In article <[log in to unmask]>, Howard
Simpson <[log in to unmask]> writes
>Scenario:
>
>12 year old girl with worsening abdominal pain for 7 days. Presents to A&E with
>severe abdominal pain, mainly in the RIF which had got significantly worse in
>the previous few hours. Off food; no bowel or urinary symptoms. History of well-
>controlled asthma only. Irregular periods (every 2-4 weeks) since menarche 8
>months ago. Mother is present.
>
>Clinical examination:
>
>White female, 75Kg, 5' 6" tall, tearful. Temperature 38.4, P 120, BP110/75, resp
>rate 25, sats 99% on air. Flushed cheeks, no lymphadenopathy. Abdomen tender,
>maximally in RIF. Some guarding, definite rebound, Rovsig sign positive. Bowel
>sounds present occasionally. No masses or organomegally palpable. PR/PV not
>done.
>
>Investigations:
>
>Full blood count, urea & electrolytes, liver enzymes, group & save are sent.
>Urine dipstick shows ketones 3+
ketonuria.. abdo pain .... a U&E's was sent ... was a glucose???
>, protein 1+, no red cells or white cells. Sample
>sent for microscopy & culture.
>
>The Questions:
>
>1: Would you perform a urine pregnancy test?
Yes... its a relevant investigation.
>2: Would you ask permission first?
No.... incidentally, would you ask permission to perform the urine
dipstick? or the bloods which were a more invasive test?
(bloods often rely on implied consent "I need to take some blood tests,"
and patient offers arm.......) .
In which case one might perform a beta-hcg on blood and claim consent
was implied! ... excepting the cost implications.
I would however tell mother and child that I'd perform the pregnancy
test as a matter of routine .. stressing the routine nature and that I
wasn't casting aspersions... just that it was routine, as was screening
for UTI.
>3: What would you do if the result is positive?
do what all good juniors do when an issue gets political... involve a
senior.....
Is the child Gillick competent.. if so then the issue should be
discussed with the child, (get the nurses to get mum out.. to get a cup
of tea or phone relatives or whatever), telling the child that test
suggest she is pregnant, advising her the truth is likely to come out..
and it would be better to involve her mother.. but that its her
decision. As Mum isn't present ... have an experienced A&E nurse with
you.. always a good move when things are going to get emotional.
If the child isn't Gillick competent... tell the mother and child
together.
Refer to paeds, informing gynae in case its an ectopic.. one can't rely
on dates alone.
Also inform child protection team (when I did paeds the child prot team
used to screen the cas cards) {A&E cards doesn't sound the same,
somehow!}, urgently if attempts to remove the child are made.
>
>
>(Rest of scenario to unfold later)
as for what I'd do different in an 18 year old....
I'd do the same clinical management.. but the issues regarding informing
mother don't apply..... if the 18 year old isn't mentally incompetent.
--
Barry Salkin (locum SHO Anaesthetics)
To reply to a news-post, delete the x from medxleg - its an antispam measure.
Private e-mail shouldn't have the x present, unless I'm replying to a news-post
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