Pediatric Primary Care Case Studies (110 page)

Key Points from the Case

1. Guidelines simplify the care of recurrent urinary tract infections, vesicoureteral reflux, and dysfunctional elimination syndrome.

2. Treatment of dysfunctional elimination syndrome, reflux, and urinary tract infection requires an understanding of the pathophysiology and development of the patient and a family care plan.

3. Urinary tract infections will not improve unless dysfunctional elimination is addressed.

4. Significant abnormalities of the urinary tract can present with urinary tract infection and must be kept in mind when evaluating a patient.

5. Antimicrobial management is dependent on age, comorbid conditions, and severity of infection.

REFERENCES

Alon, U. S. (2006). Urinary tract infection and perinephric/intranephric abscess. In F. D. Burg, J. R Ingelfinger, R. A. Polin, & A. A. Gershon (Eds.),
Current pediatric therapy
(18th ed., pp. 594–596). Philadelphia: Saunders.

Brown, J., Burns, J., & Cummings, P. (2002). Ampicillin use in infant fever: a systematic review.
Archives of Pediatric and Adolescent Medicine, 156
, 27–32.

Elder, J. S. (2007). Urologic disorders in infants and children. In R. E. Behrman, R. M. Kliegman, & H. B. Jensen (Eds.),
Nelson’s textbook of pediatrics
(18th ed., pp. 2221–2272). Philadelphia: Saunders.

Gaylord, N. M., & Starr, N. B. (2009). Genitourinary disorders. In C. Burns, M. A. Brady, A. M. Dunn, & N. Starr (Eds.),
Pediatric primary care
(4th ed., pp. 866–905). Philadelphia: Elsevier.

Koff, S. A., Wagner, T. T., & Jayanthni, V. R. (1998). The relationship among dysfunction elimination syndromes, primary vesicoureteral reflux and urinary tract infections in children.
Journal of Urology, 160
, 1019–1022.

Schöen, E. J., Colby, C. J., & Ray, G. T. (2000). Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life.
Pediatrics, 105
(4), 789–793.

Shortliffe, L. D. (2007). Infection and inflammation of the pediatric genitourinary tract. In A. J. Wein, L. R. Kavoussi, A. C. Novick, A. W. Partin, & C. A. Peters (Eds.),
Campbell-Walsh urology
(pp. 3252–3254). Philadelphia: Saunders.

Yeung, C. K., Sihoe, J. D., & Bauer, S. B. (2007). Voiding dysfunction in children: non-neurogenic and neurogenic. In A. J. Wein, L. R. Kavoussi, A. C. Novick, A. W. Partin, & C. A. Peters (Eds.),
Campbell-Walsh urology
(pp. 3604–3655). Philadelphia: Saunders.

Chapter 28

The 15-Year-Old Girl Who Wants Birth Control

Deborah Stiffler

Prescribing contraception to adolescent females can be a difficult and time-consuming task. Assisting the adolescent to choose a contraceptive that is right for her, and also finding one that she can use consistently and correctly to prevent pregnancy and help her to prevent any sexually transmitted infections, can be challenging.

Educational Objectives

1.   Differentiate among the types of contraceptives currently available.

2.   Compare the risks and benefits of each contraceptive.

3.   Choose a safe and effective contraceptive method for a patient.

4.   Formulate an individualized management plan for a patient.

   Case Presentation and Discussion

Jaime Hoskins, a 15-year-old African American young woman, presents to your office requesting birth control. Jaime relates to you that she has been sexually active for about a year. She has had two different partners in that year, but she was only having sex with one at a time. She has been with her current boyfriend, Blair, for almost 3 months. Blair is 18 years old. As far as she knows, he is only having sex with her. She does not know how many partners he has had previously. They usually use a condom when they have sex, but sometimes Blair isn’t in the mood, so they don’t use one. Jaime tells you the reason she has come in today is that she and Blair recently had a scare. They were using a condom, but it slipped off during sex. When her period was a few days late, she was sure she was pregnant. Jaime’s mom is waiting for her in the waiting room; she brought Jaime in today thinking that Jaime had a yeast infection. Jaime does not want her mom to know that she is here for birth control because “she would just freak” if she knew that Jaime was sexually active.

What questions would you ask Jaime to expand on the above information?

Jaime’s immunizations are current, she has had no surgeries, has no allergies, and is taking no medications.

Jaime’s family is fairly healthy. Her mother is 33 years old and somewhat overweight, but otherwise, she is healthy. Her maternal grandmother is deceased from a stroke at age 61. Jaime’s maternal grandfather is currently 68 years old and has adult onset diabetes. Her sisters are healthy. Jaime does not know anything about her father’s side of the family.

Jaime started her periods at age 11. They have always been regular, about 26–28 days apart, and they last for 5 days. Jaime relates moderate to heavy flow for the first 3 days, saturating three or four maxi pads each day. She also has moderate cramping with her periods. The cramping does not cause her to stay home from school, but she is “not worth much” on those days. Other than occasional condom use, she has never used any methods of birth control nor has she had a pap smear. Her last menstrual period was 2 weeks ago, and she and Blair have had unprotected intercourse since then.

Social history: Jaime is a sophomore at the local high school. She is on the cheerleading squad and plays volleyball on the school team. She lives at home with her mother and two younger sisters, ages 14 and 11. Her parents are divorced. She sees her father occasionally. She denies using street drugs and occasionally drinks alcohol, mostly beer on the weekends. She admits to being drunk twice, and doesn’t smoke.

What findings are important on the physical examination?

You chart her examination as follows: Vital signs: temperature 98.2°F, oral; blood pressure 110/58; pulse 82; respirations 16; height 64 inches; weight 137 pounds; body mass index (BMI) 23.5.

Physical examination: EENT WNL; thyroid not enlarged; heart RRR without murmurs; lungs clear to P&A; back no CVA tenderness; abdomen soft, nontender, no splenohepatomegaly. She has a negative Homan’s sign, bilaterally. Pelvic: escutcheon, normal female; vulva without lesions; vagina moist, normal leukorrhea; cervix small, nulliparous; uterus anteverted, small, no tenderness on palpation; adnexa without cysts or masses, no tenderness to palpation.

What testing should be done?

In this case, the following laboratory testing should be done:

•   
Urine human chorionic gonadotropin:
An easy test for pregnancy that can be done quickly in the office.

•   
Pap smear:
The newest guidelines from the American Cancer Society (ACS) state the first pap smear should be done by 3 years of initiation of intercourse or by the age of 21, whichever comes first (ACS, 2008).

•   
Gonorrhea/chlamydia cultures:
Jaime is already sexually active and does not always use condoms, so she is at risk for currently having or acquiring a sexually transmitted infection in the future.

•   
Hemoglobin/hematocrit count (H&H):
This will check for anemia due to Jaime’s heavy menstrual periods.

You collect the specimens and send them off for laboratory studies.

After completing the history and physical, what information should you consider?

Jaime is in her adolescent years. This is a period of time when adolescents start to take risks. Risk-taking is a way for an adolescent to define and develop his or her identity. Healthy risk-taking, such as playing sports, seeking out new friends, or starting a job is a valuable experience (Ponton, 1997); however, adolescents frequently make unhealthy choices. Adolescents are at risk for behaviors such as drinking, smoking, drug use, reckless driving, unsafe sexual activity, disordered eating, self-mutilation, running away, stealing, and gang activity. Jaime does engage in occasional binge drinking. Alcohol decreases inhibitions, and this could put Jaime at risk for unintended sexual activity, decrease the potential for using a condom, or affect her use of other contraceptives. Adolescents under the influence of alcohol or drugs may take chances with their personal safety (U.S. Department of Health and Human Services, 2008). Currently, Jaime is engaging in another unhealthy behavior: unprotected sexual activity. This is an important area to discuss with Jaime.

It is important to have Jaime start some method of contraception. However, adolescents tend to be inconsistent users of contraception (Frost, Singh, & Finer, 2007). They can be forgetful, not taking their oral contraceptive pills or not keeping a condom with them when there is the potential for intercourse (Frost et al., 2007). Adolescents who have initiated sexual activity early in their teen years have the potential for multiple sexual partners. Jaime has stated that she is only having intercourse with Blair right now, but she has been sexually active with someone previously. Plus, there is no way to know how many partners Blair has had. When Jaime has sexual intercourse with Blair, she is essentially having intercourse with every other person he has had sex with (Stiffler, Sims, & Stern, 2007). She is at risk for HIV/AIDS along with other sexually transmitted infections (STIs). Adolescent females are biologically more at risk for STIs than adolescent males (Chambers & Rew, 2003). During the adolescent years, the transformation zone of the cervix is lower in the cervical canal. This is the area where the cells are changing from squamous epithelium to columnar epithelium, and it is especially vulnerable to infection and disease (Moore et al., 2005).