Pediatric Examination and Board Review (128 page)

17.
(B)
There is little evidence that condoms with spermicide have a lower failure rate.

18.
(D)
Depomedroxyprogesterone is the contraceptive of choice in adolescent girls with seizure disorders because it increases the threshold for seizures. As opposed to progestin-only pills, which should be taken daily, injectable progestins only need to be administered every 12 weeks, a regimen which facilitates compliance. Moreover, anticonvulsants decrease the contraceptive effectiveness of combined oral contraceptives but do not affect depomedroxyprogesterone metabolism. Because long-term use of this method may be associated with a decrease in bone mineral density, it is recommended that young women using this method take calcium supplements to achieve a dietary intake of 1300 mg per day.

19.
(C)
Breakthrough bleeding is common in the first 3 months of therapy and usually resolves spontaneously. This should be discussed with all patients before starting them on oral contraceptives to avoid unneeded anxiety and discontinuation of treatment. Pregnancy and STDs should be considered under these circumstances but are unlikely in this case because she denies sexual activity for the previous 7 weeks, had a negative pregnancy test, and no evidence of sexually transmitted diseases 2 weeks earlier. Reassurance would be appropriate at this time with close follow-up if the bleeding became persistent or bothersome. In this case, an NSAID would be effective in decreasing menstrual flow. Alternatively, she should be asked to take an extra pill a day from a different package until bleeding stops.

S
UGGESTED
R
EADING

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

Hatcher RA, Trussel J, Stewart F, et al.
Contraceptive Technology.
19th ed. New York, NY: Irvington; 2007.

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

MacIsaac L, Espey E. Intrauterine contraception: the pendulum swings back.
Obstet Gynecol Clin N Am.
2007; 34:91-111.

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

CASE 77: A 15-YEAR-OLD GIRL WITH ABDOMINAL PAIN, WEIGHT GAIN, AND FATIGUE

A 15-year-old adolescent girl comes in to the clinic for a “checkup.” She has been your patient for 3 years, and a brief review of her chart reminds you that she only has been seen by you for yearly physical examinations. She has no history of chronic illness, allergies, or hospitalizations. Immunizations are up to date. She had been in counseling for “anger issues” for several years and 2 years ago was seen by a psychiatrist who diagnosed oppositional defiant disorder. She lives with her maternal grandmother (and guardian), who raised her since she was 2 years old, and a 17-year-old brother. Her brother has been recently released from jail. Grandma is a diabetic and is also on medication for hypertension. In the past she had often complained about her granddaughter’s behavior, which she describes as rebellious, hostile, and argumentative. She does not feel that “the girl can be trusted.” At times, she even suspected drug use, a notion her granddaughter vehemently denies. The patient ran away from home for 3 days on one occasion last year. Her father lives out of state and is not involved in her life; her mother is “around sometimes,” having been sporadically in rehabilitation programs for drug addiction. The patient was an average student in elementary school, but her academic performance has been declining lately. She is now in the eighth grade. The review of systems reveals tiredness, nausea, vomiting, and vaguely described periumbilical pain. A careful history of the pain fails to discern any patterns in onset, duration, progression, intensity, aggravating or relieving factors, or associated symptoms. Her appetite has increased lately. Neither her fatigue nor her abdominal pain has kept her from participating in sports. She became sexually active 6 months before this visit. She states that she is not interested at all in hormonal birth control for fear of gaining weight. Her menses have been normal since menarche at age 11. Her last period started 2 weeks before this visit and lasted 3-4 days. She has had some nausea and vomiting off and on for the past few weeks but denies diarrhea or constipation. During the previous week she has noticed increased urinary frequency. Her review of systems is otherwise negative.

On physical examination, she looks well but quiet, aloof, and “testy.” She is well developed at 5'5" and 140 lb. She has gained 8 pounds since her last visit 6 months earlier. She has a large scar on her arm, the result of “a fight” about 3 years ago. Her physical examination is otherwise unremarkable except for some fullness in her lower abdomen. There is no abdominal tenderness and no guarding or rebound. There is no CVA tenderness. You ask her to empty her bladder and to return to the examination room.

SELECT THE ONE BEST ANSWER

1.
What other elements of the clinical history would be important in this case?

(A) dysuria

(B) medications

(C) substance use

(D) number of sexual partners

(E) all of the above

2.
What elements of the physical examination are particularly important?

(A) eye examination

(B) cardiovascular examination

(C) neurologic examination

(D) pelvic examination

(E) all of the above

3.
The speculum examination shows no abnormalities. There is no uterine bleeding. The bimanual examination reveals an enlarged uterus, the size of a grapefruit, almost palpable above the symphysis pubis. The cervix is soft. No adnexal masses are felt. There is no adnexal or cervical motion tenderness. The most likely diagnosis is

(A) 4-week intrauterine pregnancy

(B) 12-week intrauterine pregnancy

(C) ectopic pregnancy

(D) missed abortion

(E) threatened abortion

4.
Which of the following could best explain the discrepancy between uterine size and the reported date of the last menstrual period when the uterus is larger than expected for dates?

(A) inaccurate dates of the last menstrual period

(B) twin pregnancy

(C) leiomyoma

(D) molar pregnancy

(E) all of the above

5.
Suppose you determine that the uterus is smaller than expected for dates. All of the following are consistent with your determination except

(A) inaccurate last menstrual period date

(B) incomplete or missed abortion

(C) ectopic pregnancy

(D) corpus luteum cyst of pregnancy

(E) hCG-secreting tumors

6.
Which of the following tests would be helpful to evaluate the cause of a discrepancy between uterine size and the last menstrual period date?

(A) pelvic ultrasonography

(B) maternal serum alpha-fetoprotein (MSAFP)

(C) serial measurements of hCG

(D) measurement of fetal heart rate

(E) A and C

7.
All of the following statements about hCG levels during pregnancy are true except

(A) a sensitive urine pregnancy test can detect hCG levels as low as 10-25 mIU/mL

(B) a sensitive urine pregnancy test may help diagnose pregnancy before a period is missed

(C) low levels of hCG early in pregnancy suggest the diagnosis of ectopic pregnancy

(D) between 5 and 8 weeks of gestation, hCG levels should increase by 66% in 48 hours

(E) between 23 and 35 days of gestation, the mean doubling time is 1.6 days

8.
All of the following would suggest the diagnosis of ectopic pregnancy except

(A) pelvic pain

(B) amenorrhea

(C) right upper quadrant (RUQ) pain

(D) irregular bleeding

(E) adnexal mass

9.
All of the following laboratory tests are indicated at this time except

(A) pregnancy test

(B) CBC, differential, and platelet count

(C) gonorrhea and chlamydia probes

(D) urinalysis

(E) amylase and lipase

10.
The pregnancy test is positive. The patient receives that news without surprise and states she is not ready for motherhood. She does not want her grandmother to know about the pregnancy. What do you do next?

(A) discuss all her options with her

(B) suggest having her grandmother involved in the decision-making process

(C) refer to an obstetrician

(D) refer to a case manager

(E) arrange a follow-up visit in 1 week

11.
The following statements regarding abortion are correct except