question in CMS peds

[Red Husky]

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Hi guys I am doing CMS and wanted to ask your opinion about the answer to this one:

An otherwise healthy 16 yo girl comes to the physician with 6-month history of increasingly severe pain with menses (severe pelvic cramps+vomiting) causing her to miss 2 days at school.Menses are regular every 28 days lasting 4-5 days. LMP 7 days ago. Has had 3 lifetime sexual partners with inconsistent condom use.
Pelvic Exam: tender, normal-sized uterus, no mass. what is the next step:

1) Pregnancy Test
2)Pelvic US
3)narcotic therapy
4)NSAID
E) SSRI

 

[1badvette]

Sound like Secondary Dysmenorrhea ... Start with Preg test to rule out ectopic , I know that LMP was 7 days ago .. But i would still pick Pregnancy test . If the pelvic exam was normal then i would start off with NSAIDS .

 

[Red Husky]

Pregnancy test makes sense but is never the right answer on the test in someone that has not missed a period yet. (i have picked it and got burned so many times! lol)
Is uterus tender in dysmenorrhea?

 

[1badvette]

It could be infection , Endometriosis etc.. But regardless , you need to make sure she's not pregnant so you could pick the right Antibiotics or decide if you wanna start her on an OCP .

Yes in secondary Dysmenorrhea the Pelvic exam is ABNORMAL, which can include tenderness , Mass, Cervical motion tenderness , discharge etc...

Primary Dysmenorrhea will have a NORMAL pelvic exam .. and it's usually due to vasoconstriction by prostaglandin , hence why the NSAIDS work best to control pain

 

[Red Husky]

So in this case with the tenderness do you go for US or a try of NSAIDs.

Pregnancy test is not the answer. Believe me I picked it 🙁

 

[1badvette]

So NSAIDs would be my other choice, this will take cafe of the cyclic pain which is most likely due to endometriosis .The 7 day since LMP is probably why it's wrong even though it's still done in real practice .

 

[Red Husky]

makes sense! thnx

 

[Red Husky]

a