Pediatric Primary Care Case Studies (59 page)

Sexually Transmitted Diseases

You tell Cassandra that no matter what one’s orientation, it is important to be free of sexually transmitted diseases. You remind her that it is important for her and her partner to learn to be totally honest about any potential for disease (such as one of them having herpes, bisexuality, needle drug use, or multiple partners) before having sex. They should encourage each other to discuss which activities feel good and which ones do not.

You ask her if she has more questions right now. She does not, so you proceed to the physical exam. You also let her know that she does not need to take birth control unless she feels that it is something she needs, regardless of what her sisters have done in the past.

The Sexual History and Physical Examination

The practitioner is cautioned to obtain a sensitive and comprehensive history in order to define those areas that require a more extensive examination. Identifying high-risk behaviors or substance abuse will direct the practitioner’s focus during the exam.

The physical exam should include an evaluation of the sexual organs (women: breasts, external genitalia, vagina, cervix, uterus, and adnexa; men: penis, scrotum, rectum, and prostate), identifying the stage of puberty, and a thorough skin assessment (paying close attention to possible signs of abuse or trauma, and sexually transmitted diseases).

According to the American Cancer Society (2008), sexually active women should begin cervical cancer screening (Pap smears) about 3 years after they start having sexual relations. If she waits to have sex until she is over 18, she should start screening no later than age 21. Regardless of the young woman’s sexual orientation, she should have a regular Pap test yearly or the newer liquid-based Pap test every 2 years. Even though human papillomavirus (HPV) and the genital warts it can cause is very common in men, HPV-related cancers are very rare in men. There is currently no approved test for men.

Making the Diagnosis

Cassandra is moving through the steps necessary to manage a homosexual lifestyle. She seems comfortable with her sexual identity but is having difficulty communicating with her mother about her sexual orientation. She also needs healthcare education related to known health risk factors for lesbian youth.

Management

Cassandra is not currently sexually active and is less than 18 years of age, so you don’t do a Pap smear. If she had been sexually active, it would have been appropriate to test for sexually transmitted diseases. These would have included chlamydia, gonorrhea, HSV-1, HSV-2, and trichomoniasis. After the exam, which was normal, you tell Cassandra that your impression is that she and her mother love each other and that this is a new stage in their relationship. This transition to being a woman and being responsible for herself will take openness and understanding from both sides. You ask her if she has someone she can confide in about her sexuality, or if she would like a referral for confidential counseling.

You let Cassandra know that this may be a difficult experience for her mother to understand and that Cassandra may have to be patient with her mother and realize that like many people in the world, her mother may not yet understand and accept that some people live different lifestyles. This lack of understanding could cause her mother to be afraid, to be in denial of the facts for a time, and perhaps to react negatively to Cassandra’s preferences. You ask Cassandra to consider that out of love, her mother is trying to assure that Cassandra has as much freedom to grow into womanhood as possible; she does not want a baby to interfere with those things right now, not realizing that Cassandra’s choices are different from her sisters. You explain that this transition to her mother’s acceptance will take time and honesty on Cassandra’s part and that this might also be facilitated by a referral with a mental health counselor where they could talk together about their experiences around this issue.

Cassandra tells you that she thinks she can talk with her mother about her sexuality without a counselor, but promises to come back if she is having difficulty or her mother seems to be too upset.

You encourage Cassandra to come back regularly for her yearly well-woman exams or if any issues arise that you may help with. Provide her with information regarding the HPV vaccine and encourage her to be vaccinated to help prevent cervical cancer and genital warts. At the end of the appointment you give her a handout of resources she can access for more information about sexual orientation and LGBT issues.

Key Points from the Case

1. Adolescents usually establish their sexual identity by the time they reach adolescence, even if they have not had an opportunity to act on it.

2. LGBT adolescents (and adults) may avoid medical care and appropriate health screenings because of a misperception that they are only necessary for heterosexuals.

3. Proper health screening and education is especially important in the primary care setting for LGBT teens because there may be nowhere else available in the community for proper screening and education to occur in an atmosphere of respect and trust.

RESOURCES

Parents, Families and Friends of Lesbians and Gays (PFLAG):
http://community.pflag.org

Gay and Lesbian Medical Association (GLMA):
http://www.glma.org

Indiana Youth Group (IYG):
http://www.indianayouthgroup.org

Lesbian & Gay Child and Adolescent Psychiatric Association, resources:
http://www.lagcapa.org/Resources.htm

The National Coalition for Gay, Lesbian, Bisexual, and Transgender Youth:
http://
www.outproud.org

REFERENCES

American Academy of Child and Adolescent Psychiatry. (1997).
Gay and lesbian teens
. Retrieved June 23, 2008, from
http://www.puberty101.com/aacap_gayteens.shtml

American Academy of Pediatrics. (1993).
Homosexuality and adolescence
. Retrieved July 26, 2008, from
http://www.medem.com/MedLB/article_detaillb_for_printer.cfm?article_ID=ZZZUHJP3KAC&sub_cat=269

American Academy of Pediatrics. (1999).
Sexual stereotypes and sexual orientation
. Retrieved June 23, 2008, from
http://www.medem.com/search/article_display.cfm?path=\\TANQUERAY\M_ContentItem&mstr=/M_ContentItem/ZZZNZ1L6W7C.html&soc=AAP
&srch_typ=NAV_SERCH

American Academy of Pediatrics, Committee on Adolescence. (1993). Homosexuality and adolescence.
Pediatrics, 92
(4), 631–634.

American Cancer Society. (2008).
Cervical cancer: Prevention and early detection
. Retrieved October 6, 2008, from
http://www.cancer.org/docroot/CRI/content/CRI_2_6x_cervical_cancer_
prevention_and_early_detection_8.asp?sitearea=PED

Centers for Disease Control and Prevention. (2007).
CDC fact sheet: Genital HPV
. Retrieved October 6, 2008, from
http://www.cdc.gov/std/HPV/hpv-fact-sheet-press.pdf

Centers for Disease Control and Prevention. (2008).
Lesbian, gay, bisexual and transgender health
. Retrieved October 6, 2008, from
http://www.cdc.gov/lgbthealth/

Kinsey Institute. (2005).
Frequently asked sexuality questions to the Kinsey Institute
. Retrieved October 5, 2008, from
http://www.indiana.edu/~kinsey/resources/FAQ.html#homosexuality

U.S. Census Bureau. (2006). Arizona. S0902. Teenagers’ Characteristics. Retrieved April 21, 2009, from
http://factfinder.census.gov/servlet/STTable?_bm=y&-qr_name=ACS_2006_EST_G00_S0902&-geo_id=04000US04&-ds_name=ACS_2006_EST_G00_&-_lang=en

UNIT III

Diseases

Chapter 16

The Child with a Fever for Six Days

Ritamarie John

Children will often be brought to the primary care provider’s office with complaints that seem relatively straightforward and are treated accordingly. The issues for the provider are twofold: maintaining a degree of healthy hesitation in arriving at the diagnosis, and being willing to reevaluate progress, or lack thereof, for the patient who has been sent down a management pathway. The correct diagnosis can sometimes be elusive and require thought and careful consideration of the possible differentials and the most appropriate tests for a problem. In developing a differential diagnosis based on the presentation of the patient, there are sometimes several opportunities where diagnoses can be missed. It is important to use the most specific and sensitive diagnostic tests while keeping in mind their accuracy, precision, and cost. This case will illustrate some of these points.

Educational Objectives

1.   Apply key points in the history and physical examination to develop a differential diagnosis.

2.   Discuss the variety of pathogens responsible for pharyngitis and infectious mononucleosis.

3.   Understand how sensitivity and specificity of laboratory tests aid in the development of the differential diagnosis.

4.   Understand how ethnic, cultural, and personal factors play a role in shared decision making when developing a diagnostic and treatment plan.

   Case Presentation and Discussion

Maya Santiago is a 7-year-old American with a Peruvian father and a Puerto Rican mother. She presents with a 6-day history of a sore throat associated with fever to 103°F (39.5°C), headache, malaise, painful lymphadenopathy, and overwhelming fatigue. On day three of the illness, Maya was seen for pharyngitis. She was diagnosed with streptococcal pharyngitis after a rapid strep test was positive and was started on Omnicef at 14 mg/kg/day due to a history of rash following Amoxil. The child is worse after 3 days of antibiotic. The mother is concerned that there is something else wrong with the child.

What questions will you need to ask the family related to the presenting complaints?

Compliance to medication is an important history point.

The child and mother confirm that they have been taking the antibiotic on a twice a day schedule using a measurer.

In doing a follow-up visit, the healthcare provider can employ the pneumonic NEEDS, which can be a helpful tool to remind the provider about key areas to explore relative to the child’s current disposition. NEEDS stands for Nutrition, Elimination, Education/Environment, Development/Daycare, and Sleep/Sexuality.

Nutritionally, the child reports she is able to drink cool liquids, puddings, ice cream, and warm soups. Regarding elimination, she is voiding at least six times a day and has a small, brown, formed stool daily. Education and environment screening indicates that she is in second grade and doing well. She has not been exposed to any sick friends or family members. Concerning development/daycare, she goes to a daycare center for an after-school program as well as being involved in gymnastics 3 days a week, although she has not attended this week. Finally, for sleep assessment, she reports taking at least two naps a day and sleeping 12 hours a night for the past 4 days. Normally she does not take naps and sleeps about 9 hours a night.