Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2892_Библиотеки_им_академика_М_И_Перельмана
.pdf
320 CASE FILES: FAMILY MEDICINE
https://t.me/medicina_free
ANSWERS
28.1 D. Protection from STIs for this patient and prevention from transmitting
HIV to her future partners are of utmost concern. Condoms are the most
effective agents to prevent the transmission of an STI. A history of STIs is
not an absolute contraindication for IUD use, but with this patient’s history
of high-risk behavior, IUDs (answer C) probably should be avoided. The
patient should be counseled extensively on the need to protect sex partners
from contracting HIV, but other forms of contraception should not be withheld given the benefits of preventing unwanted pregnancy and vertical transmission. The provider should also be on the alert that this patient may be
a victim of sex trafficking and use a nonjudgmental and supportive manner
in querying. Use of nonbarrier contraception (answer A, oral contraceptive
agent, and answer B, depot medroxyprogesterone) is unlikely to increase the
patient’s high-risk sexual behaviors, and reliable birth control will have a positive impact on her life.
28.2 B. Emergency contraception may include combination hormonal therapy,
ideally used within 72 hours, but it can cause significant nausea and vomiting. Plan B is levonorgestrel and is more effective than the combined OCPs
(such as Yuzpe method, answer A) for postcoital contraception without the
prominent side effect of nausea. Placing a copper IUD (answer C) can cause
heavy and irregular vaginal bleeding and would not be a good choice for a
patient who already experiences these symptoms. Intramuscular methotrexate (answer D) is not used for emergency contraception.
28.3 C. Eighty percent of women having unprotected intercourse will be pregnant
in 1 year. The other percentages (answer A, 20%; answer B, 40%; answer D,
100%) are not correct.
28.4 C. The POP minipill is the most effective form of birth control in the postpartum period for women desiring to breastfeed. Natural family planning
(answer B) and coitus interruptus (withdrawal method, answer E) have high
rates of user error, leading to failure. Laparoscopic tubal ligation (answer A)
is a permanent method of birth control. Combination OCPs (answer D) can
affect a woman’s milk supply and have varying safety in lactation.
28.5 B. In a woman 35 years or older, cigarette use poses an unacceptable risk with
combined oral contraceptives. Women with nonmorbid obesity (answer A)
are at greater risk for deep vein thrombosis, but the advantages of oral
contraceptives often outweigh the disadvantages in these patients. A BMI
of 35 kg/m2 or greater is a relative contraindication. A patient with sickle
cell disease (answer C) is at a higher risk of adverse events from an unintended pregnancy than from the use of combined oral contraceptives.
Combined oral contraceptives lower the risk of ovarian cancer (answer D).
Patients with varicose veins (answer E) are not at increased risk for deep
vein thrombosis.
SECTION II: CLINICAL CASES 321
https://t.me/medicina_free
CLINICAL PEARLS
» The male latex condom remains the best shield against HIV and other
STIs.
» Barrier methods, which work by keeping the sperm and egg apart,
usually have only minor side effects.
» Combination oral contraceptives offer protection against ovarian
cancer, endometrial cancer, anemia due to blood loss, PID, and fibrocystic breast disease.
» To reduce barriers to providing oral hormonal contraception, it is recom-
mended that pelvic examination not be required and a year’s worth of
prescription be provided.
» Noncontraceptive benefits of combination oral contraceptives include
decreased incidence of benign breast disease, relief from menstrual disorders (dysmenorrhea and menorrhagia), reduced risk of uterine leiomyomata, protection against ovarian cysts, reduction of acne, improvement
of bone mineral density, and a reduced risk of colorectal cancer.
» Intrauterine and implantable contraceptives are also extremely effective
and reduce the contribution of user error to the failure rate.
» Surgical sterilization must be considered permanent. Vasectomy is
considered safer than tubal ligation.
REFERENCES
Barrows-nees E, Landy K. Hormonal contraceptives in women who are overweight or obese. Am Fam
Physician. 2017;95(11):732.
Brunsell SC. Contraception. In: South-Paul JE, Matheny SC, Lewis EL, eds. CURRENT Diagnosis &
Treatment: Family Medicine. 4th ed. New York, NY: McGraw Hill; 2015. http://accessmedicine
.mhmedical.com.evms.idm.oclc.org/content.aspx?bookid=1415§ionid=77056012. Accessed
May 9, 2020.
Burkman RT, Brzezinski A. Contraception & Family Planning. In: DeCherney AH, Nathan L,
Laufer N, Roman AS, eds. CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 12th ed.
New York, NY: McGraw Hill; Chapter 60. http://accessmedicine.mhmedical.com.evms.idm.oclc
.org/content.aspx?bookid=2559§ionid=206968141. Accessed May 9, 2020.
Hardeman J, Weiss BD. Intrauterine devices: an update. Am Fam Physician. 2014;89(6):445-450.
Klein DA, Arnold JJ, Reese ES. Provision of contraception: key recommendations from the CDC.
Am Fam Physician. 2015;91(9):625-633.
Lesnewski R, Prine L. Initiating hormonal contraception. Am Fam Physician. 2006;74(1):105-112.
Smoley BA, Robinson CM. Natural family planning. Am Fam Physician. 2012;86(10):924-928.
Wieslander CK, Hadnott TN, Bukowski K. Therapeutic Gynecologic Procedures. In: DeCherney AH,
Nathan L, Laufer N, Roman AS, eds. CURRENT Diagnosis & Treatment: Obstetrics & Gynecology.
12th ed. New York, NY: McGraw Hill; Chap. 48. http://accessmedicine.mhmedical.com.evms.idm
.oclc.org/content.aspx?bookid=2559§ionid=206966408. Accessed May 9, 2020.
322 CASE FILES: FAMILY MEDICINE
https://t.me/medicina_free
Wieslander CK, Wong KS. Therapeutic gynecologic procedures. In: DeCherney AH, Nathan L,
Laufer N, Roman AS, eds. CURRENT Diagnosis & Treatment: Obstetrics & Gynecology. 11th ed.
New York, NY: McGraw Hill; 2013: Chap. 46. http://accessmedicine.mhmedical.com.evms.idm
.oclc.org/content.aspx?bookid=498&Sectionid=41008638. Accessed May 9, 2020.
CASE 29
https://t.me/medicina_free
A 16-year-old young woman presents for a routine wellness examination.
She is a junior in high school and has no significant medical history. She plays
on the school softball team and requests that you complete a preparticipation
clearance form. She is accompanied by her mother, who wants to know if her
daughter needs a routine gynecologic examination. While she is up to date on her
immunizations, her mother has questions about the human papillomavirus (HPV)
vaccine. There is no significant medical history in her nuclear family, but one of her
cousins died at the age of 21 years of a sudden cardiac death. When interviewed
without her mother in the room, the patient reports that she is generally happy,
gets As and Bs in school, and has an active social life. She has never been sexually
active and denies tobacco or illicit drug use. She reports that she has a “drink or
two” at parties with her friends once a month. On examination, her vital signs are
within normal limits. On cardiac auscultation, you hear a 2/6 systolic murmur that
gets louder when you have her perform a Valsalva maneuver. Peripheral pulses
are strong and symmetric, and there is brisk capillary refill. The remainder of the
physical examination is unremarkable.
▶ What immunizations should be recommended at this visit?
▶ At what age is it recommended to start routine cervical cancer screening?
▶ What is the most common cause of sudden cardiac death in young athletes?
▶ What is the best strategy to address sexual activity and gender identity in
adolescents?
324 CASE FILES: FAMILY MEDICINE
https://t.me/medicina_free
ANSWERS TO CASE 29:
Adolescent Health Maintenance
Summary: A healthy 16-year-old adolescent female presents with
Desire for a routine checkup and sports preparticipation examination
A 2/6 systolic murmur that gets louder when you have her perform a Valsalva
maneuver
No significant medical history in her nuclear family, but a cousin who died at the age
of 21 years of a sudden cardiac death
Denial of sexual activity or tobacco or illicit drug use
Report of having a drink or two at parties with her friends once a month
Recommended immunizations: Review of current immunization record and if not
up to date: tetanus-diphtheria-acellular pertussis (Tdap) vaccination, meningococcal vaccination, HPV vaccine series, and annual influenza vaccine (seasonal).
Recommended age to start cervical cancer screening: The United States Preventive
Services Task Force (USPSTF) and American College of Obstetrics and Gynecology recommend initial screening at age 21 years.
Most common cause of sudden cardiac death in young athletes: Hypertrophic cardiomyopathy (HCM).
Best strategy to discuss sexual activity and gender identity: Discuss with adolescent
alone after excusing parent(s); use open-ended questions and active listening.
ANALYSIS
Objectives
1. Know the evidence-based guidelines for screening and disease prevention in
adolescents. (EPA 3, 12)
2. List the immunizations routinely recommended for adolescents. (EPA 12)
3. Describe the components of sports preparticipation examinations. (EPA 12)
4. State the acceptable terminology for gender identity and how to address this
issue in adolescents. (EPA 5, 12)
Considerations
This is a healthy adolescent female who presents for a sports preparticipation
physical examination. Required preparticipation examinations provide an excellent opportunity for recommended health maintenance, including immunizations,
age-appropriate screening, risk reduction counseling, and general health education. Her medical history is unremarkable, and she has a 2/6 systolic murmur that
increases with Valsalva. The focus should be to identify potential conditions that
can lead to sudden cardiac death. The hallmark physical examination finding in
SECTION II: CLINICAL CASES 325
https://t.me/medicina_free
HCM is a systolic murmur that decreases in intensity with the athlete in the supine
position (increased ventricular filling, decreased obstruction). This contrasts with
functional outflow murmurs common in athletes that increase in intensity upon
lying down. The murmur of HCM increases with the Valsalva maneuver (decreased
ventricular filling, increased obstruction). Marfan syndrome is associated with aortic root dilation or dissection, hence stigmata of Marfan and family history are
also important. Any athlete with a new-onset murmur or any other murmur that
the examiner finds suspicious—such as this one—should be held from participation and referred to a cardiologist for evaluation. Most athletes with HCM are
asymptomatic.
APPROACH TO:
Adolescent Health Maintenance
DEFINITIONS
CISGENDER: A person whose gender identity matches sex assigned at birth.
GENDER IDENTITY: A person’s internal sense of maleness or femaleness, which
may or may not conflict with sex assigned at birth. A person’s gender identity should
not be confused with their gender expression, which is the external manifestation
of their gender. It is important to recognize that in addition to male and female
identities, a variety of nonbinary (eg, not strictly masculine or feminine) genders
are also recognized, as well as gender fluidity, in which an individual identifies with
different gender categories over time.
HUMAN PAPILLOMAVIRUS VACCINE: The nine-valent vaccine protects
against high-risk and common types of HPV to protect against cervical, vaginal,
vulvar, anal, and penile cancers as well as reduces the incidence of genital warts. The
vaccine is now recommended for females and males ages 9 to 45 years, including
high-risk males (men who have sex with men, immunocompromised males). It is
recommended to begin the series at ages 11 to 12, but can be started as early as age
9. Two-dose and three-dose schedules are offered depending upon age of initiation
of the series.
TRANSGENDER: A person whose gender identity conflicts with the sex assigned
at birth.
TRANSMAN/TRANS BOY: A person assigned female at birth who identifies as
a man.
TRANSWOMAN/TRANS GIRL: A person assigned male at birth who identifies
as a woman.
CLINICAL APPROACH TO ADOLESCENT HEALTH MAINTENANCE
Adolescence is a time of physical, emotional, cognitive, and psychosocial changes. It
is also a time of experimentation and, frequently, risk taking. For most, adolescence
326 CASE FILES: FAMILY MEDICINE
https://t.me/medicina_free
is also a time of relatively good health. The choices made during adolescence often
impact both the short-term and the long-term health of the patient. Addressing
the unique health care needs of adolescents can be challenging, as they may be
more likely to present to the clinician for acute illness rather than for health maintenance. Adolescents rarely seek advice from health care providers regarding prevention of morbidity and mortality in their age group. During health maintenance
visits, providers should discuss risks and interventions surrounding issues such as
unintended pregnancy, sexually transmitted infections (STIs), unintentional injuries, depression, and suicide.
Confidentiality. Concerns about confidentiality can be a barrier to providing
effective care to adolescent patients. Many adolescents believe that clinicians
share any information provided with their parent(s) and may not volunteer
information such as sexual activity, gender identity, and use of tobacco, alcohol,
and/or illicit drugs. It is recommended that health care providers take a history
with the parent in the room to allow the parent to present any concerns, then
interview the adolescent alone to allow the patient to speak confidentially with the
provider. Policies to ensure provider-patient confidentiality while balancing
the parent’s right to be involved should be discussed with and agreed upon by the
patient and parent in advance to promote an honest, trusting, and therapeutic
relationship.
In most states, adolescents can consent independently to STI testing and contraceptive services. Laws regarding abortion services vary from state to state and
often require parental consent. Clinicians must consider maturity and age of the
adolescent patient when contemplating breaking confidentiality. In cases of abuse
or harm to the adolescent or to other persons, clinicians are required to break
provider-patient confidentiality.
Screening
Various organizations have created and revised guidelines for preventive services
for adolescents, including Guidelines for Adolescent Preventive Services (GAPS),
the USPSTF, American Academy of Pediatrics Bright Futures, and the Advisory
Committee on Immunization Practices. Most insurance payers cover annual examinations, and current recommendations support at least three complete physical
examinations: early adolescence (age 11-14), middle adolescence (age 15-17), and
late adolescence to early adulthood (18-21).
The Society for Adolescent Medicine compiles similarities among guidelines for
preventive services. All adolescents should be screened for hypertension; obesity;
eating disorders; hyperlipidemia if indicated (in individuals at above-average risk
based on a personal history of comorbid conditions or a family history of hyperlipidemia, coronary artery disease, or other vascular diseases); tuberculosis (TB) if
at risk (having lived in a homeless shelter or an area with a high prevalence of TB,
having been incarcerated or exposed to active TB, or working in a health care setting); physical or emotional abuse; learning or school problems; substance abuse;
depression; and suicide.
Sexually Transmitted Infection Screening. The USPSTF recommends chlamydia
and gonorrhea screening in all sexually active women under age 25 years (GradeB)
SECTION II: CLINICAL CASES 327
https://t.me/medicina_free
Table 29–1 • ANTICIPATORY GUIDANCE TOPICS FOR ADOLESCENTS
Growth and development parameters
Healthy dietary habits
Exercise
Oral health
Injury prevention
Sleep hygiene
Sun protection
Responsible sexual behaviors
Avoidance of alcohol, tobacco, illicit drugs, and anabolic steroids
Safe practices of social media
Strategies to cope with bullying
with insufficient evidence to recommend for or against such screening in men
(Grade I). HIV testing is recommended for all adolescents and adults age 15 to 65
(Grade A), although the interval for screening is not certain. Screening for hepatitis B
and syphilis is recommended for those at risk.
Depression Screening. The USPSTF recommends screening for major depressive disorder in adolescents aged 12 to 18 years, with adequate systems in place to
ensure accurate diagnosis, effective treatment, and appropriate follow-up (Grade B).
Anticipatory Guidance
As with younger children, anticipatory guidance is a key component of adolescent
care. At minimum, adolescents and their parents should be counseled on a variety
of topics (see Table 29–1).
Gender Diversity
Childhood and adolescence are common times for children to explore and
develop their gender identities. Current estimates suggest that approximately
1 in 200 people in the United States is transgender or gender nonconforming.
With increased recognition of gender diversity, demand for gender-affirming services is increasing. Providers should ask adolescents about preferred pronouns
(ie, she/he/they) as well as preferred names, and these should be documented in
the medical record for future encounters. It should be made clear to patients that
being gender diverse is not a mental illness. Care should be taken to avoid implicit
rejection of the child’s identity via “watchful waiting” (deeming the experience a
phase), redirection toward cisgender norms, or attempts to convert the child to
being cisgender.
Immunizations
The adolescent health maintenance examination allows for immunization history review and interval administration. In those who have received the recommended primary series, Tdap is recommended at ages 11 to 12 years. Routine
meningococcal vaccination with conjugate vaccine (MCV) is recommended in a
two-dose series at ages 11 to 12 years and again at age 16. If the booster at age 16
328 CASE FILES: FAMILY MEDICINE
https://t.me/medicina_free
is not administered, it should be given before entering college dormitories or the
military barracks. MCV is also recommended for travelers to endemic areas or if
patients are functionally/anatomically asplenic. Catch-up vaccines for adolescents
who did not receive vaccinations on the childhood schedule can be offered for
varicella; measles, mumps, and rubella; and hepatitis B. The hepatitis A vaccine
can be offered to males who have sex with males as well as to those who live in
areas with high infection rates, travel to high-risk areas, have chronic liver disease,
or inject intravenous drugs.
HPV is recommended during adolescence. The nine-valent vaccine protects
against high-risk and common types of HPV that cause 90% of cervical, vaginal,
vulvar, anal, and penile cancers. The vaccine also reduces the incidence of strains
causing genital warts. The vaccine is now recommended for all females and males
ages 9 to 45 years. It is given as a two-dose series for those under age 16 and three
doses for those age 16 and up or anyone who is immunocompromised.
CLINICAL APPROACH TO SPORTS
PREPARTICIPATION EXAMINATION
A common reason for healthy adolescents to present to primary care providers is
for a preparticipation examination as a requirement to play a sport in school. The
goal of these examinations is to identify conditions that may place a young athlete
at risk during athletic participation. These conditions are primarily cardiac and
orthopedic, but they are not limited to these systems. A preparticipation examina-
tion allows the provider to perform a focused history and physical examination to
clear the patient for safe participation in sports. These encounters also serve to meet
legal and insurance requirements of the school or school system.
Sudden Cardiac Death
The rate of sudden cardiac death in athletes is very low. Congenital cardiac anomalies are the most common etiology, with HCM accounting for about one-third and
anomalous coronary arteries for about one-fifth of cardiac anomalies. All adolescents and their parents should be asked about personal history of exertional chest
pain, dyspnea, syncope, and heart murmurs; they should also be queried about
family history of HCM, other congenital cardiac abnormalities, or premature cardiac deaths. Other important historical information includes history of asthma or
other pulmonary disorders, orthopedic injuries, heat-related illness, and absence of
one of a paired organ (eg, single kidney, testicle, ovary, etc).
Eating Disorder Screening
It is important to screen for eating disorders, as well as for a desire to change body
weight, either for body image or for athletic purposes (eg, “weight cutting” for wrestlers). Eating disorders are more common in cisgender females than males and are
more common still among sexual orientation and gender minority populations
with highest rates for the transgender population. Female patients should be questioned about menstrual irregularities, as amenorrhea could signal anorexia, and
amenorrheic female athletes could be at risk for osteoporosis.
SECTION II: CLINICAL CASES 329
https://t.me/medicina_free
Cardiovascular Examination
Blood pressure should be measured and compared with age- and gender-appropriate
norms. General appearance, specifically looking for signs of Marfan syndrome,
should be noted. These signs, which include arachnodactyly, an arm span greater
than height, pectus excavatum, tall-thin habitus, high-arched palate, and ocular
lens subluxations, should prompt further evaluation, as persons with Marfan syndrome can have aortic abnormalities that predispose to rupture during sports. Auscultation of the heart should be performed, at minimum, in both the lying and the
standing positions. The murmur of HCM, while not always present, is best heard
along the left sternal border and accentuates with activities that decrease cardiac preload and end-diastolic volume of the left ventricle. Therefore, standing or straining
with a Valsalva maneuver would increase the murmur; conversely, squatting would
be expected to decrease the murmur. Any adolescent with stigmata of Marfan syn-
drome, a murmur suggestive of HCM, with a grade 3/6 or louder systolic murmur,
or any diastolic murmur should undergo an echocardiogram and be evaluated by a
cardiologist prior to clearance for athletic participation.
Contraindications
No specific screening tests are recommended for universal screening of all athletes,
although specific tests may be indicated based upon history or physical examination findings. Participation in athletics or exercise should be encouraged. Absolute
contraindications to all athletic participation are rare; more commonly, clearance to
participate may be delayed for further evaluation of a suspected condition, rehabilitation of an injury, or recovery from an acute illness.
CASE CORRELATION
See also Case 5 (Well-Child Care) and Case 28 (Family Planning—
Contraceptives).
COMPREHENSION QUESTIONS
29.1 A 16-year-old high school student is being evaluated for a sports preparticipation examination. The student is currently asymptomatic and desires to
participate on the basketball team. Which of the following should prompt
a referral to a cardiologist prior to clearance to participate in high school
sports?
A. Grade 2/6 systolic murmur in an asymptomatic 16-year-old adolescent girl
B. Grade 1/6 diastolic murmur heard at the apex in a 17-year-old adoles-
cent girl
C. Grade 2/6 systolic murmur in a 17-year-old adolescent boy that is heard
while lying down and that gets softer when standing
D. An asymptomatic 16-year-old whose grandfather died of a heart attack
at age 72
Соседние файлы в папке Библиотека им академика М.И. Перельмана