Her* CC (chief complaint) was “nausea.” Although I hate to sound like the proverbial adolescent doctor, my first thought was “pregnancy test.” The nurse was way ahead of me, and had already done it. “Negative,” she whispered to me, before I entered the room.
I rattled through the long list of possibilities in my mind. Gastrointestinal infection? Side effect of medications? Abuse? I took a history and performed my physical exam, and exited the room still feeling confused. I presented the patient to my attending physician.
“A 15 year-old female otherwise healthy, chief complaint of nausea, who reports acutely feeling nauseous while eating dinner last night. The nausea self-resolved, then she awoke this morning with one episode of about 100ml yellow, watery emesis (=she threw-up a little). Then felt hungry and ate normally. No fever/ chills, no abdominal pain, no diarrhea, no light-headedness, no head-aches, no unusual foods. Her last episode of emesis was ‘stomach flu’ a few years ago and ‘this does not feel the same.’”
“No medications or allergies, no past medical or surgical history. She lives with mom and dad, has “good” peer relationships- non-smoker, no alcohol, no illicit drugs, she is sexually active with one male partner, denies violence or abuse. Physical exam unremarkable. Beta HCG (pregnancy test) negative.”
Then, I eloquently explained that I wasn’t sure what was going on. Maybe an early gastrointestinal infection? But it didn’t really fit. Puzzling!
“When was her last LMP?” my preceptor asked. I admitted that hadn’t taken a detailed menstrual history because pregnancy had been ruled out. “Well, let’s find out.” We went back in the room together, and he asked her directly.
“Oh, I just got my period today actually,” she replied.
AHA! A light bulb went off for us. “Wow,” I thought, “my preceptor is brilliant.” Obviously he has been working with adolescents for many years. He knew not to expect adolescents to volunteer all the relevant information. His expression didn’t change, and he calmly began explaining how prostaglandin release during ovulatory cycles can cause a variety of symptoms, including nausea and vomiting, and how to block the prostaglandin release with ibuprofen or naproxen.
This illustrates why I love working with adolescents. They are straight-forward, but do not make health correlations on their own. This leaves more detective work for health professionals, and requires stronger history-taking skills and critical thinking. They have made the “Sherlock Holmes” aspects of my job much more interesting this month.
*Please note all patient identifying information has been intentionally changed or omitted. While the details are modified, my overall experience remains true.
