Clinical:Case Study: First Scare

Original materials created in January 2000 by Suzanne Eidson-Ton, M.D.

History

EC is an otherwise healthy 15 y/o girl who comes to your office one afternoon after school. She is not accompanied by an adult. EC complains of nausea and vague mid pelvic discomfort for a few days, worsening over the past day. When you attempt to obtain further history, including sexual and social histories, she becomes quiet, and gives vague answers. EC admits after several questions that she is extremely concerned about her mother discovering that she might be pregnant.

Discussion

The laws governing the confidentiality rights of minors, and their ability to consent, vary from state to state. Providers must be aware of the specific laws in their own state. This information can be obtained from your state medical board, facility social services, and from a variety of web sites.

In general, teenagers can be assured a limited form of confidentiality. Providers are most often mandated to report instances of child abuse or domestic violence, suicidality, or intent of the patient to harm another individual. Other topics are protected.

The rights of minors to consent to medical care and treatment, again, vary from state to state. In this specific situation there are some important considerations, and a generalization across the states may be made. Minors may consent to diagnosis and treatment of sexually transmitted infections (STI’s) and drug abuse without parental consent in all 50 states, and in most may consent to treatment of drug and alcohol problems.

Regardless of the specific laws in each state, it is recommended that providers be clear with their teenage patients about what kinds of information can and cannot be kept confidential, and what treatments can and cannot be consented to without parental involvement. An honest conversation with EC and other teen patients will reassure them that physicians respect them and their privacy, and makes them aware that certain circumstances mandate involvement of other adults in their care.

Further History

I reassured EC that I would not share our discussion with her parents or other adults her life unless someone was hurting her, or she intended to hurt herself or someone else. She seemed relieved, and told me her story. EC became sexually active with her 16 y/o boyfriend three weeks ago. He is her first and only partner, but she is unsure of how many partners he has had. They did not use any protection the first time they had intercourse, but have used male condoms the subsequent 3 times. Last intercourse was 1 week ago. She is happy with her boyfriend, and would like to continue having sex with him. She says that every episode has been consensual, and that she has not feltpressured or coerced. EC says her concern is that her usually regular period was due three days ago, and is very frightened that she may be pregnant.

She denies any abuse in this relationship, or in any other, at home or at school.

EC denies any medical or surgical history

Social History

EC lives with her brother, mother, and father. Neither of her parents smokes, and they drink occasionally. She denies cigarettes, alcohol, or street drugs, and says neither her friends nor her boyfriend use these. A/B student, involved in Track and Yearbook, and wants to be an architect.

ROS

No symptoms of depression, or suicidal ideation. Occasionally thinks about her weight, but has never restricted her diet. Shares meals with her family, eating a variety of foods.

Exam

WN/WD, unremarkable except for mild suprapubic tenderness. Normal breast and external genitalia, Tanner stage IV. This is EC’s first pelvic exam, so I asked a nurse to be present to provide reassurance. I explained every step before and during the exam, and went at EC’s pace, stopping when she asked me to. Speculum exam was normal, except for increased white discharge. Pap, cervical swab for gonorrhea and chlamydia, and wet mount were collected. Bimanual exam was normal except for the suprapubic tenderness.

Data

Wet mount positive for Whiff test on KOH preparation, pH=6.0, no hyphae present. Saline prep with 75% clue cells, no trichomonads or white blood cells. Urine yields a negative pregnancy test, and a dip shows moderate leukocytes and positive nitrites. Formal urinalysis and culture requested.

Impression

15y/o female patient, beginning heterosexual activity, consulting MD with concerns and questions, in need of both pregnancy and STI evaluation and prevention.

• New sexual activity
• Unprotected intercourse
• Pregnancy unlikely
• STI status unknown, pelvic
  inflammatory disease unlikely
• Urinary tract infection
• Bacterial vaginosis

Plan

I discussed my above findings and impression with EC, careful to be honest and sensitive to her emotional state. Based on her upbringing and experience, she may be getting to know her body and herself in new ways, and may have questions and new feelings.
I explained that she probably had a bladder infection, and bacterial vaginosis. While neither of these is sexually-transmitted, they are both sexually-associated infections, so I discussed hygiene and hydration, and prescribed appropriate antibiotics. She is at risk for STI’s, and should continue to use condoms (male or female). I offered her screening for other STI’s, which she accepted, so I ordered studies for HIV, syphilis, and hepatitis B and C.

EC was aware that condoms are useful protection vs. STI’s, but not as contraception. We discussed abstinence, and also had a lengthy discussion regarding birth control options. EC chose DepoProvera. I explained that although she is most likely not pregnant, I would like to confirm this with a blood test. She agreed, and I ordered a serum beta-HCG. I reinforced that in addition to DepoProvera, condoms are still necessary for every intercourse for STI protection

I told EC that I would call her in a few days to discuss her test results, and when her pregnancy test is negative, she could drop by for her first DepoProvera injection. I also recommended hepatitis B immunization if she is negative. I made a follow up appointment to further address her questions and concerns.

Throughout our visit, and especially in closing, I encouraged EC to be in charge of her choices. I discussed physical and emotional boundaries, and raised issues of identity and strong self. I also asked her to think about how her family and social environment affect her perceptions of herself, and her body, especially in light of her new choices. I invited her to raise any issues in our follow-up discussions, or in a phone call.

Finally, I praised EC for taking care of herself and making mature choices, and encouraged her to continue. I also encouraged her to discuss these issues with her mother or closest adult in her life, if and when she feels safe to do so.

Specific Reference

1. Kocurek, Kathryn. December 3, 1999. “Caring for Adolescent and Young Adult Women.” A discussion from Controversies in Women’s Health. Division of General Internal Medicine, Department of Medicine, University of California San Francisco School of Medicine. Cathedral Hill Hotel, San Francisco, CA
   

General Reference

Journal of Adolescent Health Adolescent Health. JAMWA, summer1999;54 (3)

For Your Patients

Our Bodies, Ourselves: For the New Century by The Boston Women’s Health Collective. Simon & Schuster, New York, NY: 1998