A 16-year-old woman comes to the office due to malodorous vaginal discharge. The patient arrives with her mother, who stays in the examination room for the evaluation. The patient has had increased vaginal discharge for the past 2 days but no abnormal vaginal bleeding or abdominal or pelvic pain. She is sexually active with a new partner and uses a progestin-releasing subdermal implant for contraception. Her last menstrual period was 2 weeks ago. She has no chronic medical conditions and takes no medications. Vital signs are normal. The patient appears anxious. Abdominal examination shows no tenderness or palpable masses. When the pelvic examination is attempted, the patient says that she is "embarrassed and anxious" and refuses the examination. Which of the following is the most appropriate course of action?

Question

A 16-year-old woman comes to the office due to malodorous vaginal discharge.  The patient arrives with her mother, who stays in the examination room for the evaluation.  The patient has had increased vaginal discharge for the past 2 days but no abnormal vaginal bleeding or abdominal or pelvic pain.  She is sexually active with a new partner and uses a progestin-releasing subdermal implant for contraception.  Her last menstrual period was 2 weeks ago.  She has no chronic medical conditions and takes no medications.  Vital signs are normal.  The patient appears anxious.  Abdominal examination shows no tenderness or palpable masses.  When the pelvic examination is attempted, the patient says that she is "embarrassed and anxious" and refuses the examination.  Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

This young, sexually active patient has malodorous vaginal discharge concerning for a sexually transmitted infection (STI), such as Neisseria gonorrhoeae or Chlamydia trachomatis, which are prevalent in patients age ≤25. In most jurisdictions, minors (age <18) can provide their own consent for the evaluation and treatment of STIs and do not need parental consent (Choice E). Evaluation typically includes a pelvic examination and cervicovaginal sampling to identify the pathogen by nucleic acid amplification testing and wet mount microscopy. The pelvic examination often provokes anxiety, particularly in patients with limited (eg, adolescents) or prior poor experiences or a history of sexual assault. Patients with capacity (ie, ability to make informed medical decisions) and the right to consent, including this minor, have the right to refuse examination. When this happens, health care providers should seek a balance between providing appropriate medical care and respecting patient autonomy. For nonemergent conditions, alternative methods can be explored to reach the diagnosis by other means; in contrast, during life-threatening emergencies (eg, obstetric hemorrhage), providers should strongly recommend proceeding with the examination but still may not proceed without patient consent. This patient's condition is nonemergent because she has no signs of severe pelvic infection (eg, fever, abdominal pain) or medical instability (eg, hypotension). Therefore, the most appropriate course of action is to not perform the examination but ask the patient to perform self-collection (eg, first-catch urine sample, vaginal self-swab) for diagnosis and appropriate treatment. (Choices A and C) In patients who consent to pelvic examination, various techniques to decrease anxiety include warming the speculum, explaining the next step in advance, conversing with them, and distracting them with questions. Benzodiazepines are typically not indicated. (Choice B) During the medical visit, a minor may feel more comfortable without the presence of the parent. Therefore, asking the parent to leave the room is often recommended to obtain further history, particularly sensitive social and sexual history. However, this patient has refused examination, and proceeding with the examination without the mother present still does not respect consent. Educational objective: Patients with the right to consent can refuse portions of the medical evaluation (eg, pelvic examination). In nonemergent cases, alternative methods for achieving the diagnosis and providing appropriate treatment (eg, patient self-collection) are appropriate. __________ References: Informed consent in decision-making in pediatric practice. (http://www.ncbi.nlm.nih.gov/pubmed/27456514)

A 16-Year-Old Woman Comes to the Office Due to Malodorous