Pediatric emergency medicine trisk 1549 1549
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Additional emphasis should be placed on the abdominal examination—palpating
for a uterine fundus, suprapubic and/or lower quadrant tenderness. Particular
attention should be placed on pelvic examination, which consists of visualizing
the external genitalia, performing the bimanual examination, and using a
speculum to visualize the vaginal vault and cervix. Visualization of the external
genitalia allows the clinician to verify the origin of the bleeding, assign Tanner
pubertal staging, and assess for signs of virilization, trauma, or discharge. For
adolescents with more significant blood loss, anemia, or concerns for sexually
transmitted infection, the examination then includes a bimanual examination to
assess for the presence of a vaginal foreign body or mass and to determine
cervical motion, uterine, and/or adnexal tenderness. The speculum examination
may be reserved for girls who have significant, ongoing blood loss as this
procedure is perceived as relatively invasive by many teens. NAAT testing on
urine has become the standard thus collecting swabs is usually not necessary.
FIGURE 79.3 Diagnostic approach to abnormal uterine bleeding after menarche—nonpregnant
patients.
Universal pregnancy testing is recommended for all adolescent girls presenting
with abnormal bleeding. Often teens do not feel comfortable disclosing their
sexual history. Uterine bleeding in the pregnant patient is an obstetric emergency.
A complete blood count (CBC) with differential is also recommended for teens
presenting with heavy bleeding because estimates of blood loss based on pad or
