Summary NR 602 - Midterm

Infant development - ANS-- -1m: dolls eyes, nose breathing, hands closed, sees 20-25cm away, sleeps 16-17 hrs a day -2m: post fontanel closes, decr head lag, coos,follows toy side to side, sleeps 8.5-10rs/night & 6-7 hrs day -3m: all primitive reflexes fading, holds head, bears weight on legs, does not reach for rattle, babbling, mirrors, recognizes familiar objects and faces, sleeps 15-16 hours per day. Infant development - ANS-- -4m: drooling, no morrow/tonic neck, sits if propped, plays with hands, pulls on things, shows mood, laughs, focus on things 1/2in from face, regular sleep/wake pattern - 5m: double birth wt, rolls back to belly, pulls objects to mouth, follows dropped object, sleeps 10-11 hrs & 3 naps. - 6m: growth slows (3-5oz/week, 1/2in/month), rolls back to belly, sits in chair with back, recognize parent, definite likes/dislikes, 13-14 hours sleep, 2-3 naps. - 7m: leans to tripod position, bounce when standing, bang objects, 4 vowels said, knows name, stranger anxiety Infant Development - ANS-- -8m: regular b/b pattern, sits unsupported, pincer grasp, knows "no", more stranger anxiety, sleeps 11-12hrs + 2-3 naps - 9m: refined pincer grasp, steadily sits unsupported, pulls to stand, wants to please parents, 2 naps -10m: mature pincer,walks holding on, grabs by the handle, "mama/dada", object permanence, 2 naps -11m: lower lat incisors, pivots when standing, imitates sounds, rolls ball when asked -12m: triples birth wt, length by 50%, walks holding 1 hand, 5-7 words, security object Tanner (pubic hair) - ANS-- 1) no pubic hair 2) initial, scarce pigmented hair along medial border of labia 3) sparse, dark, visibly pigmented curly hair on labia 4) hair coarse and curly, abundant but less than adult 5) lateral spreading, triangle spread of adult hair to medial surface of thighs Tanner (Males) - ANS-- 1) Prepubertal 2) enlargement of scrotum & testes & change in scrotum texture. May be reddened 3) further penile growth (length first) & testes & scrotum 4) significantly enlarged ion length & circumference penis. more development of glans penis. darkening of scrotal skin (facial hair after this only) 5) adult genitals Tanner (Breasts) - ANS-- 1) prepubertal 2) Breast buds palpable under areola, enlargement of areola 3) breast tissue palpable outside areola- no areolar development or separation of contour 4) Areola elevated above contour of breast forming "double scoop" appearance 5) Areola mound recedes back into single breast contour with areolar hyperpigmentation, papillae development/ projection & nipple protrusion chalazion - ANS-- -chronic sterile inflammation of eyelid from a lipogranuloma of the meibomian gland - initially, mild redness & swelling, then after a few days, a slow-growing, round, nonpigmented PAINLESS mass remains. - Acute tx: hot compress, refer to eye MD Blepharitis - ANS-- - acute or chronic bacterial (staph) inflammation of eyelash follicle or sebaceous gland of eyelid. bilateral usually -flaky, scaly debris over eyelid margin when awakening - tx: warm compress, scrub with weak shampoo, sometimes bacitracin or erythromycin, -no contacts during tx Otitis Media - ANS-- - bulging TM, ear pain, , ETD, fever,irritability, otorrhea, absent TM mobility -RSV/influenza most common viruses - onia, haemophilus, strep (bacteria) - Tx: Amoxicillin (1st time), Amox/clavu (when AOM within 30 days), ceftriaxone, azith (penicillin allergy) - <2: treat 10 days, >2, 5-7 days - ofloxacin or cipro gtts is TM perforated, or draining PE tubes Otitis Externa (Swimmer's Ear) - ANS-- - swelling of EAC and pinna/TM - sx: itching, irritation, pain, pressure in eat, conductive or SNHL, pain with tragus or pinna movement, maybe lymphadenopathy, red, crusting lesions, dry canal, -tx: DROPS- ciprodex, vasocidin (ok if rupture tm). cortisporin, cipro HC (TM intact), domeboro (cleaning only) Conjunctivitis - ANS-- -most common peds infection, yellow-green purulent discharge, matted eyes when waking, itching -bacterial (unilateral), viral (bilateral) - usually self-limiting, but may treat with atbx - tx: sodium sulfacetamide or tmp+polymyxin B, or erythromycin, azith (>12m), -floxacins (>12m). no -mycins) -newborn: chlamydia trach. (erythromycin PO), gonorrhea (ceftriaxone IM/IV). DFA conjunctival test - Milia - ANS-- - pearly, white papules over forehead, nose, and cheeks. - no tx salmon patch - ANS-- - flat lesion or vascular malformation on back of neck, upper eyelids and glabella - 60-70% of newborns have on back of neck - no spontaneous resolution Cafe au lait spots - ANS-- - First sign of Neurofibromatosis -Tan to brown macules found anywhere on skin. hemangioma - ANS-- -papule made of blood vessels impetigo - ANS-- -bacterial infection (strep, *s*, or MRSA) - Bullous: more in infants and young children. large, superficial oval pustules - Sx: fever, papules/pustules that progress to vesicles that rupture-honey colored crust. face, hands, neck, extremities, or perineum, regional lymphadenopathy - Tx: topical mupirocin. or amox/clauv, cephalexin, dicloxacillin - Prev: moisturize skin Molluscum Contagiosum - ANS-- - viral skin infection - spread by direct contact, autoinoculation - incubation period 2-7 weeks (up to 6m) - Sx: itching, small, pink or flesh papules (1-6mm), - Tx: allow to disappear (6m-2-4 years), curettage, salicylic acid, KOH, - Evaluate for HIV infection if hundreds of lesions are found Verruca Vulgaris (warts) - ANS-- - HPV virus - flesh-colored, scaly, irregular surface, black pinpoints - Tx: watchful waiting, high recurrence, salicylic acid (>20%), retinoic acid (4-6 weeks, flat warts), duct tape, cryotherapy (liquid nitrogen), surgical excision (painful, scarring) Herpetic whitlow - ANS-- - swollen, painful lesion on finger or thumb, - on thumb-sucking children with gingivostomatitis or adolescents with genital HSV infection - Tx: Acyclovir 200mg 5x/day for 5-10 days atrial septal defect - ANS-- - hole in atrial septum (5-10% OF CHD) - Sx: easily fatigued, no murmur till 2-3yo, murmur at pulmonic area split S1 sometimes, split S2, - Tx: may close spontaneously, or need surgery, ASA x 6m post surgery Murmur grading - ANS-- -1: Soft -2: Soft, but easily heard -3: loud, but without palpable thrill -4: loud and with precordial thrill -5: loud with thrill and audible with only the edge of stethoscope -6: very loud and audible with the stethoscope off the chest ventricular septal defect (VSD) - ANS-- - hole in ventricular septum (37% of all CHD) - murmur heard at 2-8 weeks, CHF symptoms, - Tx: depends on severity- diuretics, beta blockers, ace inhibitors, surgery patent ductus arteriosus (PDA) - ANS-- - PDA= connection between aorta and pulm. artery. -5-10% Of all CHD (more females)- (very high incidence in premature babies). - Sx: Soft, systolic murmur on L sternal border, then harsh murmur - Tx: watch and wait, or surgery Cyanotic shunting - ANS-- - 10-18 % of congenital heart lesions - obstruction of pulmonary blood flow or mixing of oxygenated and deoxygenated blood. Acyanotic Defects - ANS-- - ASD, VSD,A/VSD/ PDA, PVS, coarctation of the aorta, AS Cyanotic defects - ANS-- - TOF, Pulm./tricuspid atresia, hypoplastic l heart, transposition of the great vessels, truncus arteriosus. Tetralogy of Fallot (TOF) - ANS-- - 4 anatomic defects ( PV stenosis, RV hypertrophy, Aorta overrides the ventricular septum, VSD - Sx: cyanosis, dyspnea and cyanosis with feeding & crying poor wt gain, grade 3-5 harsh systolic murmur L sternal border - Tx:open heart surgery Mitral valve prolapse - ANS-- - + family hx - midsystolic click, thin, thoracic skeletal abnormalities - inverted T waves in aVF - normal CXR (coarctation) of the aorta (COA) - ANS-- - Narrowing of a small or long segment of the aorta - Risk: male, other L heart abnormalities - Sx: Severe: may be apparent in the first 6 weeks. might have no sx until 3-5 yo. Upper extremity HTN, lower ext hypo., delayed timing or weak distal arterial pulses, bounding or bounding brachial radial & carotid pulse, CHF signs, Systolic murmur, gallop - Dx: Echo will confirm, MRI defines location & severity. - Tx: PGE1 used in sev. neonates, surgery (restenosis likely if done <1yo), Kawasaki Disease - ANS-- - acute febrile illness - risk: Asian/pacific islander, <6m >9 years, male, Poor outcomes= asian, pacific, hispanic, person-person spread is low, - Sx: 5 day fever, & bilat conjunctival infection, changes of the lips/mouth, cervical lymphadenopathy, polymorphous exanthema or changes in peripheral extremities or perineal area (swelling of hands/feet). - Alb <3, Urine >10 WBC, plet > 450,000 after 7 days of fever, anemia consistent with age values, WBC > 15,000, & high alanine aminotransferase. - Triphasic: 1) acute: rash, hand/feet swelling, red eyes (spares limbus), subacute: fever, rash & lymph swelling gone, arthralgia & desquamation of skin over fingers, thrombocytosis & cardiac disease. final (around day 25): myocarditis, elevated ESR, other signs absent - Tx: IVIG therapy, high dose ASA, Rheumatic Fever - ANS-- - autoimmune inflammatory process involving joints, heath, CNS, and subq tissue. group A step - Sx: Recent strep infection, chorea, erythema marginatum, subq nodules, fever >38.5, prolonged PR, SR >30, Mitral regurg, Aortic regurg, sx last 4 weeks w/o tx, carditis - Tx: antibiotic for strep (penicillin or erythromycin), , NSAID's Asthma - ANS-- - Step 1 (intermittent): sx <2x/week, normal PFts, nighttime sx <2/month, exacerbations brief, no interference with normal activity - Step 2 (mild persistent): >2x/week but not more than 1 per day, 3-4 nighttime sx/month, FEV >80% - Step 3 (mod persistent): daily sx, daily SABA, some limitations, exacerbations affect activity and may last days. FEV >60 but <80 - Step 4 (severe persistent): Continual sx, requires SABA several x's/day, extremely limited physical activity, frequent exacerbations, nightly sx, FEV <60% Asthma treatment steps - ANS-- - Step 1: SABA PRn - Step 2: Low-dose ICS, OR LTRA, Cromolyn - Step 3: Low-dose ICS + LABA OR Med- dose ICS - Step 4: Med- dose ICS + LABA OR med-dose ICS + LTRA - Step 5: High-dose ICS + LABA AND omalizumab for pts who have allergies - Step 6: High-dose ICS + Laba + Oral steroid AND omalizumab for allergies - consult asthma specialist after step 3-4( for sure at 4) rotavirus - ANS-- - 1-3 day incubation period - more prevalent in cooler months - Acute onset fever, vomiting, watery diarrhea occur 2-4 days later in children <5, esp those between 3-24 months. -3-8 days till recovery - fecal-oral transmission, lives on inanimate objects, rarely contaminated water or food - Testing: enzyme immunoassay & latex agglutination assay for group a rotavirus - Tx: supportive care, correct dehydration, Prevent: diaper precautions in daycare Salmonella - ANS-- - 1-3 day incubation, 4-7 day duration of illness - s/s: diarrhea, fever, abd cramps, rebound tenderness, n/v - typhy & paratyphi produce typhoid with insidious onset with fever, HA, constipation, malaise, chills, myalgia, diarrhea is uncommon and vomiting not severe -transmitted through eggs, poultry, unpasteurized milk/juice, cheese, raw fruit & veggies. Typhi: epidemics from fecal contamination of water supply -test: stool cultures: leukocytosis, gross blood. WBC high -tx: supportive care. ATB ONLY for infants <3m, those with chronic GI disease, cancer, HIV, immunosuppressed (Ampicillin or Amox, Azith, or TMP-SMX ORR ceftriax) C. diff - ANS-- - unknown incubation, duration: after several weeks of ATB - Sx: explosive diarrhea, bloody stools, abd pain, fever, n/v - acquired from the environment or oral-fecal route -Test: stool culture, enzyme immunoassay for toxin a or a and B - Tx: d/c ATB (esp. clinda, ampa, or cephalosporins), fluid & lyte replacement. ** If ATB still needed, treat with oral Metronidadole or Vanco for 7-10 days, probiotic Cryptosporidium parvum - ANS-- - 3-14 day incubation, Self-limiting duration (6-14 days) -Sx: watery diarrhea, ABD cramps, bloating, slight fever, anorexia, wt loss, n/v, flatulence, fatigue - Fecal/oral route from uncooked food or contaminated from an ill person , drinking water ( collects on water filters that cannot be disinfected) - test: Cryptosporidium test using antigen detection test. - Tx: supportive, if person immunocompromised, Paromomycin x 7 days. For children 1-11 years, Nitazoxanide x3 days Intussusception - ANS-- - A section of intestine being pulled antegrade into the adjacent intestine and being trapped. - Most common cause of bowel obstruction in children - Usually between 5-10 months. 80% of cases before 2 years old - Sx: Triad- crampy abd pain, vomiting, and bloody mucous stools (<25% of cases), screaming with drawing up legs, periods of calm/sleeping, stool maybe with blood and diarrhea, infant may appear glassy-eyed and sedated between episodes, sausage like mass in RUQ & emptiness in RLQ -Normal x-ray, *Ultrasound*, air contrast enema is both diagnostic and a treatment - Tx: surgery is necessary for perforation, peritonitis, hypovolemic shock. IV ATB, radiologic reduction Celiac Disease - ANS-- - Gluten-sensitivity. Immune mediated systemic disorder - Frequently occurs with other autoimmune diseases (DM 1, liver disease, IgA nephropathy, juvenile chronic arthritis) -Risk: immigration from another country, born by c-section, 6m-2years, female, - Sx: Chronic or intermittent diarrhea, persistent or unexplained Gi symptoms, wt loss, prolonged fatigue, growth failure, steatorrhea, low trauma fractures, dental enamel defects - Test: serologic testing, IgA tTGA and IGA EMA (more expensive and less accurate in <2yo). No home blood testing. Endoscopy & biopsy for definitive dx. -Tx: strict GFD (<10mg gluten) Juvenile Idiopathic Arthritis (JIA) - ANS-- - previously known as rheumatoid arthritis -Cause unknown, but may be environmentally induced in genetically predisposed people. Girls - Arthritis >6 weeks in child <16yo., mild-mod pain, joint stiffness, joint effusion and warmth, behavior regression, irritability, nonspecific sx-decr appetite, myalgia, inactivity, failure to thrive, loss of joint ROM, walk with a limp, nail pits, salmon-color rash on trunk - no one diagnostic test. dx of exclusion. must r/o lymes. CDC (exclude leukemia), -Tx: refer to rheumatology, and ophthalmology (d/t uveitis), NSAIDs, DMARDs, oral glucocorticoids, no cure - 85% of kids- disease wanes with age and completely subsides. - Oligoarticular (most common)- 4 or less joints affected. morning limp. 70% of kids have an ANA (risk for uveitis) - Polyarticular- (30-35% of kids have). 5 or more joints during the first 6 months, RF neg ANA +. Osteomyelitis - ANS-- -inflammation of bone and bone marrow - can occur is a puncture wound penetrates a bone or joint - toddler, child, and adolescent - mild pain, malaise, low to high fever, child refuse to walk or move limb, point tenderness, 7-10 days to see radiographic bony change, 25% incr WBC & incr CPR - S. aureus likely organism in DM pts, and p. aeruginosa in non DM pts ( on foot) - ATB for 7 days IV, 3-4 weeks total (nafcillin,cefazolin, Vanco-staph), (cefepime- P. aerug) Transient synovitis - ANS-- - 3-8 year olds -mild to mod fever, mild irritability. resolves within 1 week.Limited hip motion, ESR <25mm/h - hx of inflammatory reaction; unknown etiology, often URI prior - Tx: rest Legg-Calve-Perthes Disease - ANS-- -avascular necrosis of the femoral head, causing infarction of the body epiphysis. - Cause: insufficient blood supply to the femoral head. The area revascularizes and necrotic bone is replaced with new bone (18-24 months). - lateral subluxation of the femoral head=poorer outcomes - risk: boys, lower socioeconomic group, low birth wt. 4-8 years old. bilateral in 10-20% of kids. - s/s: acute or chronic onset with or without hx of trauma, intermittent limb (abductor lurch), mild or mild pain in groin & ant. hip or laterally around the greater trochanter. muscle spasm. decreased abduction, int rotation and extension of hip -tx: referral to orthopedist. activity limitation, NSAIDs, PT, bedrest with traction p- not preventable Scoliosis - ANS-- - Curvature >10 deg. using Cobb method - Most curves do not increase after growth is complete. -Congenital- structural anomaly present at birth - neuromuscular- cerebral palsy, neurofibromatosis, marfan - Sx: unequal shoulder height, scapula height, waist, and rib height. - Adams test. forward bending to look at the posterior chest. Idiopathic scoliosis - ANS-- -most common type (infant 0-3), Juvenile (3-10), Adolescent (11+). Familial or genetic pattern. - Tx: Observation (<20 deg.), Brace (>30 deg. or skeletal immaturity with 20-25 deg that's shown > 5 deg progression), Surgery (>45-50 deg or do not respond to brace). - females are more likely to have curve progression and need close monitoring - equal occurrence in boys and girls, but girls have a higher risk for curves >30 deg. - usually found in adolescents Dysplasia of the hip - ANS-- - Risk: Female, family hx, high birth wt, breech positioning, in utero postural deformities - Barlow & Ortolani- only until 3 months old - Klisic & Galeazzi(put knees up and unequal leg length)- older infants - Normal abduction with comfort is 70-80 degrees. limited is <60 - Sx: marked lordosis, painless limping, waddling gait, limited abduction, asymmetric gluteal folds, -dx: ultrasound after 6 weeks. AP & lateral Lauenstein X-ray after 4-6 months - Tx: refer newborn to ortho, reexamine in 2 weeks, most resolve by 6-8 weeks. Pavlik harness (keeps hips >90 degrees of flexion. worn 24 hours/day except bathing. usually 3-6 weeks, then decreased to wake hours only), if no response-surgery. Osgood-Schlatter disease - ANS-- -Caused by microtrauma in deep fibers of the patellar tendon at its insertion on the tibial tuberosity. - Often seen in adolescent years after rapid growth spurt last year. - risk: girls:8-12 yo, boys: 10-15 yo, recent physical activity, pain during and immediately after activity, better with rest, bilateral in 20-50%, pain with extension of the knee against resistance, squatting, swelling and point tenderness at tibial tuberosity, full knee ROM. - No dx test needed. Based on H&P. - Tx: avoid painful activities, Ice, NSAIDs, stretching, neoprene sleeve over knee, casting or bracing Febrile Seizures - ANS-- - usually between 6-60m (5y). - Simple: generalized seizure < 15 min. - Complex: generalized or focal, >15 min, and/or with clustering of seizures. - Not related to an underlying CNS problem - risk for recurrence: < 18m when first seizure, low temp at time of seizure, no fever until after seizure, family hx of febrile seizures. - Dx: EEG & MRI for all complex seizures - no real tx. rectal diazepam, intranasal midazolam or buccal clonazepam as "rescue" meds testicular torsion - ANS-- - twisting of the spermatic cord. - 6 hour window before significant ischemic damage and alteration in spermatic morphology occurs - happens after physical exertion, trauma, or on arising. usually <10 yo, Left side (longer spermatic cord). - S/s: unilateral unrelenting scrotal pain, N/V, may have hx of intermittent pain, usually no or minimal fever, swelling, redness, warmth, tender, "blue dot" sign, thick, twisted, tender cord, *elevation of testes increases pain*, absent cremasteric reflex - Dx: Normal UA, Doppler ultrasound - Tx: surgical emergency (orchiopexy) Varicocele - ANS-- - enlargement/dilation of testicular veins - sx: dull, aching, throbbing scrotum *bag of worms*, usually on L -exacerbated by standing - Tx: NSAIDs, elevation, varicocelectomy Epididymitis - ANS-- - usually caused by STI ( chlam or gono), or other infection ( ) - Sx: gradually, increasing dull, unilateral pain, recent GU procedures or sexual activity, edema, normal position and consistency of testes - elevation of testis relieves pain, prostate tenderness - tender, swollen epididymis, NORMAL cremasteric reflex - Dx: UA (pyuria), doppler ultrasound - Tx: empiric abx - ceftriaxone IM + doxy x10 days. OR ofloxacin/levo x10 days wilms tumor staging - ANS-- • Stage I: The tumor is limited to the kidney and can be completely excised with the capsular surface intact. • Stage II: The tumor extends beyond the kidney but can still be completely peritoneal involvement • Stage III: No mets, but residual tumor remains • Stage IV: There is hematogenous metastasis, most frequently to the lung. • Stage V: There is bilateral kidney involvement. Wilms tumor - ANS-- - Most common GU malignancy - S/s: Firm, smooth mass in abdomen or flank that does not cross the midline, fever, dyspnea diarrhea, wt loss, vomiting, malaise, - risk: usually 2-5yo (peak @ 3.5yo), family hx, hypospadias, cryptorchidism, ambiguous genitalia, cardiac abnormalities, African american (lower in asian), female, family hx, exposure to pesticides, 1st born - Dx: Chest/abd X ray (to differentiate neuroblastoma), ABD/renal ultrasound, UA (hematuria in 25-33%), CT of C,A,&P. - Tx: refer to oncology. Surgery/chemo - high risk: renal ultrasound every 3-4 months until 5yo Turner Syndrome (XO) - ANS-- -Sx: short stature, short neck with webbing and low posterior hairline, posteriorly rotated ears & narrow canals, ptosis, short 4-5th metacarpals, short legs, hyperconvex nails, cardiac disorders, hip dysplasia, scoliosis or kyphosis, horseshoe kidney, chronic OM with conductive hearing loss, delayed puberty/ infertility. nonverbal learning disabilities, hearing loss, strabismus - annual hearing exam, early onset osteopenia, may need estrogen therapy, monitor BP (HTN), annual thyroid screen, ongoing celiac disease test (Tissue transglut. immuno A), Incr risk of HLD & cardiac defects & renal abnormalities, forms keloids Down Syndrome (Trisomy 21) - ANS-- - extra copy of chromosome 21 - Sx: short stature, brachycephaly, midface hypoplasia with flat nasal bridge, brushfield spots, small mouth with protruding tongue, myopia/cataracts, small ears, narrow canals, extra skin at nape of neck, lax joints, short broad hands/feet/digits, single palmar crease, exaggerated pace between great and 2nd toe, congenital heart disease, risk for leukemia, hypothyroidism and AD, hearing loss, hypotonia, cognitive delays - monitor for OSA, Incr risk for celiac disease, neuro conditions & leukemia Precocious puberty - ANS-- - thelarche or pubarche before 8yo (girl) and 9yo (boy) (except in non-hispanic AA and Mexican-american girls=normal), accelerated linear growth, breast development, testicular or penile enlargement, - Central, gonadotropin dependent: idiopathic, CNS tumors, infection, trauma. - Peripheral, gonadotropin independent: ovarian cyst or tumor, McCune-Albright syndrome (girls), testicular tumor, testotoxicosis (boys), hypothyroidism, HCG-secreting tumor - Risk: female, AA, - Dx: bone age x-ray of L wrist/hand, LH, FSH, est, test, MRI ( if LH/FSH high) - Tx: refer to ped. endocrinology, long-acting GnRH agonist menarche - ANS-- - First menstrual period - around 12.5 yo, but between 9-15 - about 2.5 years after thelarche Primary dysmenorrhea - ANS-- - onset of cramps usually 1-2 years after onset of menses, but can be anytime - crampy, stabbing pain in lower or mid-band, may radiate to back or thighs - NSAIDs and heat usually helpful, but does not alleviate sx - missing school and activities if pain in severe - No pain outside of menstruation -normal physical exam (absence of pelvic pathology) - due to the release of prostaglandins from the endometrium. Contraceptives - ANS-- - OCP do not increase risk of breast CA (decr. cervical CA) - No IUD restrictions based on age, parity, STDs, ectopic pregnancy or hx of PID. - combined oral contraceptives should be avoided in people with migraines WITH aura. - all contraceptives are safe with epilepsy. but some anticonvulsants like topiramate can decrease the contraceptives efficacy. - Implant: suppresses ovulation,. thicken cervical mucus,good for teens. progestin only. most effective BC. no pelvic exam required, relief of dysmenorrhea - IUD: pts don't need to check their strings. woman will still ovulate - Depo: progestin only. Q 3 months. suppresses ovulation, thins lining of endometrium. I need a pregnancy test. repeat injection can be given 2 weeks late without additional contraceptive protection or preg. test. menstrual suppression/irregular bleeding. wt gain. may affect bone density that is reversed when discontinued. - COC: No pelvic exam or pregnancy test needed. Progestin only pills do not effectively suppress ovulation- thicken cervical mucus.