PO B. Accept referrals from other health care professions and communicate consultation fi ndings and recommendations to the referring provider and col- laborative network.
PO C. Utilize consultation recommendations for decision-making while main- taining primary responsibility for care.
PO D. Evaluate outcomes of interventions.
PO E. Provide ongoing patient follow-up and monitor outcomes of collabora- tive network interventions.
DOMAIN 3, COMPETENCY 2
Evaluate gaps in health care access that compromise optimal patient out- comes, and apply current knowledge of the organization and fi nancing of health care systems to ameliorate negative impact.
PO A. Identify gaps in access that compromise patient’s optimum care.
PO B. Identify gaps in reimbursement that compromise patient’s optimum care.
PO C. Demonstrate patient advocacy in the provision of continuous and comprehensive care.
PO D. Apply current knowledge of the organization to ameliorate negative impact.
PO E. Apply current knowledge of health care systems to ameliorate negative impact.
Chapter 11 Adolescent Female With Secondary Amenorrhea
141
Informant: Seventeen-year-old African American female who appears to be a reliable informant.
Chief complaint: Patient reports, “My last period was two months ago. I am worried about being pregnant.”
History of Present Illness
Patient B arrives unaccompanied to the offi ce for her yearly physical exami- nation. Her chief complaint is not getting her period for a few months and the possibility of pregnancy. Her last menstrual period was “two months ago.” She has had unprotected intercourse over the past three months with the same partner. She has had only one partner. She denies nausea and vomiting. She complains of some breast tenderness.
She does not want her parents or boyfriend to know if she is pregnant.
She wants to fi nish high school and go to college. She does not believe she could do this if she had a baby. She also believes her family would be judg- mental and nonsupportive if she told them she was pregnant. She does not want to share decision-making with her boyfriend for fear he would leave her.
Medical History
Prenatal History: Patient B is the eldest of three children. She was the prod- uct of an uncomplicated pregnancy. Her mother started prenatal care during the fi rst trimester. She was born via normal spontaneous vaginal delivery. It is not known whether medications were used during labor and delivery. There were no complications in the nursery, and the patient went home with her mother. She was breast-fed for the fi rst three months, and then formula-fed for the rest of the year.
Childhood Illnesses (Chart Review):
During the past year, Patient B has been seen for one episode of coughing,
•
diagnosed as bronchitis, and treated with over-the-counter cough medica- tion. Her symptoms resolved in approximately 10 days.
Twenty-pound weight loss last year. The pediatrician checked thyroid func-
•
tion tests that were normal. Patient denies any increased stressors or use of drugs. She had been slightly overweight when she was younger and wanted to lose some weight. Her diet is not healthy, and she often skips breakfast.
Her weight has remained stable for the past six months.
Three episodes of viral pharyngitis over the past four years.
•
One uncomplicated urinary tract infection treated with antibiotics.
•
Grade I/VI functional heart murmur diagnosed at age seven.
•
Positive Mantoux test after travel to an endemic country at age eight. Her
•
chest x-ray was unremarkable. She was treated with INH (Isoniazid), 125 mg once daily, and Pyridoxine (vitamin B6), 50 mg daily, for nine months. She was seen in this offi ce for side effects and liver function tests until the full course of treatment was completed.
At age 14, she was seen with complaints of menorrhagia of two months’
•
duration. According to the gynecologist’s notes, the patient was diagnosed with dysfunctional uterine bleeding. A CBC demonstrated microcytic ane- mia. She was treated with oral contraceptive pills. The patient was seen by a hematologist two months later to rule out a bleeding disorder. A follow-up CBC demonstrated slight improvement of her anemia. A hemoglobin electrophoresis showed no evidence of thalassemia. She was treated with ferrous sulfate (Feosol) and followed for the next three months, at which time her anemia improved, and she was discharged from hematology. She was advised to continue iron therapy for at least three months. Patient B continued the ferrous sulfate (Feosol) for more than three months and the oral contraceptive pills for six months.
Hospitalizations: There are no recorded hospitalizations, accidents, or surgeries.
Medications: Past medications include Isoniazid (INH), pyridoxine (vitamin B6), ferrous sulfate (Feosol), and oral contraceptive pills. At present she is not taking any prescribed, over-the-counter, herbal, or homeopathic medications.
Allergies: There is no known history of medication, food, or environmental allergies.
Immunizations:
1989 1990 1992 1993 1994 1995 1997 2004 2007 2008
DTaP x xx x x
IPV x xx x
HiB x
HepA x x
HepB xx x
MMR x x
Varicella x x
Meningitis x
Td x
Tdap
HPV x
Chapter 11 Adolescent Female With Secondary Amenorrhea
143
Current Health Status: Patient B states that she is currently healthy.
Family History
HEADS Assessment
Home
Patient B was born in Haiti and immigrated to the United States with her father and mother when she was two years old. She lives in a single-family- dwelling in suburban New York. The house is 15 years old and in good repair.
Her household consists of her mother, father, and two younger siblings ages 15 and 11 years. She states that everyone gets along well. Her father works for the post offi ce, and her mother is employed as a nurse in a local hospital. Her mother works the night shift so she can spend time with the family. When her mother is home, she is often busy with Patient B’s younger siblings, keeping the house clean, and sleeping. Her family is economically “comfortable.”
Patient B states that she gets approximately eight hours of sleep most nights.
Patient B states that her relationship with her parents is good. Most of the punishment that she receives is related to missing curfew, and consists of grounding “for a while.” Her parents have never hit her or her siblings, and issues are usually resolved through discussion.
Patient B states that although there are gangs in school, she and her friends are not a part of that group. She knows that there are drugs in school, but does not associate with those individuals who are involved with them.
Education and Employment
Patient B attends the local high school and is entering 12th grade. She has many friends. She is not involved in after-school activities because she works to have money to buy the “extras” that her parents cannot afford. She spends most of her money on CDs, clothes, and her cell phone bill.
15 y
17 y 11 y
37 y 75 y
40 y
65 y 57 y
Functional heart murmur Positive ppd––treated
Anemia
Dysfunctional uterine bleeding
Hypercholesterolemia Hypertension
55 y Hypertension Hypercholesterolemia
No consanguinity Ethnicity: Haitian
Until this year, she was a “good” student who maintained a B average. This year, she failed science and the state science examination. She attended sum- mer school to maintain eligibility to take the next science class. She is doing poorly in math. She enjoys languages and history, but fi nds science and math too hard.
Patient B would like to attend college out of state, but does not know what she would like to study. Her parents believe that since she is not doing well in school, she should attend the local community college until she decides on a major and improves her grade point average. She thinks that if she stays home, her parents will continue to treat her like a child, and she wants to make her own decisions.
Patient B works weekends for six hours at a clothing store in the local mall. She enjoys her work because she receives an hourly wage and a 10 percent discount on clothes she buys in the store. With the extra money she earns, she purchases CDs and clothes, and goes out with her friends.
Religion
Patient B is Roman Catholic and attends Mass on a regular basis with her family. She is not involved in church activities, except those in which her family participates. Her parents are strict and did not let her date until she was 17 years of age.
Family Stressors
Patient B has not been sleeping well, because she believes she is pregnant and feels very stressed. She thinks she will be less stressed when the preg- nancy is terminated and she is able to resume her life. Patient B does not believe any family stressors exist at the present time because her family does not know about the pregnancy. She believes her parents would want her to have the baby. She feels that a baby would be too emotionally and fi nancially stressful for herself and her family. She would have to rely on her parents to help her care for the infant. She believes she would not be able to fi nish school and would not have a career or a successful future. She does not think her boyfriend would help raise the infant.
Activities
Patient B enjoys being with her best friends, listening to music, and texting.
She does not spend a lot of time watching TV, but spends most of her free time on the computer chatting with her friends. She denies talking with strangers via the Internet.
Drugs
B denies the use of recreational drugs, including marijuana, cocaine, huffi ng, snorting, skin popping, and mainlining. She states that although she goes to parties where alcohol is served, she has never had more than one beer a night and has never been intoxicated. She admits to smoking two to four cigarettes a week. She has no suicidal ideation. Up until this visit, she was a happy teenager. She is now concerned and sad about the possibility that she may be pregnant.
Chapter 11 Adolescent Female With Secondary Amenorrhea
145
Nutrition
Patient B skips breakfast on weekday mornings because of lack of time. Lunch usually consists of a sandwich from the school cafeteria, with a bag of chips or pretzels and soda. Dinner is whatever her mother prepares and leaves for the family to eat. On days that Patient B eats at home, she eats with her siblings when they are available; otherwise, she eats alone. Her father usually eats dinner while watching TV. On days that she works, she purchases fast food, either a hamburger and fries or a slice of pizza with a soda. She states that she does not often snack, but uses the vending machines at school or buys coffee and donuts at work when she does.
Eighty percent of adolescents do not follow recommended dietary guidelines (Stephens, 2006).
CEBM, level 5.
Parents encourage their adolescent children at home by providing relatively controlled food choices. At the same time, teenagers ignore their parents’
advice by making unhealthy food choices when on their own. Adolescents understand the healthiness of certain foods but have limited concern about the future. Their eating habits are characterized by frequent snacking, skip- ping meals, junk food consumption and consistently low intake of fruits and vegetables. (Bassett, Chapman, & Beagan, 2007).
CEBM, level 2b.
Sexual History and Gynecological Information (confi dential)
Menarche: 13 years, 6 months. Periods every 30–31 days and last 6 to 7 days.
She has no complaints of dysmenorrhea.
Last menstrual period: A little over two months ago.
Patient B states she has only one boyfriend and has become sexually active with him during the past three months. She has not used condoms or other methods of birth control. She denies oral sex. She has not seen a gynecologist since age 16, when she was told she no longer needed to take oral contracep- tive pills for dysfunctional uterine bleeding. She states her mother was relieved because she felt that oral contraceptive pills promoted sexual promiscuity. She denies any history of sexually transmitted infections, although she states she has never been tested because she and her partner were virgins.
Review of Systems
General: She denies any weakness or fever but states that she has been a little more tired lately.
Skin: Denies any rashes, skin, or hair changes.
Head: Denies any trauma.
Eyes: Her last eye exam was one year ago. She wears contact lenses. She denies any irritation, dry eyes, discharge, or blurred vision.
Ears: Her last hearing test was almost one year ago. She denies any hearing dif- fi culties. Her only exposure to loud noise is when she listens to her MP3 player.
She states she does not frequently go to concerts where loud music is played.
Nose/sinuses: Denies frequent colds, nasal congestion, or nosebleeds.
Throat: Denies frequent episodes of sore throats or tonsillitis.
Dentition: Last dental exam was one year ago. She denies any tooth pain, bleeding gums, or diffi culty chewing.
Neck: Denies any neck pain, swelling, or diffi culty swallowing.
Respiratory: Denies any shortness of breath, coughing, or wheezing.
Heart: Denies any chest pain or palpitations.
Gastrointestinal: Denies any problems with diarrhea, constipation, or refl ux.
She has no nausea, vomiting, or abdominal pain.
Genitourinary/reproductive: See “History of Present Illness” and “Sexual History and Information.” Patient B states she does not regularly perform breast self-examination.
Musculoskeletal: Denies muscle pain or stiffness, diffi culty walking, back pain, or decreased range of motion.
Neurological: Patient B states she gets headaches approximately one to two times a month for the past year. Headaches occur when she skips meals and are relieved by acetaminophen (Tylenol). There is no relationship to her men- strual cycle. Headaches have not increased in frequency, intensity, or duration.
She has no accompanying symptoms, including photophobia, phonophobia, auras, fainting, dizziness, or numbness in her extremities. There is no family history of migraines.
Psychiatric: Patient B denies mood swings, violence, or suicidal ideation. She states that she has many friends. She is anxious about the fact that she may be pregnant. She is concerned that her school grades have declined and she does not have suffi cient time to study because of the hours she works.
Endocrine: Patient B states that she has no heat or cold intolerance, excessive sweating, or thirst.
Physical Examination
General: African American female who appears stated age. She is apprehen- sive and nervous.
Vital signs: Temp. 98.3° oral; BP 110/60; Pulse 68; Wt. 140.8; Ht. 66 1/4”; BMI 22.6.
Eyes: Conjunctiva clear; pupils equally round and reactive to light; extra- ocular movements intact; Fundi: no AV nicking. Vision: OU 20/25, OD 20/40 without glasses.
Chapter 11 Adolescent Female With Secondary Amenorrhea
147
Ears: No tenderness, discharge, or lesions noted; ear canal with slight amount of cerumen bilaterally; tympanic membranes pearl color; light refl ex and landmarks intact; hearing test: 25 decibel bilaterally.
Nose: Symmetric, no sinus tenderness, nasal obstruction, exudate, or infl ammation.
Throat: Lips moist, teeth in good repair, tonsils 2+ with no crypts noted.
Neck: Full range of motion without pain; no lymph nodes palpated; thyroid non-palpable; no bruits auscultated.
Chest: Symmetric, respirations unlabored, no adventitious sounds.
Heart: Regular rate and rhythm, S1, S2, no murmur auscultated.
Breast: Symmetric in shape, no skin dimpling, no masses, slightly tender to touch; no nipple discharge.
Abdomen: Flat, bowel sounds active in all four quadrants. Non-palpable liver and spleen. No guarding or tenderness to palpation.
Pelvic: Deferred to gynecology as per institutional protocol.
Rectal: Deferred.
Musculoskeletal: Full range of motion. No tenderness to palpation. No edema noted. All extremities warm to the touch.
Peripheral vascular: No change in skin color or temperature. Radial, femoral, popliteal and dorsalis pedis pulses 2+ and equal bilaterally.
Neurologic: Cranial nerves II-XII intact. Brachioradialis, quadriceps, and ankle refl exes 2+ equal bilaterally. Toes are down going.
Diagnostic testing: Urine pregnancy test positive.
Assessment
17-year-old healthy African American female presents for comprehensive examination.
Her chief complaint is amenorrhea of two months duration. Patient is anxious that she may be pregnant and is concerned about family and social implications. Physical examination reveals breast tenderness; BMI is 22.6, which is acceptable percentile for age. Urine pregnancy test is positive. She had normal thyroid studies. The differential diagnosis for secondary amenor- rhea includes pregnancy, stress, medication, chronic illness, low body weight, excessive exercise, thyroid malfunction, pituitary tumor, and early meno- pause. Based on the history and diagnostic testing, the most likely diagnosis is pregnancy. Gestational age is approximately eight weeks by dates.
Health concerns reevaluated today include:
History of heart murmur: There was no evidence of a heart murmur on
•
auscultation. This was most likely a functional murmur of childhood that has resolved.
Anemia on previous lab has since resolved. Was most likely due to dysfunc-
•
tional uterine bleeding; adequately treated with oral contraceptive pills and ferrous sulfate.
ICD-9 Codes (chronologically)
Heart murmur: inactive 785.2
Dysfunctional uterine bleeding: inactive 626.2 Anemia: inactive 285.9
Pregnancy: active V22.2
Plan
Health Maintenance
While examining Patient B, I instructed her in breast self-examination. She returned the demonstration accurately.
Despite the lack of defi nitive data for or against breast self-examination, breast self-examination has the potential to detect palpable breast cancer and can be recommended (Kearney & Murray, 2006).
Oxford Centre for Evidence-Based Medicine (CEBM), level 1a.
In discussing immunizations, Patient B elected to defer the HPV (GARDASIL) vaccine until her follow-up visit.
Federal law states that immunization from communicable diseases is in the public interest and may therefore be administered to minors without paren- tal consent. If the HPV (GARDASIL) vaccine is seen as protection from a communicable disease then adolescents may consent. However, if the HPV (GARDASIL) vaccine is seen as part of routine medical care in which standard vaccines are provided adolescents would not be able to access the vaccine on their own because, by law, minors are not permitted to consent for their own general medical care. Instead, parental authorization would be required, as it is currently for other vaccines. Since precedence has been set by the minor treatment status regarding untreated STIs, it should not be problematic to extend these treatment statutes to adolescents who seek administration of the HPV (GARDASIL) vaccine without involvement of their parents (Farrell &
Rome, 2007).
CEBM, level 5.
The Committee on Bioethics of the American Academy of Pediatrics concluded in their position paper that the “physician’s responsibility to his/her child patient exists independently of parental desires and proxy consent.” It is suggested that the role of the health care provider is to “do no harm” for the patient remains an important part of the physician-patient relationship (Diaz et al., 2004).
CEBM, level 5.
Chapter 11 Adolescent Female With Secondary Amenorrhea
149
Counseling/Education
I discuss the following issues:
Safe sex, including abstinence and condom use.
•
Contraception for the prevention of subsequent pregnancies and sexually
•
transmitted infections.
Illicit drugs and alcohol use and abuse were discussed. I counseled her
•
to never drive while under the infl uence of drugs or alcohol, as well as to never get into a car with an intoxicated driver. She was also advised to never pick up a beverage at a party that has been left unattended.
Cigarette smoking. Because Patient B smokes a few cigarettes a week,
•
we speak about the dangers of cigarette smoking and secondhand smoke effects. I ask whether she wants to quit and would like information and the phone number of the New York State Smokers’ Quitline. At the moment, she does not see smoking as a problem.
Seat belt usage. Although Patient B states that she wears a seat belt in the
•
front seat, she often does not wear it while in the backseat.
Accidents, suicide and homicide are the leading causes of death among American adolescents. Additional morbidity and mortality is related to drugs, alcohol and tobacco use. Alcohol and drug use contribute to more than 40%
of adolescent deaths from motor vehicle accidents. More than 75% of adoles- cents have used alcohol, and more than 25% have engaged in binge drinking.
Tobacco use is also common in adolescents with 60% reporting to have at least used tobacco once. The fi ve A’s strategy (ask, advise, assess, assist and arrange) has been used for counseling for smoking cessation but can be used for other high-risk behaviors (Stephens, 2006).
CEBM, level 5.
Stressors for adolescents include poor self-esteem, lack of support, and
•
peer pressure. I advise her that there are many county agencies to which I can refer her to deal with stressors and lack of perceived support. I also inform her that she can contact me at any time to discuss problems she may be experiencing.
Parents and peers play a role in adolescent socialization, and superior out- comes are found among those adolescents who have high levels of support from their mothers, fathers, and friends. Deviant peers and unskilled parents have demonstrated a debilitating effect on adolescent adjustment. The source of support though may be less important than the fact that support is avail- able (Laursen & Mooney, 2008).
CEBM, level 2b.
I discuss getting extra help for math and science, such as speaking with
•
her teachers about extra help in the morning or getting a student tutor on the weekend. I impress upon her the importance of coming forward if she feels depressed or unhappy so I can refer her for counseling or access the high school counselors.