Hot Seat #150: Denouement

Posted on: April 23, 2020, by :

The case: a 13 yr old girl with a vulvar abscess requiring surgical I&D, found to be trichomonas positive.

Here’s how you answered the questions:

Discussion:

This case raises both ethical and medical dilemmas. From an ethical stand point, we have a young post-pubertal girl presenting with a sexually transmitted infection. While concerning, most would only discuss with the patient and would encourage her to disclose her sexual activity with her parents. Having social work speak with the patient is also a reasonable option, particularly to ensure that the sexual activity was consensual. Dr. Sigman  reinforced that this is the appropriate response as in DC, individuals younger than 18 can manage their own healthcare decisions related to sexual health, mental health, and pregnancy. Thus, this patient has the right to privacy (assuming no signs of abuse).  More information on HIPAA and adolescents can be found here and here.

The medical dilemma comes in the treatment of this patient, as she requires both I&D and antibiotics for Trichomas. The abscess require definitive source control with an I&D and her infection requires PO antibiotics that often cause nausea +/- vomiting. Most respondents felt that prioritizing transfer to the OR rather than giving antibiotics (and potentially delaying surgery/anesthesia due to emesis) was the best course of action. As Dr. Tashiro (Surgery) noted, it is a short procedure and the patient can be given the antibiotics following. From an anesthesia perspective, administering PO medication is not a contraindication to anesthesia and done frequently in the pre-operative setting.

Regardless of the social and medical dilemmas in this case, everyone agreed that a discussion with the PMD and close PMD was imperative, as well as calling the family to ensure that she received appropriate antibiotic treatment. 

Denouement:

This patient had later agreed to have ER MD discuss STI results with her mother and disclose that she was sexually active. She was not given metronidazole 2g PO in the ER per the case, and only received IV metronidazole 500 mg in the OR. Same day efforts to contact the family was unsuccessful, but voicemail was left for them to follow up with PMD for test of cure.

Contact with PMD was unsuccessful as this case presented over the weekend. However, upon outpatient chart review, the patient had followed up with PMD for test of cure and post-op abscess drainage follow up.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Mary Beth Howard

Pediatric Emergency Medicine Fellow at Children's National Health System
Mary Beth Howard

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