CASE STUDY: OB/GYN - UTI & Domestic Violence

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A case study of a woman in a hispanic community who sought healthcare for a Urinary Tract Infection, but it was discovered that she was being seriously sexually abused. How it was handled and difficulties encountered.

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CASE STUDY: OB/GYN - UTI & Domestic Violence

  1. 1. A case study by Ann Sparks, RN, BSN ILLINOIS STATE UNIVERSITY
  2. 2. CC:Here for “possible UTI” on 6/20/11  Client is a 44 year-old, female, Hispanic, Spanish-only speaking patient  Her 22 y/o daughter who speaks English accompanies her HPI: Bilateral groin pain X 7 days but became worse in midline pelvic region. Currently pain is 4/10 severity  Burning on urination  (+) frequency  (+) hesitancy  (+) urgency  Nothing seems to make the pain better or worse  Has not tried any treatment Elvira, office assistant, was present for translation
  3. 3.  General: No weight loss, (+) chills, (+) night sweats  Head: No trauma, no headache or visual changes  Ears: No hearing loss or tinnitus  CV: No chest pain. (+) DOE since birth of second child 20 years ago  Resp: No cough, SOB at rest, no sputum production. Denies chronic lung disease  GI: (-) N/V or indigestion; (+) constipation X 1 month  GU: (+) Burning on urination, (+) frequency, (+) hesitancy, (+) urgency. Pain in the bilateral groin and suprapubic area for one week is 4/10 SEVERITY  Genital:  STD hx& treatment: none  sexual interest: heterosexual function/problems: does not want to have sexual relations with husband (separated X 4 months), marital problems
  4. 4.  FEMALE: Mild-moderate dysmenorrhea with cramping, and “normal cycle” with menstruation; LMP 6/10/11, No itching, but states she feels blisters inside of her vagina. She states discharge has increased and is clear-yellow and odorless  MSK: Denies weakness  Neuro: Denies dizziness, tremors or blackouts  Hematologic: No abnormal bleeding or bruising  Endocrine: No diabetes or thyroid problems  Psych/sleep: Reports, “Lots of stress,” and sleep is without difficulty
  5. 5.  The patient became extremely tearful  Even though she and her husband were separated 4 months, he keeps coming to her residence and forcing her to have sex  The daughter added that he is stalking the patient and threatening other relationships
  6. 6.  Gravida: 4, Para: 4, AB: 0  Last PAP, 4 years ago  Last mammogram, none  History of HTN – not currently on medication  1st visit - March 31, 2011:  Somatic neck muscle pain / Cervicalgia –  Flexoril 5mg PRN  Ibuprofen 800mg TID  Depression with first recorded incidence on 3/31/11  Recommended by PCP to attend counseling for depression  She attended counseling 4/5/11 and Citalopram 20mg was ordered  i PO daily #30  -0- refill
  7. 7.  Patient was a no call, no show for a F. U. appointment with the Nurse Practitioner on 4/29/11  Had only come for first office visit and one session of counseling. Not seen since 4/5/11
  8. 8. FAMILY HISTORY  Mother is living  HTN  Father is living  Diabetes  Four living children – no significant illness  22 y/o F – lives next door  19 y/o M – lives with pt  18 y/o M – lives with pt  11 y/o F – lives with pt SOCIAL/ENVIRONMENTAL HISTORY  Employment: Factory worker w/ annual income: ~ $20,000  Highest grade completed: 8th grade  Religion: Catholic  Denies drug/alcohol/tobacco use  No exercise program
  9. 9. CULTURAL  Pt is of Hispanic descent – Native of Mexico  Spanish-speaking only  Living in Chicago area  PAST SURGICAL HISTORY: None  MEDICATION PROFILE:  Pt reports she is not currently taking medication  NKDA SCREENING TESTS: Per LCSW 4/5/11, patient is sad most days, lack of interest in pleasurable activities, Hypersomnia/insomnia, anxiety and difficulty controlling worry  Axis I Major Depressive Disorder  Axis II 0  Axis III 0  Axis IV Financial, Matrimonial  GAF 60 (Global Assessment of Functioning) 60 = Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers).
  10. 10.  There is a lot of data missing  More detailed family history would be helpful – Mental illness? Dysfunctional family of origin?  What is her relationship like with her adult sons who live with her?  Possibly volatile with the “machisimo” cultural beliefs of the Hispanic population  Catholic faith can be paternalistic and/or shaming in nature  These are the types of things that would come out in counseling
  11. 11.  With depression, IPV, financial restraints and language/cultural barriers, likely the only reason this patient sought assistance this day was for acute pain of the UTI  Patient needs to learn to be empowered  Only SHE can choose to make changes in her life  Only SHE can choose support systems to help her  Will she return for follow-up?
  12. 12.  On original intake, pt denied Domestic Violence  She states, “He doesn’t hit me,” and, “He yells at me a lot.”  Pt needs definition of domestic violence  During ROS, pt denied sleep problems  Visit to LCSW on 4/5 showed hypersomnia/insomnia as a symptom –  pt needs definition of normal sleep patterns
  13. 13.  looks or acts in ways that are frightening  tries to control what the other person does, who the other person sees or talks to, or where the other person goes or tries to stop the other person from seeing friends or family members  tries to take the other person’s $$$  makes the other person ask for money or refuses to give the other person money that is supposed to be shared  makes all of the decisions  threatens to take away or hurt the children  prevents the other person from working or attending school  acts like the abuse is no big deal, denies doing it, or blames something or someone else, even the person being abused  destroys the other person’s property or threatens to kill pets  intimidates the other person with guns, knives or other weapons  Shoves, slaps, chokes or hits the other person  forces the other person to try and drop charges  threatens to commit suicide  threatens to kill the other person ________________________________ If you answered ‘yes’ to even one of these questions, you may be in an abusive relationship. For support and more information call the National Domestic Violence Hotline at 1-800-799-SAFE (7233) or at TTY 1-800-787-3224.
  14. 14.  GENERAL: Well- developed, well-nourished; tearful intermittently. Pt is well-groomed, but appears tired with otherwise flat affect  VS: Stable  T - 98.6 F  P - 80  R - 20  BP- 124/88  Hgt (inches) 60.5  Wgt (pounds) 169# --> 0.8# loss: Change  BMI 33 – No Change  SKIN: Intact, W/D, without ecchymosis or scars  Head: NC/AT  HEART: Regular rate and rhythm, normal S1, S2, no murmurs, rubs, gallops, or clicks  LUNGS: Chest symmetrical with resps; Clear to auscultation, bilaterally; no respiratory distress  ABDOMEN: Symmetrical. Slightly rounded, soft, non- tender. Some guarding noted. No dullness to percussion. (+) CVA tenderness
  15. 15.  GU:(+) guarding in groin/pelvic area. EGBUS WNL. Vaginal exam shows no lesions, tears, or unusual discharge. “Normal Female” genitalia  RECTAL: Sphincter tone intact with one hemorrhoid noted, non- thrombosed  MSK: Normal symmetric tone  NEUROLOGIC: Alert and appropriate. Normal strength and tone Pertinent Lab Values 6/20/11 Urinalysis shows: Leukocytes Moderate Nitrite (+) Urobili Normal Protein Negative PH 7.5 Blood Moderate Spec Grav 1.010 KetonesNeg BiliNeg Glucose Neg
  16. 16.  Looking back, the symptoms presented on March 31, 2011 (Somatic neck muscle pain / Cervicalgia) could have well been from an injury sustained during an episode of rape  Always beware of patients who simply don’t understand healthy lifestyles or “what IS healthy”  Be alert for symptoms of abuse even when not a word is said about it – missed appointments, multiple system involvement, flat affect and lack of eye contact can be symptoms of a much deeper problem
  17. 17.  (+) chills, (+) night sweats  (+) DOE since birth of second child 20 years ago  (+) constipation X 1 month  (+) Burning on urination, (+) frequency, (+) hesitancy, (+) urgency. Pain in the bilateral groin and suprapubic area for one week  WBC count WNL  (+) Mild-moderate dysmenorrhea with cramping, and “normal cycle” with menstruation; LMP 6/10/11, No itching  She feels blisters inside of her vagina, though Vag exam normal  Discharge has increased and is clear-yellow and odorless  “Lots of stress”  Sexual contact being forced on her by husband after separation
  18. 18.  UTI  IPV (Intimate Partner Violence)  STD risk  Depression  Constipation  Peri-menopause  UTIs, constipation and STDs are symptoms of Intimate Partner Violence (IPV) (Draucker, 2002)  Depression, shame, la nguage barriers, isolation, fina ncial dependence add to the symptoms and risks for IPV (Montalvo-Liendo, 2009)
  19. 19.  UTI – UA w/ leukocytes, nitrites and blood  IPV (Intimate Partner Violence)  Depression  STD risk  Peri- menopause  Constipation  Immediate goals:  address pain/infection  safety  Education and Trust- building essential element for her return for F.U.
  20. 20.  The cycle of IPV is  Abuse  Promises of change  Subsequent increasing abusive behavior  The most grim consequence of D.V. is death  Majority of women who are killed in the U.S. are killed by a current or former intimate partner (Draucker, 2002)
  21. 21.  Rape / sexual assault  Three in four women (76%) who reported they had been raped and/or physically assaulted since age 18 said that an intimate partner (current or former husband, cohabiting partner, or date) committed the assault. 
(U.S. Department of Justice, Prevalence, Incidence , and Consequences of Violence Against Women: Findings from the National Violence Against Women Survey, November 1998)  One in five (21%) women reported she had been raped or physically or sexually assaulted in her lifetime. 
(The Commonwealth Fund, Health Concerns Across a Woman’s Lifespan: 1998 Survey of Women’s Health, 1999)  Stalking  Annually in the United
  22. 22. Problem List:  UTI – lower and upper  IPV - rape  Constipation  HTN  Depression  Needs Annual female exam: CBE, Pap, pelvic *** Chronic stress decreases immunity Priorities of Care: 1. UTI  Bactrim DS 1 tab PO BID X 10 days #20 -0- Refill  Educate: Increase water consumption to 8-12 glasses daily 2. Family Disruption  Education/counseling on D.V.
  23. 23. FAMILY DISRUPTION – Cont’d  Previously, PCP ordered counseling Attended only one session  Started Citalopram 20mg daily on 4/5/11  No call, no show on 4/29/11. No follow-up since 4/5/11  Today presents with same complaints  Reinforced follow-up  Follow-up with counseling and health care will help her help herself
  24. 24. FAMILY DISRUPTION -- Cont’d  EDUCATED:  REINFORCED - Return for follow-up  Counseling  Medications  Other health needs of HTN, Depression, Annual Female exam  REINFORCED - That ACCESS to CARE is the name of the clinic  Don’t let inability to pay prevent getting the care needed  Even if paying $1.00, services are provided
  25. 25. FAMILY DISRUPTION – Cont’d  Plan now to see LCSW in A.M. for counseling. Pt voices understanding of counseling appt. at 1100 6/21/11 here at clinic  If stable, restart antidepressant  Pt encouraged to protect self  Instructed the patient that not setting and keeping firm limits on this man’s behavior is giving him permission to continue his inappropriate behaviors  Desires local PD involvement. Wishes granted and 9-1-1 called for domestic violence complaint  Pt counseled that police are there to help & protect her  Police at clinic 6/20/11, report unknown
  26. 26. FAMILY DISRUPTION -- Cont’d Labs ordered:  HIV  GC/CT  RPR  Herpes I & II  CBC  Labs resulted 6/23/11 F.U. CARE:  RTC:  6/21/11 to see Suzanne, LCSW  RTC:  In 2 weeks for STD results and UTI F.U.  RTC if symptoms worsen
  27. 27. PLAN FUTURE VISITS FOR:  If continued constipation problems  Resume Depression care and referrals for support group(s)  HTN evaluation  Needs Annual female exam: CBE, Pap, pelvic and mammogram
  28. 28.  CBC Result Normal Values  WBC 5.5 (4.5 - 11.0) TH/mm3  RBC 4.31 (4.0 - 5.2) mil/mm3  Hgb 12.9 (12.0 – 16.0) gm/dl  Hct 38.5 (36.0 – 46.0) %  MCV 89.2 (80 – 100) FL  MCH 30.0 (26.0 – 34.0) PG  MCHC 33.6 (31.0 – 37.0) %  RDW 14.7 *** (11.5 – 14.5) RDW UNI  Plt 292 (150 – 450) TH/mm3  MPV 8.8 (7.0 – 10.4) FL
  29. 29.  HIV 1 & 2 Non-reactive  RPR Non-reactive  Chlamydia, Ampl Negative  GC, Amplified Negative  Herpes I IGG > 5.00 – High ***  Herpes II IGG < 0.90 (Negative)
  30. 30.  This pt has poor coping skills and limited support systems  Multi-faceted problem needs a multidisciplinary approach (Youngkin, 2004) Resources patient needs:  Health services  Counseling  Support groups  Legal Help  Children’s Services  Financial Assistance  Safe House information
  31. 31.  She’s likely been in survival mode a long time  Much of what this patient needs is basic caring and teaching about her value as a human being  Define terms for her such as “abuse,” and “normal sleep” patterns  Give information on preventative care  Stress reduction  Support groups  Health maintenance exams and F. U.  The key is getting her plugged into resources  A list of resources available, in Spanish
  32. 32.  This clinic has bold posters on the wall of the bathroom  What to take with you when you leave a domestic violence situation  Resources for the abused in multiple languages
  33. 33.  The primary goal after the infection/pain and safety, is for the patient to return for care Clearly this patient has multiple needs yet to be addressed
  34. 34.  Pt did arrive to her scheduled counseling appointment on 6/21/11  She had been summoned for a restraining order (Order of Protection) to be at court 6/21/11, but she missed that court date (she didn’t realize she had to be present)  Likely <50% chance that this patient will follow- up for lab results or further routine care  Cultural values are to seek assistance for pain, but preventative care is not commonly sought  Follow-up appointment for week of 7/5/11 for STD results and UTI F. U.
  35. 35.  Appointment 7/5/11:
  36. 36. Center for Disease Control (CDC). Sexual Violence website. Retrieved June 30, 2011. http://www.cdc.gov/ViolencePrevention/sexualviolence/index.html Domestic Violence Awareness Project. Retrieved July 1, 2011http://dvam.vawnet.org/about/aboutdv.php Domestic Violence Resource Center (DVRC). Retrieved July 1, 2011. http://www.dvrc- or.org/domestic/violence/resources/C61/ Draucker, Claire Burke (January 31, 2002). "Domestic Violence: The Challenge For Nursing" Online Journal of Issues in Nursing. Vol. 7 No. 1, Manuscript 1. Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Tableof Contents/Volume72002/No1Jan2002/DomesticViolenceChallenge.aspx Montalvo-Liendo, N. (2009). Review paper: Cross-cultural factors in disclosure of intimate partner violence: an integrated review. Journal of Advanced Nursing. 65(1), 20–34 doi: 10.1111/j.1365- 2648.2008.04850.x World Health Organization (WHO). Sexual Violence website. Retrieved June 30, 2011. http://www.who.int/violence_injury_prevention/violence/global_campaign/en/chap6.pdf Youngkin, E. Q., & Davis, M. S. (2004). Woman’s Health: A primary care clinical guide. 3rd Edition. Pearson/Prentice Hall, Upper Saddle River, NJ.

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