A 32-year-old woman comes to the office due to lower back pain for the past week. She developed the pain after lifting some heavy furniture. She has no other symptoms. Physical examination shows mild paraspinal muscle tenderness. There is no radiation of pain with straight leg raise on either side, and no neurologic deficits are noted in the lower extremities. However, multiple bruises of various ages are noted on her abdomen, back, and chest. When the bruises are pointed out, the woman begins to cry. She is also quiet and avoids eye contact. Which of the following is the most appropriate initial response?

Question

A 32-year-old woman comes to the office due to lower back pain for the past week.  She developed the pain after lifting some heavy furniture.  She has no other symptoms.  Physical examination shows mild paraspinal muscle tenderness.  There is no radiation of pain with straight leg raise on either side, and no neurologic deficits are noted in the lower extremities.  However, multiple bruises of various ages are noted on her abdomen, back, and chest.  When the bruises are pointed out, the woman begins to cry.  She is also quiet and avoids eye contact.  Which of the following is the most appropriate initial response?

Quizplus · Accepted Answer

Physicians should be alert to clues suggesting physical abuse as patients may not always report such incidents spontaneously. Multiple bruises, recurrent fractures, or repeated visits to the physician for unexplained injuries are all signs of possible abuse. In cases of possible abuse, the physician must be able to conduct an effective patient interview to provide proper care, ensure patient safety, and fulfill legal reporting requirements. The initial statement in such cases should be made tactfully and take into account the patient's personality, emotional state, socioeconomic and cultural background, and the broader physician-patient relationship. Open-ended questions and general statements of observation usually provide the best introduction to such a discussion and allow patients to discuss the issues in their own words. Acknowledging the patient's feelings and/or encouraging further dialogue about the bruises would be good starting points. (Choice A) Patients who are victims of abuse may have significant associated emotional symptoms, whether as a result of the abuse itself, from pre-existing affective illness, or from concurrent illicit substance use. However, the physician should first gain an understanding of the abuse situation and then ensure immediate patient safety. Once immediate safety has been addressed, the physician and patient can discuss what steps may be taken to address concurrent affective symptoms. (Choice B) At some point in the conversation, the physician should discuss a safety plan with the patient. However, before making specific recommendations, it is necessary to understand the nature of the possible abuse and explore what options she may have already considered. (Choice C) Advising the patient to consider reporting the incident to the police may be appropriate in cases of suspected abuse, but this is not a good opening statement. The prospect of filing charges may frighten the patient into denying the abuse and discourage a more thorough discussion of the issue. (Choice E) Although the physician may suspect abuse, it is important not to make unfounded assumptions. The possibility of abuse should be explored in an open and caring conversation with the patient. Value judgments, if any, should originate from the patient rather than the physician. Educational objective: Patients who are victims of suspected physical abuse should be approached with empathic interviewing techniques. The physician should ask open-ended questions to allow patients to describe their situation on their own terms. The first priorities are to obtain an accurate and thorough understanding of the abuse and take any necessary action to ensure patient safety. Additional steps may then be needed to address concurrent emotional symptoms and satisfy legal reporting requirements. References: Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. preventive services task force recommendation statement. (http://www.ncbi.nlm.nih.gov/pubmed/23338828)

A 32-Year-Old Woman Comes to the Office Due to Lower