A 63-year-old woman comes to the office for her annual checkup. Her medical problems include intermittent insomnia and chronic headaches and stomach pains for several years. She reports no significant change in the frequency and intensity of her headaches or any change in bowel habits. The patient has a history of major depressive disorder treated with citalopram 20 mg. She reports that her mood is "okay" and her appetite is good. She does not use tobacco or alcohol but confides, "I'm worried about my husband because he has been under a lot of stress lately and his drinking is getting worse. We have been arguing and he promises that he will cut down his drinking, but it has been difficult."
Vital signs are within normal limits. Physical examination shows normal heart and lungs; a soft, nontender abdomen with normal bowel sounds; and some mild bruising on her arms that the patient says she sustained while moving heavy furniture. She is tearful when discussing her husband but denies depression or suicidal thoughts.
Which of the following is the most appropriate next step in management of this patient?

Question

A 63-year-old woman comes to the office for her annual checkup.  Her medical problems include intermittent insomnia and chronic headaches and stomach pains for several years.  She reports no significant change in the frequency and intensity of her headaches or any change in bowel habits.  The patient has a history of major depressive disorder treated with citalopram 20 mg.  She reports that her mood is "okay" and her appetite is good.  She does not use tobacco or alcohol but confides, "I'm worried about my husband because he has been under a lot of stress lately and his drinking is getting worse.  We have been arguing and he promises that he will cut down his drinking, but it has been difficult."
Vital signs are within normal limits.  Physical examination shows normal heart and lungs; a soft, nontender abdomen with normal bowel sounds; and some mild bruising on her arms that the patient says she sustained while moving heavy furniture.  She is tearful when discussing her husband but denies depression or suicidal thoughts.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_98c2_710d_853d_63a2b78a8a5d_MD0002_00 All patients should be screened routinely for intimate partner violence (IPV), and this patient's distressed affect, bruises on examination, and report of her husband's escalating alcohol use are especially concerning. The most appropriate next step is to screen this patient for IPV by asking if she is being hurt or feels threatened by her husband. Women in abusive relationships may have chronic somatic symptoms and conceal, minimize, or deny abuse due to shame, feeling that there is no alternative or believing that the abuse is deserved. In responding to a positive screen for IPV, physicians should validate that any abuse is wrong and undeserved, but should not pressure the patient to disclose, report the abuse or leave the partner. The physician should ask the patient if she feels safe and assist in developing an emergency safety plan in the event she decides to leave or needs to escape immediately. Information regarding available community resources, including domestic violence shelters and counseling services, should be provided. (Choices A and D) Although this patient may benefit from participating in an Alcoholics Anonymous family support group and/or couple's therapy, the priority is to ascertain whether she is being abused. (Choice B) Although assessing depressive symptoms in greater detail would be helpful, the first step is to screen for IPV, as the patient's safety may be threatened. (Choice C) The reasons individuals stay in difficult relationships are complex, and exploring this before determining if the patient's safety is at risk would be inappropriate. Educational objective: Patients should be routinely screened for intimate partner violence. The presence of chronic somatic symptoms and poorly explained injuries should raise particular concern. __________ References: A scoping review of intimate partner violence screening programs for health care professionals. (http://www.ncbi.nlm.nih.gov/pubmed/27977769) Screening for intimate partner violence. (http://www.ncbi.nlm.nih.gov/pubmed/26990666)

A 63-Year-Old Woman Comes to the Office for Her Annual