Counseling Case (13-18 Year Old)
A well-woman visit provides an excellent opportunity for screening and counseling about maintaining health and minimizing risks. Teenagers aged 13 to 18 years should visit the healthcare provider every 1 to 2 years for a physical exam, check for development, and perform counseling ((Harris et al., 2017). The areas that should be emphasized during counseling include diet and physical activity, sexual activity, substance abuse, and mental health.
Adolescence, the stage between 12 to 18 years, is a period of dramatic physical, emotional, and cognitive transformation. Regarding the aspect of sexual activity, I will counsel the patient on abstinence if they are not sexually active and encourage the use of condoms during sexual intercourse. During this visit, it is important to address the use of contraceptives regardless of the patient’s age and provide thorough information about sexually transmitted infections (Harris et al., 2017). Additionally, I will counsel on the need for human papillomavirus (HPV) vaccination if not given between ages 11 and 12 as recommended to prevent cervical cancer.
Adolescent risky health behaviors that require counseling include diet and physical activity, substance abuse, and mental health issues like depression (Harris et al., 2017). During the wellness visit, I will emphasize the need to monitor diet and engage in physical activity to prevent obesity, diabetes, and heart disease. I will discuss substance abuse including marijuana, tobacco, alcohol, and other dangerous substances like cocaine that may be harmful to the patient’s health (Harris et al., 2017). Lastly, I will focus on mental health issues like depression, suicidal ideation, and other forms of intentional injury.
Abnormal Uterine Bleeding
Abnormal uterine bleeding (AUB) is the most common symptom of gynecological issues among women (Wouk & Helton, 2019). AUB is a broad term that describes irregularities in the menstrual cycle involving the volume, duration, frequency, and regularity of menstrual flow. According to the International Federation of Obstetrics and Gynecology (FIGO), AUB represents bleeding that falls outside the population-based 5th to 95th of menstrual volume, duration, frequency, and regularity (Sun et al., 2018). The prevalence of AUB internationally is estimated to be between 10% to 30% with the highest rates observed around menarche and perimenopause. It is important to address AUB because it negatively affects the quality of life and increases the financial burden on patients and healthcare organizations.
Menstrual cycle variability and irregularity are common in adolescence and perimenopause. The main causes of AUB across all age groups can be described using the acronym PALM-COIEN (Sun et al., 2018). The structural causes may include polyp, adenomyosis, leiomyoma, malignancy, and hyperplasia. The most common structural cause of AUB is the presence of polyps followed by uterine fibroids (Sun et al., 2018). The non-structural causes of AUB include may include coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise classified conditions like endometritis. Mortality due to AUB is rare because bleeding can be controlled using medication. Morbidity is related to the amount of blood loss during menses and severe cases can cause hemorrhagic shock. AUB accounts for two-thirds of all hysterectomies and on some occasions can cause anemia and reduced quality of life.
The pathophysiology of AUB is dependent on various factors. For instance, anovulatory dysfunctional uterine bleeding results from the disturbance of the hypothalamic-pituitary-ovarian axis (Wouk & Helton, 2019). Failure to ovulate causes a lack of progesterone hormone which functions to stabilize the endometrium leading to persistent bleeding. During menstruation, AUB can occur due to structural and non-structural changes that disturb the normal shedding and repair of the functional layer of the endometrium. An example is the presence of polyps or derangement in blood clotting pathways.
The diagnosis of AUB is dependent on the physical symptoms of the patient and laboratory findings. During the initial assessment, a pelvic exam is essential for sexually active women (Sun et al., 2018). Symptoms like abdominal pain, anemia, and reporting bleeding that is heavy can be observed. The duration of menstrual bleeding can be described as longer than 8 days and most have heavy flow greater than 80 mL (Wouk & Helton, 2019). Patients with AUB can also have signs like pain, weight loss, and bowel or bladder symptoms. The initial laboratory testing for AUB involves a complete blood count, pregnancy test, testing for STIs, and thyroid function tests.
Any bleeding from the genitourinary tract or gastrointestinal tract can mimic symptoms of AUB. For instance, infections like PUD and acute or chronic endometritis can cause abnormal bleeding (Wouk & Helton, 2019). Pregnancy complications like abortion, placenta abruption, and ectopic pregnancy can manifest with symptoms of AUB. The first-line treatment of AUB involves the use of hormonal methods. Intravenous conjugated equine estrogen combined with oral contraceptives is the best option (Wouk & Helton, 2019). During emergency care, IV tranexamic acid 10 mg per kg given 8 hourly can serve to control bleeding (Wouk & Helton, 2019). Based on the PALM-COEIN acronym, different management approaches like surgery can be used to address the underlying cause.
16-Year-Old with Pelvic Pain
Kyla is a 16-year-old patient seeking emergency care due to severe abdominal pain. Upon history taking, it is observed that she was seen a couple of days ago and diagnosed with Pelvic inflammatory disease (PID). Her symptoms include vomiting and severe pain in the left lower quadrant rated 10 on a 10-point Likert scale aggravated by movement. Kyla has failed to respond to the doxycycline prescribed in her last visit and the use of pain medication like ibuprofen does not seem to reduce her pain. Effective management of the patient should involve complete history taking, physical examination, and laboratory testing, medical management and education.
Pelvic pain is discomfort in the lower abdomen that may originate from female reproductive organs or other body structures like the intestines or urinary tract (Bonnema et al., 2018). The first aspect of the physical exam I will consider for Kyla is vital signs. Taking the temperature, pulse, blood pressure, heart rate, and pain assessment will help establish baseline data about the patient’s health condition. For example, increased temperature above the normal range (98.6 F- 99 F) will indicate signs of infection (Bonnema et al., 2018). A review of the patient’s BP will indicate signs of hemodynamic instability like hypotension.
Physical examination for patients with pelvic pain should involve an abdominal and pelvic examination. A bimanual pelvic examination for women of reproductive age is necessary to evaluate masses, discharge, and cervical motion tenderness (Bonnema et al., 2018). I will check for evidence of guarding or rebound tenderness that may indicate surgical emergencies like ovarian torsion, ruptured ectopic, or appendicitis. I will perform a bimanual exam to assess for adnexal tenderness and fullness.
Kyla presents with sudden onset of severe pain in her left lower quadrant accompanied with vomiting. These signs are consistent with the diagnosis of ovarian torsion which presents with sudden onset of unilateral stabbing pain commonly accompanied with nausea and vomiting. A transvaginal and pelvic ultrasound with a doppler or MRI is the most definitive diagnostic tool for detecting torsion (Huang et al., 2017). The treatment of ovarian torsion is surgical detorsion whereby the ovary is untwisted as soon as possible to restore blood flow. If the tissue is not necrotic, the ovary is termed viable. In cases where the ovarian tissue is necrotic, a salphingo-oophorectomy will be the likely course. Additionally, most cases of torsion involve cysts that are removed during surgery.
Education and Possible Long-Term Sequelae
The patient should be informed that ovarian torsion is not usually life-threatening and early management can save her ovaries. I will inform the patient about the causes of ovarian torsion, especially masses and cysts. The majority of ovarian masses are benign and are easily resolved during surgery. The most important aspect of education is seeking care immediately to allow for timely diagnosis and treatment. I will also educate the patient about risk factors like known cysts and a history of prior torsion.
When providing care for adolescents, confidentiality is an evidence-based component of quality care that promotes trustworthy relationships. During Kyla’s care, it is important to determine if the parent agrees to the presence of a confidential relationship between the clinician and the patient (Pathak & Chou, 2019). The provider should keep the patient’s information like sex life confidential and discuss only pertinent history to the diagnosis of ovarian torsion.
Bonnema, R., McNamara, M., Harsh, J., & Hopkins, E. (2018). Primary care management of chronic pelvic pain in women. Cleveland Clinic Journal of Medicine, 85(3), 215–223. https://doi.org/10.3949/ccjm.85a.16038
Harris, S. K., Aalsma, M. C., Weitzman, E. R., Garcia-Huidobro, D., Wong, C., Hadland, S. E., … & Ozer, E. M. (2017). Research on clinical preventive services for adolescents and young adults: Where are we and where do we need to go?. Journal of Adolescent Health, 60(3), 249-260.
Huang, C., Hong, M. K., & Ding, D. C. (2017). A review of ovary torsion. Ci ji yi xue za zhi = Tzu-chi Medical Journal, 29(3), 143–147.
Pathak, P. R., & Chou, A. (2019). Confidential care for adolescents in the U.S. health care system. Journal of Patient-Centered Research and Reviews, 6(1), 46–50. https://doi.org/10.17294/2330-0698.1656
Sun, Y., Wang, Y., Mao, L., Wen, J., & Bai, W. (2018). Prevalence of abnormal uterine bleeding according to new International Federation of Gynecology and Obstetrics classification in Chinese women of reproductive age: A cross-sectional study. Medicine, 97(31), e11457.
Wouk, N., & Helton, M. (2019). Abnormal uterine bleeding in premenopausal women. American Family Physician, 99(7), 435-443.
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