Pediatric Primary Care Case Studies (117 page)

2.   Prevention of pregnancy

•   “Are you or your partner trying to get pregnant?”

•
   If no, “What are you doing to prevent pregnancy?”

3.   Protection from STIs

•   “What do you do to protect yourself from STIs and HIV?”

4.   Practices

•   “To understand your risks for STIs, I need to understand the kind of sex you have had recently.”

•   “Have you had vaginal sex, meaning ‘penis in vagina sex’?”

•
   If yes, “Do you use condoms: never, sometimes, or always?”

•   “Have you had anal sex, meaning ‘penis in rectum/anus sex’?”

•
   If yes, “Do you use condoms: never, sometimes, or always?”

•   “Have you had oral sex, meaning ‘mouth on penis/vagina’?”

For condom answers:

•   If never: “Why don’t you use condoms?”

•   If sometimes: “In what situations, or with whom, do you not use condoms?”

5.   Past history of STIs

•   “Have you ever had an STI?”

•   “Have any of your partners had an STI?”

Additional questions to identify HIV and hepatitis risk:

•   “Have you or any of your partners ever injected drugs?”

•   “Have any of your partners exchanged money or drugs for sex?”

•   “Is there anything else about your sexual practices that I need to know about?”

Source:
From Centers for Disease Control and Prevention. (2006b).
Sexually transmitted diseases: treatment guidelines, clinical prevention guidance
. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved September 17, 2008, from
http://www.cdc.gov/std/treatment/2006/clinical.htm#clinical2

Menarche was at age 12; her cycles are usually regular every 28 to 30 days and last about 4 days. She complains of severe cramping for the first 2 days with medium flow. Her last menstrual period (LMP) was approximately 2 weeks ago, although she does not really keep track of dates for her cycles.

She denies a history of any skin lesions or rash, dysuria, abdominal pain, dyspareunia, or a sexually transmitted infection. She has noticed a little spotting a couple of times this last month, especially after having sex, and a little white vaginal discharge for the past few weeks.

She has a negative personal medical history. Her family history is positive for hypertension (father) and type 2 diabetes (maternal grandmother).

Leslie’s social history is positive for “occasional” alcohol at parties, which she describes as three to four drinks once a month. She admits to smoking socially when at parties, but denies any other drug use. She describes herself as a “good” student with a B average. She plans to go to college but is unsure what she wants to major in.

What are your concerns after getting this history?

See the STI risk factors listed in
Box 29-2
.

Leslie is at risk for both pregnancy and STIs due to irregular condom use and having three sexual partners in the last year. She is having some vaginal spotting, which could be related to a STI. She is also using both alcohol and tobacco.

What are your working diagnoses prior to your physical examination?

You start with the following working diagnoses:

•   Contraceptive need

•   Rule out pregnancy

•   Rule out STIs

•   Bloody vaginal spotting and discharge of unknown etiology

•   Alcohol and tobacco use

What type of physical examination would you do?

In accordance with current recommendations of the American Cancer Society’s “Guidelines for Early Detection of Cervical Cancer,” which states that screening should begin approximately 3 years after first sexual intercourse (Saslow et al., 2002), she does not need a pap screening today. However, she does need a pelvic and STI examination.

What clinical findings are you looking for?

The three most common sexually transmitted infections in teenage women are chlamydia, gonorrhea, and syphilis. Chlamydia is the most common of these. In 30–70% of women chlamydia is asymptomatic, but the usual symptoms, if they appear, include vaginal discharge that may be clear to white or yellow; bloody vaginal spotting; dysuria and/or pyuria; mucopurulent cervicitis with edema, erythema, and hypertrophy; mild abdominal pain;
Fitz-Hugh-Curtis syndrome (right upper quadrant pain); or foreign body sensation in eyes with conjunctivitis.

Box 29–2   Risk Factors for Sexually Transmitted Infections

•   Adolescent younger than 15 years of age

•   Sexually active adolescent, especially with two or more partners in 6 months, high frequency of intercourse, or high rate of new partners

•   Use of drugs or alcohol, or other high-risk behaviors

•   Pregnancy or abortion

•   Homosexual

•   Victim of abuse, rape, or incest

•   Incarcerated, runaway, homeless, or in a group shelter or detention home

•   Clients in sexually transmitted infection (STI) clinics or with any other STI or previous history of STI

•   Lack of family availability; low level of parental support and monitoring

•   Beliefs about normative behaviors among peers

•   Inappropriate healthcare behaviors (e.g., not seeking medical care, not adhering to treatment regimen, failure to recognize symptoms, delay in notifying partners, nonuse of barrier contraceptive)

Sources:
In Gerlt, T. J., Kollar, L. M., & Starr, N. B. (2009). Gynecologic conditions. In C. E. Burns, A. M. Dunn, M. A. Brady, N. B. Starr, & C. Blosser (Eds.),
Pediatric primary care
(4th ed., p. 933). Philadelphia, WB Saunders; data from Biro, F. M., & Rosenthal, S. L. (1995). Adolescent STDs: diagnosis, developmental issues, and prevention.
Journal of Pediatric Health Care, 9
, 256–262; Bonny, A. E., & Biro, F. M. (1998). Recognizing and treating STDs in adolescent girls.
Contemporary Pediatrics, 15
, 119–143; Shrier, L. A. (2005). Bacterial sexually transmitted infections: gonorrhea, chlamydia, pelvic inflammatory disease, and syphilis. In S. J. Emans, M. R. Laufer, & D. P. Goldstein (Eds.),
Pediatric and adolescent gynecology
(5th ed., pp. 565–614). Philadelphia: Lippincott Williams & Wilkins.

Gonorrhea (GC) is also usually asymptomatic in women. The typical signs and symptoms of GC infection include dysuria; urethritis; thick, green, profuse vaginal discharge; cervicitis; bleeding; dyspareunia; Skene’s or Bartholin’s gland abscess; or exudative pharyngitis.

Syphilis is less common. The primary form usually presents with a single painless papule with serous discharge on a smooth base with raised edges. The location of the chancre may be vaginal, anal, or oral. In secondary syphilis, the classic copper-penny rash presents, generally on the palms of the hands and soles of the feet. There also may be mucocutaneous lesions and painless regional lymphadenopathy.

Height and weight, body mass index (BMI), blood pressure, thyroid, heart, lungs, breast, abdominal, and pelvic examinations are all parts of the assessment needed before beginning hormonal contraception and to rule out STIs.

Leslie’s general physical examination reveals: height 5’ 3”; weight 112 pounds; BMI 19.8 (25%); blood pressure 116/68. Her thyroid is smooth, without enlargement. Her heart rate is regular with no murmurs, rubs, or clicks. Lungs are clear to auscultation. Breasts are nontender, Tanner stage 4, without masses. Her abdomen is soft, nontender, with no masses, and without organomegaly.

Pelvic examination: Your examination reveals external genitalia without lesions, negative Bartholin’s, urethra, and Skene’s; Tanner stage 4. Her vagina is pink with normal ruga and minimal clear to white discharge. Her cervix appears nulliparous and pink with thick clear mucous at the os.

Bimanual examination: You perform a bimanual examination and find her uterus to be anteverted, firm, smooth, nontender, and nonenlarged; her adnexa is without masses or tenderness; and the cervix is firm, without cervical motion tenderness.

What laboratory studies would you order?