A simple test?

Tread carefully when discussing seemingly routine matters with adolescent patients.

Issue: February 2007

I try so hard to entertain, yet, not offend my teenage patients. I attempt to be quite cognizant of their need for both modesty and praise. But do you ever get the feeling that you just inserted your foot in your mouth, without even recognizing the width of your shoe size?

The following encounter reminds me of the ultimate “girlie question” from my wife: “Do you love me more now than when you first married me?”

Now listen guys, there is NO right answer to this query. Think about it. I’ve been around girls (five of them) too long to realize a doomed response is inevitable. An old proverb stated, “A drowning man will grasp at a straw.”

Stan L. Block

It was one of those days. I just thought it would be prudent to order an additional “simple test.”

The ‘hoarse’ is out of the barn

Amy came into the office for a simple upper respiratory tract infection. She was running a low-grade fever and suffering from hoarseness and rhinorrhea. She was still taking her Advair and occasionally her albuterol. She was worried that her asthma was flaring up. The cough was antagonizing her sleep at night.

Upon a careful physical examination, I determined that she was afflicted with a mild case of the parainfluenza virus that was circulating in a mini epidemic in our community.

I reassured Amy that her lungs were clear and devoid of any wheezing.

“Nope, your asthma is doing just fine, Amy. Your continued use of preventive medications has worked wonders for keeping your asthma under control.”

I have known Amy since she was about 5. Having seen her through numerous significant wheezing episodes and other respiratory conditions, among our six partners, she always asked to see me when she was ill or needed help.

I had even helped her through her most challenging problem in her life — her unintentional pregnancy at age 17 years. Believe me, I tried numerous times to get her on a stable regimen of oral contraceptive pills. But she continued running out of medication or forgetting to take her pills. I begged her just to call the office when she was in short supply — we could always get her a temporary prescription to tide her over until her appointment.

A long track record

On numerous occasions, I have even seen Amy in the office simultaneously with her baby, when both were sick. Because she had no one else to assist her, I sometimes had to hold the infant while I examined her. (“I forgot the car seat, Dr. Block.”) I consider that an honor actually.

I had also seen Amy through some nasty years during her mid teens. Her father had essentially disowned her and refused to have any contact with her or her mother. The relationship had become so volatile that her father even threatened that “he would shoot her” if she ever came around his house again, especially with that “no good boyfriend of hers.”

Talk about a “Montel Williams” moment! I attempted to console her through this heartbreaking tumult, with calm words of reassurance and by trying to emphasize that her father owned the problem, not her. I explained that he was just not accepting her recent pregnancy and was extremely distraught about the entire situation.

We often discussed her multiple problems in her relationship with her mother.

In fact, over the last year, Amy had become so depressed and unsmiling that I had elected to initiate therapy with a selective serotonin reuptake inhibitor. This worked its usual magic, and she had become more resilient to the everyday pressures of school, a baby and an estranged father.

She had regained her teenage girl sparkle again. The simple smile and gleam in her eye that had been lost for a while returned. It is hard to define, but if you look carefully at the reciprocating smile, the eye contact and the ability to laugh at your dumb jokes and self-deprecation, most of your content teenage girl patients emanate a certain glow.

So in essence, she trusted me implicitly.

But at the end of this examination, there was one of those “Oh by the way” moments.

No horsing around

“Dr. Block, by the way, my urine is bothering me again, sort of like last time,” she said. “I had a urinary tract infection three weeks ago, and I am starting to feel the same sort of urgency to pee. I finished my medicine a week ago. It’s not really burning, it just feels sort of funny.”

“Well, let’s just check your urine again to see if your UTI has recurred. Have you had any sores or vaginal itching or change in the nature of your vaginal discharge?”

“No.”

With the urine analysis results in hand, I explained to her that her urine had 5-10 white blood cells and no other findings. The peculiar urinary symptoms were most likely related to a mild yeast infection.

“We will need to wait for the urine culture to return tomorrow. And I will need to order one ‘additional simple test’ on your urine. Your problem might be an occult urethritis from chlamydia or even gonorrhea.”

Then came the mercurial adolescent meltdown. The tears began to flow, and she appeared quite distraught. I could not have anticipated the cascade of emotions that followed over the next 15 minutes.

Once I calmed her down, she explained that she could not believe that I thought she was being promiscuous. She had not been with anyone else but her current boyfriend. I had betrayed her confidence in some manner.

“How many years have you known me? I would never do that sort of thing,” she said.

It was easy for me to look at this adolescent girl with the baby in her arms and think that she would be extremely unlikely to be monogamous. Boy, did she let me know differently.

Changing horses in midstream

I tried to explain that possibly her boyfriend may have had sexual contact with someone else in the last year or two and infected her. But that was met with more anguish.

“Never.”

Backpedaling, finally, I explained to her that her obstetrician over the last few years performed these same tests on her with every PAP smear. This simple test was not an accusation, but an important precaution.

“But you should know that I would never do that sort of thing.”

I told her I still respected her and appreciated her high standards and the fact that she had trusted me so much as well. The simple test was performed. And it was negative, just as she had predicted.

Now, I cannot wait until we receive a mandate for everyday practitioners to perform yet another simple test on every adolescent. An HIV test at that! I have never seen a case of HIV in our large rural Kentucky practice in more than 25 years. Talk about a contentious proposition and some necessary backpedaling with our parents and our adolescents! Like I said, I try not to offend my adolescent patients.

For more information:

Stan L. Block, MD, has a pediatric practice in Bardstown, Ky., and is a member of the Infectious Diseases in Children editorial board.