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Adolescent Medicine

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  1. Adolescent Medicine 16 May 2006

  2. 0900 Routine Appt

  3. Case 1 TC a 16 y/o male CC: Allergies per mother

  4. HPI His mother comes back to the room and says his eyes have been red for the last 4 months She thinks he has allergies. He doesn’t think there is any problem.

  5. Symptoms FH Medications HEADSS LABS Physical What do you want to know?

  6. HEADSS • Parents recently divorced • Failing independent studies. • Hanging out with friends • Smokes • Has had 1 LTP • Not suicidal

  7. PE • Alert normal vital signs • Presence of gynecomastia • Otherwise normal exam

  8. Marijuana

  9. Marijuana

  10. Tools of use

  11. “New” Marijuana • Marijuana of the 60’s had a THC concentration of 0.5% to 1% • Marijuana of today has been engineered to have a THC concentration of 6% to 15%

  12. Effects • Elation • Euphoria • Impaired short-term memory • Divided attention tasks difficult • (e.g. driving) • Loss of critical judgment • Distortion of time perception

  13. Bad effects • Visual hallucinations • Perceived body distortions • Panic attacks • Paranoia • Amotivational syndrome

  14. Lowered temperature Tachycardia Hypertension Tachypnea (experienced user) Plasma testosterone suppression Lowers sperm count Gynecomastia Questionable physiologic dependency Clinical manifestations

  15. Back to TC • His mom said she wants a drug test

  16. Marijuana drug screen • Detection window 7 to 30 days • Screen • RIA/EIA • Confirmation • GC / MS • Interpretation • Second-hand exposure • foods

  17. 2230 Sat

  18. Case 2 • CC a 17 year old boy • Stat consult to ER for strange behavior

  19. HPI • 17 Y/O male being restrained in the E.D. Says the terrorists are after him.

  20. ABCDE PE LABS Meds What do you do?

  21. PE • Pulse 160 • BP 180/100 • Temp 101 • Agitated • His pupils are dilated.

  22. UDS AMPHETAMINES……………….PENDING BENZODIAZEPINES……………PENDING COCAINE…………………………PENDING OPIATES………………………….PENDING THC(CANNABINOIDS)………… PENDING BARBITUATES………………….. PENDING PCP(PHENCYCLIDINE)……….. PENDING METHADONE…………………….PENDING TCAs(DeWitt)

  23. Cocaine • Epidemiology • Use dropped from 1985 – 1990 • 5.8 million to 1.6 million users • (use in prior 30 days) • High school seniors (Ever used) • 17.3% (1985) • 5.9% (1994) • 8.7% (1997) • 4.7% (2003) • Crack is about ½ of total cocaine use

  24. Cocaine

  25. Cocaine

  26. Cocaine

  27. Cocaine • Clinical manifestations • Euphoria • Increased motor activity • Decreased fatigability • Paranoid ideation (occasionally)

  28. Cocaine • Clinical manifestations • Pupillary dilatation • Tachycardia • Hypertension • Hyperthermia • Death • “Speedball” • Cocaine injected with heroin

  29. Cocaine Drug Screen • Detection period 2-4 days, 8 days for long-term use • Metabolized to benzoylegonine and ecgonine methyl ester • Plasma 1/2-life of cocaine is 1 hour, metabolites 7.5 and 3.6 hours • FALSE positive with Health Inca Tea (HIT)

  30. 10:00 Routine Appt

  31. Case 3 LD - 16 y/o male CC: Mom wouldn’t say

  32. HPI Mom reports that Saturday night he was very silly and confused Spontaneously laughed Said he saw sound but then changed his story He’s acting fine now

  33. PMH FH HEADSS PE LABS What now?

  34. Hallucinogens • LSD • MDMA (Ecstasy) • GHB • PCP • Ketamine • 1997 • 15.1% seniors tried in lifetime • 13.6% - LSD • 6.9% - MDMA • 3.9% - PCP • 12.8% MDMA 2003

  35. LSD • Lysergic acid diethylamide • “Acid,” “big ‘D,’” “blotters” • Rye fungus • Highly potent • Can be applied to small objects (stamps) • Onset 30-60 minutes • Lasts 10-12 hours • Mechanisms of action unknown

  36. LSD

  37. LSD

  38. LSD • Clinical manifestations • Somatic • Nausea • Dizziness • Dilated pupils • Fever • Flushing • Tachycardia

  39. LSD • Clinical manifestations • Perceptual • Synesthesia • “Seeing” smells • “Hearing” or “tasting” colors • Psychic • Delusions • Body distortion • Suspiciousness • Toxic psychosis

  40. In Service question often missed! How do you treat a bad trip?

  41. LSD • Treatment • “Bad trip” • User terrified, panicked • Remove person from setting • Attempt to re-establish contact with reality • Calm verbal interaction • “Flashbacks” • LSD-induced states after drug worn off • No withdrawal syndrome

  42. 0100 Sat Morning

  43. Case 4 • PP is 16 Y/O female brought in to ED after being “found” at a friends house.

  44. ABCDE PE LABS What now?

  45. PE • Pinpoint pupils, poor response to stimulation. • Arms with multiple small scars and needle marks

  46. Opiates • Epidemiology • Use decreased during 1980s • Seniors use • 0.9% 1991 • 2.1% 1997 • 2.9% 2003 • Increase may be related to route • Snort and smoke more often

  47. Heroin • Pharmacology • Heroine hydrolyzed to morphine • Onset of action • Inhaled (snorting): 30 min • SQ (skin-popping): few minutes • IV (mainlining): immediate • Tolerance • Yes to euphoric effect • No to inhibit of smooth muscle • Constipation and miosis

  48. Heroin • Clinical manifestations • Euphoria • Diminution of pain • Pinpoint pupils • Loss of libido

  49. Poppy

  50. Heroin