A 30-year-old woman with type I diabetes mellitus and familial hypercholesterolemia since age 13 is followed by a local practice. Her provider meets her at the emergency department of the local hospital to perform an examination after being notified that the patient was admitted for vaginal bleeding. When interviewed alone, the patient explains that she and her husband were engaging in "rough sex" and the lacerations were accidental. She says, "Sometimes my husband doesn't know his own strength and it can get a little out of control. I'm really fine and the pain is not too bad." The patient's husband and 2 children are also seen in the same practice. Vital signs are normal. Physical examination reveals bruising on the inner thighs and vaginal lacerations with active bright red bleeding. Hemoglobin is 12 g/dL. Blood glucose level is 78 mg/dL. Laceration repair is performed under anesthesia. The provider comes to see the patient following the procedure and informs her that it went well. He also explains that her diabetes mellitus places her at increased risk for poor wound healing. Which of the following is the most appropriate next statement by the provider?

Question

A 30-year-old woman with type I diabetes mellitus and familial hypercholesterolemia since age 13 is followed by a local practice.  Her provider meets her at the emergency department of the local hospital to perform an examination after being notified that the patient was admitted for vaginal bleeding.  When interviewed alone, the patient explains that she and her husband were engaging in "rough sex" and the lacerations were accidental.  She says, "Sometimes my husband doesn't know his own strength and it can get a little out of control.  I'm really fine and the pain is not too bad."  The patient's husband and 2 children are also seen in the same practice.  Vital signs are normal.  Physical examination reveals bruising on the inner thighs and vaginal lacerations with active bright red bleeding.  Hemoglobin is 12 g/dL.  Blood glucose level is 78 mg/dL.  Laceration repair is performed under anesthesia.  The provider comes to see the patient following the procedure and informs her that it went well.  He also explains that her diabetes mellitus places her at increased risk for poor wound healing.  Which of the following is the most appropriate next statement by the provider?

Quizplus · Accepted Answer

Explanation: Vaginal wounds (eg, lacerations, abrasions, hematomas) are often due to accidents or trauma and are rare with intercourse, except in cases of forced intercourse. The possibility of sexual abuse or assault must always be considered in any woman with vaginal wounds. When there is suspicion of abuse, providers have a responsibility to inquire about the issue, discuss it with the patient, and offer assistance. This patient has vaginal lacerations that she attributes to rough, consensual intercourse with her husband. Many women in abusive relationships do not seek assistance, deny abuse when asked, and cover up their injuries with excuses. Feelings of shame and humiliation, fears about partner retaliation, or beliefs that the abuse is deserved may contribute to reluctance to disclose. The provider in this case has a long-standing relationship with the patient and is the best person to initiate discussion of the issue. Empathic, nonjudgmental inquiry, conducted in private, has the best chance of facilitating a discussion. An open-ended inquiry about the patient's relationship with her husband would be the most appropriate next step. (Choice A) Although it is important to explain the medical risks of the sexual behavior, this statement assumes that the behavior is under the patient's control and could be interpreted as being critical of the patient. In cases of abuse, this may further discourage the patient from seeking assistance for fear of being judged. (Choice C) The first step is to assess the patient for intimate partner violence privately rather than in the presence of the partner - who may inhibit the patient from speaking freely or retaliate later, putting her safety at risk. (Choice D) The patient describes the sexual intercourse as consensual and claims the injuries are accidental. Although it is reasonable to have concerns that the patient is minimizing or concealing the abuse, confronting her denial at this time is unlikely to facilitate discussion. An empathic, open-ended approach is more productive. (Choice E) Encouraging the patient to pursue couples counseling or sex therapy does not address the more immediate concern of suspected abuse. Educational objective: Patients with inadequately explained traumatic injuries should be assessed for intimate partner violence. Initial inquiry should be open-ended and nonjudgmental. In cases of suspected abuse, providers should inquire if the patient feels safe in the relationship with the partner and provide support and counseling in a private, confidential setting. References: Primary care-based interventions for intimate partner violence: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/24439354) Domestic Violence and Abuse screening in emergency department: A rapid review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/28029719)

A 30-Year-Old Woman with Type I Diabetes Mellitus and Familial