Women’s Health Case Study

Internal Medicine 14: 18-year-old woman for pre-college physical

User: Ariana Amini

Email: aamini@gwu.edu

Date: November 11, 2019 2:19AM

Learning Objectives

The student should be able to:

Obtain a history that differentiates among etiologies of dysuria.

Differentiate /distinguish signs and symptoms of lower versus upper urinary tract infection.

Recognize /recommend when to order diagnostic and laboratory tests in evaluation of dysuria, including urinalysis, wet prep, and KOH stain.

Describe current recommendations for cervical cancer screening.

Discuss safe sexual practices and efficacy of common methods of contraception. Women’s Health Case Study

Knowledge

Adolescent Interview – Safety

Violence

The leading causes of death in older adolescents are violent: suicide, injuries, and homicide. Bullying, family violence, sexual abuse, date rape and

school violence are all common. In many urban communities, up to one in four students report carrying a weapon to school. Family violence and

dating violence cross all economic and social boundaries.

Injuries

For some teens, school violence and guns are the major risks, and in others, sports injuries and injuries from wheeled vehicles are more likely. It is

important to address use of a seat belt and bike helmets with every adolescent.

Even though you address the safety issues most prevalent in the patient’s community first, do not skip any part of the history based on assumptions

about the patient’s ethnic background or economic status.

Recommended Vaccinations for Adolescents and Teenagers

MMR

MMR is recommended in adults who have not been previously vaccinated as children. An exception to this recommendation is the

case of pregnant women. Pregnant women should not be vaccinated with MMR because of a risk of fetal transmission since it is a

live virus vaccine.

Hepatitis B Hepatitis B vaccination is effective in preventing hepatitis B virus infection and its sequelae of cirrhosis and hepatic carcinoma. The

series of three injections is recommended for adolescents if they did not receive them when younger.

Meningococcal

The meningococcal vaccine is given to prevent meningococcal meningitis. It is commonly given once at age 11-12 years during the

routine preadolescent immunization visit with a booster dose at age 16 and is recommended for all previously unvaccinated

adolescents aged 11-18 years.

Human

papillomavirus

There are two different human papillomavirus vaccines available. They vary by the number of strains of HPV they protects against,

ranging from four to nine, and can prevent most cases of cervical cancer and genital warts. It is recommended for girls and women

9-26 years old.

The Advisory Committee on Immunization Practices (ACIP) recommends the use of the HPV vaccine in males 11 or 12 years of age.

ACIP also recommends vaccination in males ages 13 through 21 who have not been vaccinated previously or who have not

completed the three-dose series. ACIP states that males aged 22 through 26 years may be vaccinated, but does not recommend routine vaccination in this age group. Women’s Health Case Study

Tetanus,

diphtheria,

acellular

pertussis

The tetanus, diphtheria, acellular pertussis (Tdap) vaccine protects against tetanus, diphtheria and pertussis. It contains acellular

pertussis vaccine (ap), which is less reactogenic than the older whole-cell pertussis vaccine that caused high fever and neurologic

symptoms when given to older children and adults. Tdap, which was licensed in 2005, is the first vaccine for adolescents and adults

that protects against all three diseases.

Adolescents should receive a single dose of Tdap as a booster between the ages of 11 and 18, with the preferred timing between 11

and 12 years. If a patient has received a Td booster, then waiting at least five years between Td and Tdap is encouraged because

the incidence of side effects is lower.

The exception to this rule is the case of type III hypersensitivity reactions. Type III hypersensitivity reactions (Arthus reactions), which

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are characterized by immune complex deposition in blood vessels, can rarely be seen following receipt of tetanus toxoid or

diphtheria toxoid-containing vaccines. These reactions are characterized by severe pain, swelling, and sometimes necrosis at the

injection site and occur between 4 and 12 hours following vaccination. It is recommended that patients who have had such a type III

hypersensitivity reaction avoid receiving a tetanus toxoid-containing vaccine more frequently than every 10 years.

Varicella

The varicella vaccine series, which is a live virus vaccine, should be given to adolescents who have never had chickenpox or have

not received the vaccine.

Varicella was added to the list of standard childhood vaccines in 1995. Two doses are required, with the first administered at 12-15

months of age and the second at 4-6 years of age. There is also a combination measles, mumps, rubella, and varicella vaccine

(MMRV) available.

Influenza

The influenza vaccine is recommended for everyone who is at least age six months. It is usually administered in September through

December when the influenza season is imminent.

The H1N1 strain, or “swine” influenza, the predominant strain circulating in the U.S. over the past several years, has high rates of

morbidity and mortality among children and adolescents.

Pneumococcal The pneumococcal vaccine is indicated for adolescents with certain chronic health conditions.

Haemophilus

influenzae type

b

Haemophilus influenzae type b vaccine protects against meningitis, pneumonia, epiglottitis, and bacteremia in infants and young

children, but it is not recommended after the age of five years.

When a Pelvic Examination Is Indicated

Cervical cancer screening should start at age 21 regardless of sexual activity and should continue through the age of 65. There is recent

evidence that screening for cervical cancer in women less than 21 years of age leads to procedures and more harm than benefit. The frequency of

cervical cancer screening with the Papanicolaou (Pap) test for immunocompetent individuals with previously normal tests is once every three years

or, for women ages 30 to 65 years, screening with a combination of cytology and human papillomavirus (HPV) testing every five years. Women’s Health Case Study

STI Screening Recommendations

Current recommendations are for all patients age 15 to 65 years to be screened for HIV infection.

Test results for some STIs such as gonorrhea must be reported to the public health department.

Most Common Causes of Cystitis

E. coli causes a majority of all cases of uncomplicated urinary tract infections.

Other common organisms include Staphylococcus saprophyticus, Klebsiella pneumonia, and Proteus mirabilis.

Differentiating Cystitis from Pyelonephritis

It is important to make the distinction between cystitis and pyelonephritis because the treatment differs.

Cystitis Pyelonephritis

Clinical

manifestations

dysuria, frequency, urgency,

suprapubic pain, and/or

hematuria

may or may not have symptoms of cystitis together with fever (> 38ºC) and other systemic

symptoms such as, chills, flank pain, costovertebral angle tenderness, and nausea/vomiting

Urinalysis pyuria pyuria, white blood cell casts (pathognomonic)

Treatment

short-course antibiotic therapy

(three days);

hospitalization usually not

required

at least seven days of treatment;

hospitalization may be required

Dysuria in Males

Disease Presentation Diagnosis

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UTI and

cystitis

Isolated acute cystitis is rare in males because their longer urethra hinders

bacteria from reaching the bladder, and prostatic fluid has antibacterial

properties.

Most males with acute cystitis have functional or anatomic abnormalities, and

need further evaluation.

Symptoms of lower and upper tract infections are the same in males and

females.

Midstream culture and sensitivity of the urine

Urethritis

Usually sexually transmitted gonococcal and/or chlamydia infection.

Gonococcal urethritis is more likely in males with acute symptoms and

purulent urethral discharge.

Chlamydia is likely when dysuria is present alone or with minimal discharge.

Males with chlamydia infection may be asymptomatic.

Recommended that patients be treated presumptively for both gonorrhea and

chlamydia, pending results.

Herpes simplex virus is a rare cause of urethritis, but may be suggested by

the history of penile lesions.

Diagnosis can be made on a gram stain of

a urethral swab.

Leukocytes and gram-negative

intracellular diplococci confirm the

diagnosis of gonorrhea.

White cells without organisms suggest

non-gonococcal urethritis (NGU) which is

usually chlamydia but can also be

Trichomonas vaginalis.

Because many outpatient offices are not

equipped to do gram stains, NAAT testing

of the urethra or urine is becoming the

preferred diagnostic test for gonorrhea

and chlamydia.