Pediatric Primary Care Case Studies (116 page)

Since Jaime is just starting COCs for the first time, she should return to the office within 1–2 months. At this visit, her blood pressure can be taken to rule out any hypertension as a result of starting the COCs. Information on how to take COCs can be reviewed and further instructions can be given if Jaime is having any problems. If Jaime is doing well at that time and does not have any questions or concerns, she should receive a prescription for up to 9 months (1 year total).

Jaime returns to your office a little more than a month after her first visit. Her blood pressure is 116/54, pulse 78, and respirations 12. She tells you that she is doing well remembering to take her pills every day. She has had some slight nausea and breast tenderness, but this seems to be improving. She has had one period since beginning her COCs. She was very happy that her cramping wasn’t bad, and she didn’t seem to flood as much. She relates that she still hasn’t talked to her mother, but she does want to. She and Blair are doing well together and he is doing better about wearing condoms, though he still doesn’t like it much. Jaime has thought about the HPV vaccine and would like to start it today. You review with Jaime how to take COCs and the warning signs to watch for, and give her a prescription for 9 months of COCs. You administer her first HPV immunization injection and remind her to return at 2 and 6 months for the other shots. Jaime states that she doesn’t have any other questions and that she will come back for the rest of the injections.

Other than for the vaccinations, she should return to the office in 1 year unless she has any concerns prior to that time.

Key Points from the Case

1. It is important to look at the whole person when providing contraceptive counseling and prescribing. Assisting the patient to choose the appropriate type of contraception will increase her ability to take/use it effectively.

2. The hormones estrogen and progesterone, although safe, do have side effects associated with their use. Careful explanation of the potential risks is crucial along with warning signs to watch for.

3. Although in this case Jaime came to the office for contraception, there were other very important issues that needed to be addressed. Be watchful for these other issues.

4. Try to help the adolescent to feel comfortable with the care being provided. Make the office a safe place where she feels comfortable discussing anything with you.

REFERENCES

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prevention_and_early_detection_8.asp?sitearea=PED

Cates, Jr., W., & Raymond, E. G. (2007). Vaginal barriers and spermicides. In R. A. Hatcher, J. Trussel, T. L. Nelson, W. Cates Jr., & F. Stewart (Eds.),
Contraceptive technology
(19th ed., pp. 317–336). New York: Ardent Media.

Caufield, K. A. (2004). Controlling fertility. In E. Q. Youngkin & M. S. Davis (Eds.),
Women’s Health: A Primary Care Clinical Guide
(3rd ed., pp. 165–226). Upper Saddle River, NJ: Pearson/Prentice Hall.

Chambers, K. B., & Rew, L. (2003). Safer sexual decision making in adolescent women: perspectives from the conflict theory of decision-making.
Issues in Comprehensive Pediatric Nursing, 26
(3), 129–143.

Commendador, K. A. (2003). Concept analysis of adolescent decision making and contraception.
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Frost, J. J., Singh, S., & Finer, L. B. (2007). Factors associated with contraceptive use and nonuse.
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Grimes, D. A. (2007). Intrauterine devices (IUDs). In R. A. Hatcher, J. Trussel, T. L. Nelson, W. Cates Jr., & F. Stewart (Eds.),
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Harvey, S. M., Bird, S. T., Galavotti, C., Duncan, E. A., & Greenberg, D. (2002). Relationship power, sexual decision making and condom use among women at risk for HIV/AIDS.
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(4), 69–84.

Jennings, V. H., & Arevalo, M. (2007). Fertility awareness-based methods. In R. A. Hatcher, J. Trussel, T. L. Nelson, W. Cates Jr., & F. Stewart (Eds.),
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Kowal, D. (2007). Abstinence and the range of sexual expression. In R. A. Hatcher, J. Trussel, T. L. Nelson, W. Cates Jr., & F. Stewart (Eds.),
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Manlove, J., Ryan, S., & Franzetta, K. (2003). Patterns of contraceptive use within teenagers’ first sexual relationships.
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Moore, A., Cofer, L., Elliot, G., Lanneau, J., Walker, M., & Gold, M. (2005). Adolescent cervical dysplasia: histologic evaluation, treatment, and outcomes.
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Nelson, A. (2007). Combined oral contraceptives. In R. A. Hatcher, J. Trussel, T. L. Nelson, W. Cates Jr., & F. Stewart (Eds.),
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Stewart, F., Trussel, J., & Van Look, P. F. A. (2007). Emergency contraception. In R. A. Hatcher, J. Trussel, T. L. Nelson, W. Cates Jr., & F. Stewart (Eds.),
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Chapter 29

The 16-Year-Old Girl with a Vaginal Discharge

Teral Gerlt

Working with adolescents is both challenging and rewarding. Adolescent healthcare encounters are often situations in which the provider’s agenda may be quite different from that of the teen. There is so much that healthcare providers need to teach teens about healthy life behaviors and practices, and the reception is frequently lukewarm at best. Time, patience, and mutual respect are essentials for open communication.

Educational Objectives

1.   Identify the developmental influences impacting adolescent behaviors and learning.

2.   Describe important components when communicating with adolescents.

3.   Identify factors that increase the risk for sexually transmitted infections (STIs).

4.   Apply the Centers for Disease Control and Prevention (CDC) guidelines concerning management and treatment of STIs.

   Case Presentation and Discussion

Leslie Montgomery, a 16-year-old white female, comes to your clinic today because she wants to start birth control pills. She has been in a new relationship for the past 2 months and wants to use something to keep her from getting pregnant “besides condoms.” She is very concerned about having to have a pelvic exam because she has never had one before. She was told by one of her girlfriends that she didn’t have to have one to start the pill. She also mentions that perhaps she should have an examination because she has a discharge that is new and she doesn’t like it.

How will you approach this teen?

Approach to Taking a Sexual History from an Adolescent

Generally, adolescents, especially females, are reluctant to seek health care about sexuality concerns or issues unless they can depend upon a confidential environment in which to do so (Reddy, Fleming, & Swain, 2002). Therefore, it is important to establish confidentiality at the start. Also, keep in mind that an
open, respectful, and nonjudgmental attitude is essential when working with adolescents in order to obtain a thorough sexual history and deliver prevention messages effectively.

Taking a sexual history should be integrated into the general health history. The clinician should reassure the individual that asking sexual questions is a normal part of clinical practice: “I’m going to ask you a few questions that I ask all my young-adult patients about their health and relationships” (Rakel, 2002, p. 14). Giving appropriate, factual information that uses medical-sexual terminology rather than slang is helpful to the extent that the teen understands what is being said.

One also needs to ask open-ended, broad, nonjudgmental questions that will allow the teen to discuss his or her ideas and sexual activities. For example, asking the question, “Have you ever had a romantic relationship with a boy or a girl?” allows for a more inclusive description of sexual activity than asking the traditional, “Are you sexually active?” question. Phrases such as “Explain how that happened,” “What happened next,” or “Tell me about a typical date” elicit more complete information than do close-ended questions. “When you think of people to whom you are sexually attracted, are they males, females, both, neither, or are you not sure yet?” is a useful question that opens up a conversation for youth struggling with their sexual orientation (Murphy & Elias, 2006). Questions that contain “why” can require a level of analysis beyond the capabilities of young people operating at a concrete level of cognition.

Phrase questions that may be emotionally laden in a way that lets clients know that their experience may not be exceptional (e.g., “Many people have been sexually abused or molested as children; did this happen to you?” [Rakel, 2002] or “How often do you masturbate?” rather than “Do you masturbate?” [Rakel]).

Begin the interview using open-ended questions, setting the tone to be accepting as much as possible. It is essential that you assure the teen that the information from the visit will be kept confidential unless the provider believes the teen may do harm to him- or herself or someone else.

The Centers for Disease Control and Prevention (CDC) has a practical set of questions to incorporate into the sexual history (see
Box 29-1
).

Further sexual history reveals that she and her partner do not always use condoms because her partner does not like them. Their last vaginal intercourse was this past weekend but she says, “we did use condoms that time.” Her current partner is an 18-year-old who dropped out of high school his junior year but is working. Age at first coitus for Leslie was 15 years and consensual. She has had two other sexual partners in the past. She states that she has never had anal intercourse but does have both oral and vaginal intercourse with her current partner. She has only had sex with males and has only used condoms as a birth control method.

Box 29–1   The CDC’s Five Ps

1.   Partners

•   “Do you have sex with men, women, or both?”

•   “In the past 2 months, how many partners have you had sex with?”

•   “In the past 12 months, how many partners have you had sex with?”