Pediatric Examination and Board Review (123 page)

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8.
(B)
Prostaglandin synthetase inhibitors (NSAIDs) are the drugs of choice in the treatment of primary dysmenorrhea. NSAIDs are thought to be more effective if administered just before the onset of pain. Mefenamic acid, ibuprofen, and naproxen sodium are popular choices. NSAIDs are contraindicated in adolescents with peptic ulcer disease, hepatic or renal disease, or a bleeding disorder.

9.
(E)
For optimal effectiveness, NSAIDs should be started as soon as the symptoms develop and even on the day before the one when menses are anticipated in those teens with reasonably predictable periods. A loading dose is needed when using naproxen and mefenamic acid.

10.
(E)
Combined oral contraceptives are useful for adolescents with primary dysmenorrhea who fail to respond to a trial of NSAIDs and for those who need both relief of menstrual pain and contraception. Oral contraceptives may take 2-3 months to provide adequate relief from dysmenorrhea, and NSAIDs can be used concomitantly in the interim.

11.
(B)
Endometriosis is the most common cause of chronic pelvic pain lasting more than 3 months and not responding to NSAIDs or oral contraceptives. Clinical features of endometriosis include chronic pelvic pain usually worsening during menses, pain on defecation, dyspareunia, and abnormal uterine bleeding. On physical examination, tenderness over the adnexa and cul-de-sac is more common in teens than the classical finding of thickened, nodular sacrouterine ligaments often found in adult women with endometriosis.

12.
(E)
Adolescent girls with acute pelvic pain deserve an urgent and thorough evaluation to rule out potentially life-threatening conditions. The differential diagnosis of acute pelvic pain includes gynecologic conditions, such as PID, adnexal torsion, ovarian cysts, threatened or spontaneous abortion, and endometriosis. PID is the most common cause of acute pain leading to hospitalization in women of reproductive age in the United States. Nongynecologic causes include gastrointestinal, genitourinary, musculoskeletal, and psychological disorders.

13.
(E)
The list of gastrointestinal conditions responsible for acute pelvic pain in teens is quite lengthy and includes, among others, appendicitis, intestinal obstruction, gastric ulcer, inflammatory bowel disease, lactose intolerance, irritable bowel syndrome, diverticular disease, constipation, and mesenteric adenitis.

14.
(A)
The initial evaluation of acute pelvic pain with suspected underlying organic pathology should include a thorough clinical and psychosocial history, a physical examination, and laboratory testing. Ultrasonography is a useful procedure in the evaluation of acute pelvic pain, particularly for those in whom a thorough pelvic examination is not possible. However, a normal ultrasound does not exclude endometriosis or PID.

15.
(E)
Although the predictive value of an abnormal pelvic ultrasound is 92%, a normal ultrasound only has a predictive value of 50%. In a large study evaluating laparoscopic findings among adolescents with chronic pelvic pain, 75% of patients had intrapelvic pathology, whereas no obvious cause of chronic pain was found in the remaining 25%. Among those with organic pathology, endometriosis was the leading diagnosis followed by postoperative adhesions secondary to appendectomy or ovarian cystectomy.

16.
(E)
According to the World Health Organization (WHO) Medical Eligibility Criteria (2001), among the listed conditions, only hypertension would preclude initiation of a combined oral contraceptive.

S
UGGESTED
R
EADING

Emans SJ, Laufer MR, Goldstein DP.
Pediatric and Adolescent
Gynecology
. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2005.

Johnson BE, Johnson CA, Murray JL, Apgar BS.
Women’s Health
Care Handbook.
2nd ed. Philadelphia, PA: Hanley & Belfus; 2000.

Neinstein LS.
Adolescent Health Care. A Practical Guide.
5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2007.

CASE 75: A 14-YEAR-OLD GIRL WITH PAINFUL URINATION

A 14-year-old girl is brought in by her aunt (who is the patient’s guardian) for an urgent care visit with the complaint of acute-onset painful urination. This is the first time you have met this family. The present symptoms started about 2 days ago and are now severe enough to keep her from attending school. She has been healthy except for vague, recurrent stomachaches for several years. There is no previous history of urinary tract infection (UTI). A review of systems reveals that she has been tired, “achy,” and had a slight fever during the previous week. She started her menses 8 months before this visit and states that she has skipped her periods 2 or 3 times since then. She had her latest menstrual period 3 weeks ago. The family history is positive for arthritis in an older sister and insulin-dependent diabetes on the paternal side of the family. She lives with her aunt, her older sister, 2 cousins, and a niece. She used to be an average student, but her grades have shown a significant decline since she started high school 6 months ago. She denies cigarette smoking or alcohol use but states that she smokes marijuana with her friends on weekends. Her aunt worries about her increasing rebelliousness. After a recent confrontation she ran away from home and returned 3 days later. She is a thin, small-for-age girl who looks younger than her stated age.

SELECT THE ONE BEST ANSWER

1.
The differential diagnosis of dysuria in adolescent girls includes all of the following except

(A) UTI

(B) chlamydial urethritis

(C) herpes simplex type 2 vaginitis

(D) traumatic urethritis

(E) endometriosis

2.
Among the following, which is the most common pathogen responsible for UTI in healthy, nonpregnant adolescent girls?

(A)
Escherichia coli
(B)
Gardnerella vaginalis
(C)
Staphylococcus saprophyticus
(D) Group B streptococci

(E)
Enterococcus
species

3.
Which of the following conditions are included in the differential diagnosis of dysuria in adolescent boys?

(A) gonococcal urethritis

(B) nongonococcal urethritis

(C) prostatitis

(D) chemical irritation from spermicides

(E) all of the above

4.
The following factors predispose adolescent girls to UTIs except

(A) start of sexual activity

(B) new sexual partner

(C) recent history of streptococcal pharyngitis

(D) poor perineal hygiene

(E) use of diaphragms

5.
In taking the clinical history from this adolescent girl, which of the following is the least helpful information?

(A) use of douches, deodorant soaps, and bubble baths

(B) abnormal vaginal discharge and itching

(C) sexual history, including number of partners, condom and other contraceptive use, and potential exposure to STDs

(D) family history of hypertension

(E) history of fever and flank pain

6.
In accordance with your office guidelines, you have already discussed the extent and limits of your privacy and confidentiality policy with the parent (or guardian) and the patient earlier in the visit. On interviewing the patient privately, she tells you tearfully that she had unprotected vaginal intercourse with her 15-year-old new boyfriend a week earlier. She has not discussed this with her aunt and would prefer to keep it confidential. She became sexually active at age 13 years and had 2 previous sexual partners. She is not using hormonal contraception and uses condoms inconsistently. The physical examination should include all except

(A) abdominal examination

(B) search for costovertebral angle tenderness

(C) inspection of the external genitalia

(D) speculum examination

(E) all of the above

7.
You perform a physical examination with a chaperone in attendance. You find her to be a welldeveloped, quiet, cooperative 14-year-old girl, emotionally somewhat immature for her age. She is afebrile. There are no abnormal clinical findings on the general examination. The abdomen is soft. There are no masses, guarding, rebound, or visceromegalies. There is no costovertebral tenderness. Her pubertal development is at Tanner stage 4. The external genital examination shows normal labia and absence of inguinal lymphadenopathy. There is some scant yellowish discharge in the introitus where you also find 2 small clusters of vesicular lesions, some of them ulcerated and very tender to touch. A careful and gentle speculum examination shows a red and friable cervix and thick, foamy discharge in the cul-de-sac. The bimanual examination is poorly tolerated, but there are no obvious masses or cervical motion tenderness. All of the following tests will be necessary at this time except