This week's topic is Sexuality and STDs in the ED. There is no way that we will be able to cover all of the potential topics in our first hour's case and discussion. This is a topic that should not be new; I suspect that everyone in the class has either witnessed or discussed dilemmas related to gender, sexual health, terminations of pregnancy or harassment. This week's challenge is for you to practice setting up a dilemma.
In about 100 words, write a case related to STDs or sexuality. Be sure that all personal identifications are obscured, and give us a title that identifies your case.
Don't analyze the case for us, but when you write a case, it's important to be aware of which principles, rules or laws are central to its analysis. The case need not be set in the ER, nor need it be based on a personal story. It could even be a few sentences. Consider writing about something you have experienced OR something inspired by any of the readings.
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A 32 year old, married woman, approached her family doctor with complaints of vaginal discharge and itchiness. After several exams, the doctor gives her a second appointment and asks her to come with her husband. He advises them that she has an STD and that they should abstain from further sexual interaction. He asks the husband to submit to lab testing given the legal reporting requirement to the public health authorities. The information caused a major marital rift and the couple divorced. Turns out, the husband was free of infection. The doctor later apologized to the wife after he discovered that she only had a treatable vaginal yeast infection, but the laboratory had submitted to him information belonging to another patient.
ReplyDeleteA few months ago I saw a 30ish year old guy who came in for evaluation of dysuria. I asked him about recent sexual partners and he said that he had been steady with one girl for the past two months, but had no other partners and said that as far as he knew she was symptom free. He later admitted to this woman being married to another man. Urethral swabs came back positive for chlamydia and gonorrhea.
ReplyDeleteWow carlos…..what a story. The case I have was told to me by a friend who encountered this patient in clinic this summer. A woman who had come in std screening requesting that she be informed of the results by email. She hadn't heard back for a few weeks so she stopped by the clinic and was told that her screening tests were negative. She proceeded to have unprotected sex with her partner - with whom she had been abstinent until the results. Some time later, she got a letter in the mail stating that her pap smear had come back with a high degree of dysplasia and HPV positive. She was incredibly upset about this. Her boyfriend later came in with rapid growing genital warts. The clinic said that they had a policy of not informing people over the phone or via email of positive results. But they told her that her chlamydia, herpes, gonococcal, and HIV tests were all negative.
ReplyDeleteSo I will apologize for this one, it was one of my first patient experiences in the ED - one I don't think I will ever forget.
ReplyDelete37 year old male presents to ED with severe anal bleeding. He was infected with genital warts and attempted to cut them off with scissors. Upon exam his sphincter, rectum, and sigmoid colon were in need of emergent repair. His hematocrit was dropping and upon signing surgery consent forms the patient says he wants his wife called but does not want her to know why he is having surgery. He explained he contacted the STD through an same sex affair.
We contacted the wife and told her that he was going to have surgery, but she was unable to get there prior to him leaving for the OR. I am not sure what happen once the patient left the ED...
This is a case that has been brought up in one of our 1st year classes... You are a med student doing a rotation in an HIV clinic. You see the partner of one of your closest friends in to see the doctor. As a student, you are not directly involved with the patient's care but the partner is obviously there to be tested for HIV. In class, we then talked about what you as the student would do with this information, if you approach the partner, your friend, etc.
ReplyDeleteI took care of a 19 year old woman who developed severe ARDS due to PCP pneumonia. She was found to be HIV positive early in her hospital stay. At that time she declined to allow us to discuss this with anyone (other than her boyfriend who had to be notified by law). She got progressively sicker, ended up in shock with multiple chest tubes and with multi-system organ failure. We had several family meetings to discuss end-of-life care, but felt we could not discuss her HIV positive status (which is what made her care futile) with her family as she had specifically refused to allow us to discuss with her family (even saying so just before she was intubated).
ReplyDeleteA woman and her husband have been trying to get pregnant for a couple of years with no success. The woman finally conceives, but then decides she isn't ready to be a mother so she comes to you for an abortion. She has not consulted with her husband and admits to planning on tell him she miscarried their child if asked.
ReplyDeleteA 28 year old man is admitted to the ER for massive chest injuries from a car accident. He dies. His wife requests that his sperm be harvested before it dies.
ReplyDeleteThese are great. I look forward to class tonight.
ReplyDeleteWhen doing a routine intake exam for a new patient (maybe more in the primary care setting), you ask about sexual history. You discover your patient has multiple risk factors (numerous partners, unprotected sex, IVDU, whatever). What can / should you do for this patient?
ReplyDeleteWhen working in a primary care clinic a routine tests was to test for herpes 2. Numerous times the test would come back positive without the women knowing that she was positive. The issue was trying to explain to her how she got it, future treatment and the effects on her future baby. Telling partners is difficult, it is also difficult to break difficult news to expectant mothers even more when it can affect her child.
ReplyDeleteGreat comments, everyone!
ReplyDeleteAnother twist on sexuality in the ED: A queer woman comes in with abdominal pain, her female partner at the bedside. The urine is negative for infection but positive for pregnancy. You have the female partner step outside as you explain the results to the patient.