Family physician commentary
Although this case is unusual, several key points are worth noting.
- The family physician as case coordinator allows patients access to specialized medical care, particularly if problems are potentially difficult medically or socially. In this instance, multispecialty care with family physician support is what enabled the final diagnosis.
- The question remains: Why is a premenarchal female affected by pilonidal disease? The most reasonable explanation is that the patient began to experience other changes associated with puberty including secondary hair growth. The “nests of hair” in the deep intergluteal regions may also have been stimulated, leading to the inflammation, necrosis, and infection demonstrated by the pathology and culture findings.
- Fortunately, in follow up, the patient has done well and has continued to be followed by the family practitioner, who provided ongoing care and interpretation for this family.
Discussing sexual abuse. The approach to discussing possible sexual abuse is a difficult one. Many physicians do not feel comfortable dealing with such a sensitive situation. The physician cannot take away his or her human side when presented with this kind of situation. The key is clear, unbiased communication with both the parent and the child.
The child can initially be interviewed with the parent present. Then the child should be interviewed alone in a nonthreatening environment. When the family physician takes the time to sit and talk with the child, the child may reveal things otherwise not discussed. Any questions must be age-appropriate and openended, being careful not to lead the child. The parent should also be interviewed alone in a nonconfrontational manner, stating what is known at the present and what is the plan, including further evaluation and reports to appropriate agencies. Again, a calm demeanor is important. In all of these interviews, clear documentation is paramount.
Referral to child advocacy centers as this patient experienced can also be appropriate. Referral may allow the physician to serve as the case coordinator as done in this instance. The physician can also remain neutral, giving a unique perspective of the family as the situation is investigated.
Acknowledgements
The author would like to thank Jessie Junker, MD, Albert Meyer, MD, and Barbara Walker, DO, at New Hanover Regional Medical Center, Residency in Family Medicine, Wilmington, NC; and Beth Deaton, FNP, at Wilmington Health Access for Teens, Wilmington, NC.
Conflict Of Interest
The author has no conflicts of interest to declare.