Clinical guidelines
Week 10
What is (are) the most likely diagnosis (diagnoses)? What were the clinical findings that confirmed the diagnosis (diagnoses)?
- How is it (are they) treated according to the most recent clinical guidelines? Cite the guidelines.
- Describe a plan of care for the patient, including patient education, and additional tests.
Learning Objectives
The student should be able to:
Describe and recall the HEEADSS mnemonic approach to adolescent counseling. 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.
Knowledge
HEEADSSS Approach to Adolescent Counseling
The HEEADSSS approach to adolescent counseling addresses the main categories of Home/health, Education/employment, Eating disorders, Activities, Drugs, Sexuality, Safety/violence, and Suicide/depression. View examples of screening questions for the HEEADSSS history. One of the nice qualities about the HEEADSSS approach is that it starts with less threatening issues and proceeds to more personal questions, so the interviewer has a chance to establish rapport before exploring sensitive, intrusive topics. Be sure to ask questions in a nonjudgmental way, and avoid questions that can be answered with “OK” or with a “Yes/No” (i.e., “Do you get along with your mom and dad?”; “How are you doing in school?”; “Do you have any activities outside of school?”; “Do you do drugs?”; “Are you sexually active?”; “Are you careful about being safe?”). Remember to avoid making assumptions about a teen’s behaviors. For example, don’t assume that your patient is heterosexual, sexually active, or even dating.
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 the use of seat belts 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
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.
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.
© 2021 Aquifer, Inc. – Daniela Fernandez (daniela1295@stu.southuniversity.edu) – 2021-09-15 21:56 EDT 1/10
Human papillomavirus
There are two different human papillomavirus vaccines available. They vary in the number of strains of HPV they protect against, ranging from four to nine, and can prevent most cases of cervical cancer and genital warts. It is recommended for girls and females 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 – 21 who have not been vaccinated previously or who have not completed the three-dose series. ACIP states that males aged 22 – 26 years may be vaccinated, but does not recommend routine vaccination in this age group.
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.
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.
MMR MMR is recommended in adults who have not been previously vaccinated as children. An exception to this recommendation is the case of pregnant females. Pregnant females should not be vaccinated with MMR because of a risk of fetal transmission since it is a live virus vaccine.
Pneumococcal The pneumococcal vaccine is indicated for adolescents with certain chronic health conditions.
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 5 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 are characterized by immune complex deposition in blood vessels, can rarely be seen following receipt of vaccines containing tetanus toxoid or diphtheria toxoid. 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.
Hepatitis A Hepatitis A vaccination is effective in preventing hepatitis A virus infection. The series of two to three injections(depending on the type of vaccine) is recommended for adolescents if they did not receive them when younger.
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 females less than 21 years of age leads to potentially unnecessary 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 females ages 30 – 65 years, screening with high-risk human papillomavirus (HPV) testing alone or in combination with cytology every five years.
STI Screening Recommendations
Current recommendations are for all patients age 15 to 65 years to be screened for HIV infection. © 2021 Aquifer, Inc. – Daniela Fernandez (daniela1295@stu.southuniversity.edu) – 2021-09-15 21:56 EDT 2/10
Test results for most STIs, such as gonorrhea, chlamydia, HIV etc. 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 Klebsiella pneumonia, Proteus mirabilis and Staphylococcus saprophyticus.
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 (> 38 C) 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
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.
© 2021 Aquifer, Inc. – Daniela Fernandez (daniela1295@stu.southuniversity.edu) – 2021-09-15 21:56 EDT 3/10
Prostatitis
Acute prostatitis
Presents with UTI symptoms of fever, chills, dysuria, dribbling, and hesitancy, and is caused by Gram-negative rods (Enterobacteriaceae, Pseudomonas, Proteus), Gram-positive organisms (Enterococcus, S. aureus), and sexually transmitted agents such as Neisseria gonorrhoeae and Chlamydia trachomatis.
Prostate is edematous and very tender on digital rectal examination.
Chronic prostatitis
Characterized by lower urinary tract symptoms, perineal discomfort, pain with ejaculation, and occasionally deep pelvic pain that radiates to the back. The symptoms are often subtle and sometimes may be absent, and the physical exam may be normal.
This diagnosis should be considered in males with recurrent UTIs without risk factors.
Diagnosis can be difficult to make and may require submitting urine specimens gathered following prostatic massage for microscopic urinalysis and culture.
Epididymitis
Patients with epididymitis present with dysuria, frequency, urgency, and unilateral testicular pain.
Fever and rigors may be present and there may be redness and tenderness of the entire affected testicle.
Testicular torsion should be considered in all cases, especially when the patient is an adolescent and the onset is sudden.
Epididymitis in males < 35 years is usually caused by Chlamydia trachomatis or Neisseria gonorrhoeae; in those > 35, enteric Gram-negative rods (Escherichia coli) are the most common causes.
If the diagnosis is questionable, color duplex doppler scanning should be obtained immediately.
Factors that Contribute to Complicated Urinary Tract Infections
Anatomic or functional abnormalities of the urinary tract
Anatomic or functional abnormalities of the urinary tract lead to stasis and impede the free flow of urine, promoting bacterial growth and causing complicated infections.
Hospital-acquired Hospital-acquired urinary tract infections are considered complicated because patients are more susceptible to developing infections with antibiotic-resistant organisms that are found in the hospital environment.
Immunosuppressed or recently treated with antibiotics
Patients who are immunosuppressed or who recently have been treated with antibiotics are considered to have complicated infections.
Male Urinary tract infections in males are complicated because they are commonly associated with bladder outlet obstruction, instrumentation, or other urologic abnormalities. However, a small number of adult males can develop uncomplicated UTIs. Risk factors associated with these infections are homosexuality, intercourse with a urinary tract-infected female partner, and lack of circumcision.
Pregnant Urinary tract infections in pregnant females are considered complicated because they can progress to andcan induce preterm labor.
Urinary catheter or recent instrumentation
Urinary tract infections in patients with urinary catheters or recent instrumentation are considered complicated because they introduce external pathogens into the urinary tract and, in the case of indwelling catheters, provide a nidus for bacterial growth.
Birth Control Options
Percentage of females experiencing an unintended pregnancy within the first year of use: United States
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