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-=-=-=-=-=> DOMESTIC VIOLENCE Doorway information about patient The patient is a 45-year-old woman who comes to the clinic due to bruises on her arms and face after fall Vital signs . Temperature : 36.7’C . Blood pressure : 122/80 mmHg . Heart rate : 90 / min . Respirations : 14 / min Approach to the patient Assessment of intimate partner violence Concerning signs . location of injuries (genital , breasts , abdomen , head , neck , teeth) . Inconsistent explanation of injuries. . Sexually transmitted disease , chronic pelvic pain. . Non adherence to visit & treatment / frequent emergency department visits . Overly attentive / intrusive partner who resists allowing patient to be seen alone . Discomfort / refusal to undress or consent to genital . rectal examination . Distress affect : Fearful , tearful , evasive Interview strategies . Ensure privacy(ask others to leave for interview) . Nonjudgemental , empathic , open-ended questioning . No pressure to discclose , report , press changes , or leave partner. . Ask if patient feels safe . Determine if patient has an emergency safety plan , provide referrals for shelters , domestic violence agency , mental health assistance as needed Recognition of intimate partner violence is commonly addressed in the USMLE Step 2 CS exam. The simulated patient may come ostensibly for evaluation of some other problem with the violent behavior apparent only after extensive discussion . For this reason , you should be alert for signs of domestic violence in the simulated patients you see thought the test day. Different diagnosis Intimate partner violence should be considered in the differential diagnosis of acute chronic trauma., It should also be considered in case in which the cause of symptoms in uncertain , or if the patient’s symptoms and examination findings are not consistent with the reported mechanism off injury. In addition to the primary injury , the physical should be aware of any comorbid conditions , disabilities , and substance abuse issue (in the patient or partake ) that should affect the ability of he patient to respond to the abuser . In particular , individuals with intellectual disabilities are more likely be be victims of violence and may be less able to escape or report their injuries. HISTORY AND PHYSICAL EXAMINATION The medical history should be open and direct , but empathetic and nonjudgmental . Do not pressure the patient to disclose details of abuse . Extra times should be allowed to explore psychiatric and social history , and patients should be queried for suicidality and risk for self-harm. History History of present illness . I noticed that you have a number of bruises . ow did these occur? . Are you currently in a relationship where you are physically hurt , threatened , or feel afraid? . Have you ever been attacked with weapon? . How long have you been in this relationship? . Has this happened before? . Are you afraid it will happen again? . Has anyone ever made you had sea when you didn’t want to? . How are things between your partner and your children? . Dose the person you live with use alcohol or drugs? . Have you ever left home ? If nit , have you ever wished you could leave ? What prevented it? . Are you planning to leave/divorce your partner? . Has your partner ever threatened or tried to commit suicide ? . Do you think of suicide as a way out off the relationship ? Do you have a plan that involves killing yourself or your partner? . Are your friends or family aware of your situation? Social history . Who loves at home with you now? . Where do you go when you are not at home? . Do you smoke ? At what age did you start and how much do you smoke? . Do you drink alcohol? How much and how often? . Have you used recreational drugs? The physical examination of a patient with intimate partner violence is not significantly different from a patient with similar injuries but without a history of violence . However , unusual wounds , wounds in unusual locations ,and wounds in multiple -stages of healing- should be noted and suggest possible abuse. Patient who are victims amy refuse to disrobe or allow examination of certain body parts . If the patient refuses examination , explain the reason you need to do the examination . If the patient is still resistant , abide by these wishes move on . Remember also that you are -not permitted- to perform genitourinary , rectal , pelvic , inguinal hernia, or female breast examinations in the USMLE Step 2 CS exam (if examination is necessary you may indicated this in the diagnostic workup section of the documentation). Closing the encounter Individuals in abusive relationships may minis or deny abuse due to shame , fear or partner retaliation , believing that there is no alternative , or feeling that the abuse is deserved. the physician should affirm that nay abuse is wrong but avoid counseling the patient in a directive way. Confrontation of denial , pressuring the patient to report the abuse , or urging the patient to l;eave the partner is inappropriate . Physicians also should confront of discuss suspected abuse with the partner as this can endanger the patient. physicians should assess the immediate and future safety of patients with intimate partner violence . the most important initial intervention is identification of an -emergency safety plan- (eg, “Where is a safe place that you can go when you are afraid?”) . In addition , discuss community resources , including domestic violence shelters and counseling services. Diagnostic studies Diagnostic studies are primarily used to guide patient management but may also occasionally be used in the course of subsequent legal proceedings. You should bot order tests that are not otherwise medically indicated “ just in case “(eg, x-ray of asymptotic body parts). However , it is appropriate to have lower threshold for ordering tests that can provide contemporaneous evidence of any injuries you do note . In most cases , plain film radiographs are adequate m although CT scan should be considered for craniofacial injuries. Incase of -sexual assault- , additional studies may include: . Nucleic acid amplification testing for chlamydia and gonorrhea (swab site of exposure) . HIV screen . Hepatitis B screen . VDRL or rapid reagin screen for syphilis . Pregnancy test -=-=-=-=-=>
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