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 Tallas age and the potential for various underlying causes, a sensitive and supportive approach is vital.
