Hot Seat #197: 13-year-old with knee pain
Posted on: October 13, 2022, by : Harrison Hayward
13-year-old female initially presented with right knee pain 2 weeks ago and had an X-ray that showed a distal femoral epiphyseal lesion.
She then had an outpatient interventional radiology-guided biopsy of it 6 days prior to today. The patient reports her pain was controlled well initially. However, over the last 24 hours, she has had increased pain of the right knee and difficulty with knee extension. She has been using alternating ibuprofen and acetaminophen with some improvement. Can bear weight with crutches. No fevers. Incision sites on right knee does not appear erythematous. Denies recent increase in swelling. Pain was 6/10 at home but now is 2/10.
Mother states she was told the lesion was likely a benign chondroblastoma and they have an orthopedics appointment scheduled in two days to review biopsy results.
PMHx: None related to current complaint
Meds: ibuprofen prn, acetaminophen prn
All: None
FH: None related to current complaint
SH: Accompanied by mom.
Imm: UTD
Exam:
VS: Temp 37.2 HR 76 RR 20 BP 106/78, SpO2 99% on RA
General: Alert, sitting in chair in sub-waiting. No acute distress
Skin: No rash, warm.
Head: Atraumatic, normocephalic.
Neck: Supple, no significant lymphadenopathy
Eyes: PERRL, EOMI, normal conjunctiva
ENMT: oral mucosa moist, no pharyngeal erythema
CV: RRR, cap refill <2s in distal extremities
Resp: CTAB, non-labored
GI: Soft, non-tender, non-distended.
MSK: Slight swelling of right knee compared to left. Knee is warm however no overlying skin changes. Tender to palpation over R anterior distal femur. Needle biopsy site without surrounding erythema, no purulence, or fluctuance. R knee held in flexion, reports pain with knee extension.
Neuro: No focal neurologic deficits
After the exam, patient states her pain has improved since waiting in the ED and they want to be discharged home. However, on chart review after examining the patient you see that the biopsy pathology results are consistent with aggressive diffuse Large B-cell Lymphoma.
You decide to consult the orthopedics resident who agrees that the patient’s exam is reassuring. They recommend not disclosing results and discharging the patient home if pain is improved. The resident states that the patient can be direct admitted from clinic if needed.
Given the known long wait times for inpatient you decide to consult the oncology resident regarding the need for admission and further work-up. The oncology resident discusses with their attending who agree that there is not an immediate need for admission if the patient is well appearing. They recommend that results should not be disclosed in the emergency department at this time, and that the patient’s appointment in two days in the orthopedics clinic is a more appropriate setting.
I find this to be ethically challenging. On the one hand, I think it is best to have the disclosure of a serious diagnosis like this come from experts (orthopedics or oncology) who will be able to provide details on next steps, prognosis, etc. On the other hand, I find it difficult to keep this important information from the family. It sounds like this mother wasn’t very anxious (“was told it was a benign chondroblastoma”) and I wonder if that would factor into my decision-making. In other words, if the family was extremely worried about the results and wanted to know, I may be more inclined to disclose, versus if they seem calm and unworried. I don’t actually know if this is an appropriate approach, however, since this is me subjectively assessing their “level of worry” which may appear different for each person. Tricky, tricky, Dr. Hayward…
I feel strongly that results should bever be withheld from families in order for the setting be “better.” While situations in the emergency department may not be ideal, so many patients can be lost to follow up that I struggle ethically with withholding information. What if the patient’s pain improves and they do not show up to the orthopedic appointment in two day?