleeding, nose bleeds, abnormal bruising, pregnancy-no excessive bleeding! ▪ Treatment : DDAVP, Alphanate, plasma, factor VIII preparations, NO ASA/NSAIDS, caution surgery ▪ Labs : platelet count, bleeding time, clotting tests, Factor VIII level, Von Willebrand specifics 87 use iron dextran and chelating agent leafy vegetables. bananas, fish, liver increased need, recheck 100mg/wk IM. Check prescription. peanut butter, oatmeal levels in 2 months. 90 retic count @ 1wk; check Hgb @ 2wks and wheat bran. PT-motor, OT- neuropathy Osteoporosis Definition and Epidemiology ● Characterized by ↑ bone fragility and ↑ susceptibility to fracture ● ↑ bone fragility results from ↓ in bone mass & deterioration of bone microarchitecture that occur as the result of estrogen deficiency & aging ● Also defined by the WHO as a bone mineral density (BMD) of 2.5 standard deviations or less below the young normal mean ● There is an ↑ likelihood of fracture with a decreasing BMD Pathophysiology ● The rate of bone resorption > that of bone formation; a consequence of estrogen deficiency ● Most pronounced in the first 5 to 10 years after menopause ● Glucocorticoid use is the most common cause of secondary osteoporosis ● ↑ bone resorption and ↓ bone formation  to a rapid loss of bone and impaired bone quality ● Risk factors : ↑ the risk of bone loss or osteoporotic fracture ○ Advanced age, female gender, a prior osteoporotic fracture, femoral neck BMD, ↓BMI, oral glucocorticoid use of 5 mg of prednisone or more per day for 3 or more months (ever), RA, secondary osteoporosis, parental history of hip fracture, current smoking & ETOH intake of 3 or more drinks/day Diagnosis: ● Most cost-effective work-up to identifying secondary causes of osteoporosis among postmenopausal women: ○ Serum calcium concentration, PTH level, TSH level in those receiving thyroid hormone and a 24 hour urine calcium excretion ● Vitamin D deficiency is common among women with osteoporosis ● Biochemical markers are urine & blood tests that measure breakdown products of bone & collagen; ↑ levels imply ↑ bone turnover; at this time the role of bone markers in primary care is unclear ● Plain radiographs are useful primarily in confirming the presence of fracture ● In the absence of fracture, the definitive method for diagnosis of osteoporosis is bone densitometry, by dual energy x-ray absorptiometry, of the hip and posteroanterior lumbar spine ○ The wrist may be used in very obese patients, uninterpretable hip and spine scans, and primary hyperparathyroidism 91 92 ○ TX: Positive reinforcement. Fruits & veggies; fiber (no bananas). ↑ water; ↓ dairy ■ School-Age Child ▪ First time event or ongoing ▪ Stress, change, change in bowel pattern ▪ Fear of using school bathroom ○ TX: Positive reinforcement; reassurance. DIET. Water. ■ Treatment when diet doesn’t work… ▪ MOM (titrate 1-3 tsp bid or qd; 1-3ml/kg/day ▪ Mineral oil (1-5 ml/kg/day; caution aspiration) ▪ Citrucel, Metamucil, Benefiber ( daily with plenty of water) ▪ Miralax 17 gr (1/2 to 1 capful QD x 2 weeks) ▪ Stool softeners such as Colace or Senokot (short-term) • Obstipation ■ Long intervals between stools • Encopresis ■ Constipation with soiling or leaking • Hirschsprung’s Disease ■ A congenital anomaly that results in mechanical obstruction from inadequate motility in part of the intestine ■ Patho: Absence of ganglion cells in segments of the colon (rectum and distal colon). These cells are responsible for peristalsis and relaxation of the internal sphincter. ■ More common in males ■ HX of delayed passage of meconium ■ S/S: • Encopresi s o Constipation, Vomiting, Abdominal Distention, Ribbon-like stools o Digital exam reveals narrow, empty rectal vault o Rectal stimulation may relieve obstruction o TX: Surgery ■ An elimination disorder in children greater than 5 years of age ■ Coincides with enuresis (the passing of urine in places other than the toilet) ■ S/S ▪ Lack of appetite, Abdominal pain, Leaking of stools, Anal irritation, Withdrawal from friends and family, Social isolation, Secretive behavior with bowel habits ■ Cause: Chronic constipation lasting longer than 3 months ▪ Large mass of stool, stretches rectum, dulls nerve endings, child loses sensation, loses urge ▪ Mass becomes so big, liquid stool leaks around mass, loses sense of smell ■ Greater in boys ■ DX: 95 ▪ Hx and PE, xrays ■ Goal of treatment: ▪ Prevent constipation & encourage good bowel habits, educate family & child ■ TX: ▪ Clean out phase (Miralax 1-3g/kg/day or enemas) ▪ Keep stool soft and easy to pass with oral laxatives x6-12 months ▪ Regular times on the toilet ▪ Change diet; high fiber & increase fluids ▪ Education ▪ Counseling • Gastro esophageal Reflux (GER) ■ Passage of GI contents into the esophagus ■ Becomes GERD w/ complications: FTT, bleeding dysphagia, apnea, bronchospasm, laryngospasm, & pneumonia ■ Cause ▪ Dysfunction of lower esophageal sphincter; transient relaxation not tone ▪ Delay in gastric emptying ▪ Poor clearance of gastric acid ▪ Susceptibility of the esophageal mucosa to injury ▪ Factors that cause LES dysfunction ➢ Abdominal distention ➢ ↑abdominal pressure (coughing) ➢ CNS disease ▪ Infant ○ S/S ■ Emesis; spitting up ■ ■ Arching with feedings or afterwards Gagging/choking after feedings, smacking ■ ■ Irritability; fussy after feeds Poor weight gain ■ ■ Aspiration pneumonia, chronic pneumonias Apnea ○ DX: Hx and PE ■ Detailed of feedings & associated s/s ■ Upper GI; Barium swallow ○ TX ■ Small, frequent feedings ■ May thicken feeds with rice cereal ■ Keep infant upright x 30 minutes after feeds ■ Avoid stimu lation and abdo minal press ure 96 ➢ Delayed emptying ➢ Hiatal hernia ➢ Gastrostomy placement ➢ Side effect of medications ■ pH probe ■ EGD 97