This study resource wasshared via CourseHero.comThis w

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shared via CourseHero.com
This week, complete the Aquifer case titled Family Medicine
20: 28-year-old female with abdominal pain.
· Discuss the questions that would be important to include when
interviewing a patient with this issue.
Abdomen pain can have a multitude of causes and can present
differently with every patient. Chest pain is always ruled out
first for abdomen pain is an atypical symptom of a Myocardial
infarction. Being this patient is under increased stress and has a
history of chest pain, panic attacks and ongoing pain. I would
like to address cardiac in my examination. This patient has been
without medical treatment for the last four years to which was
specialized care of an active pregnancy. She does not have a
primary provider thus her medical history is incomplete. I
would want to address her past history in detail prior to making
a diagnosis.
Some questions to ask would be:
When did the pain first start, when did you first notice
discomfort? What were you doing at the time you noticed the
pain?
Were you doing any activity prior that day?
Have you had any bleeding and was it spotting or large clots? If
bleeding what color is the blood, bright red, dark red?
How regular are your menstrual cycles? Tell me about your
pregnancy?

Did you breastfeed?
Do you have mood swings, depression, fatigue, irritability with
menstruation? At what age did you start menstruation?
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Have you ever had an abortion or miscarrage? When was your
last pelvic exam?
We know of the one four years ago have you seen any other
providers? What is your diet like, do you drink lots of fluids?
Do you use alcohol, smoke or use any drugs? Do you take any
medications?
Have you had any injuries? Have you had any surgeries
Have you ever thought of suicide or harming yourself? Have
you had intercourse recently?
Has intercourse been painful?
Have you felt this pain before or cramping before that
resembles this pain? Do you have any stabbing pain in your
lower back?
Have you used any medication today or yesterday?
Have you felt that you are coming down with a cold or flu? Do
you have burning when you urinate or itching?
Have you ever had a yeast infection before or a history of
UTI’s?
What are your bowel movements like any issues and have you
been constipated? Last time you had a bowel movement?

Have you ever been tested for STD’s? Have you ever had an
STD or been treated?
With previous or current sexual partners was intercourse
consensual? How often have you had unprotected intercourse?
Do you have any allergies?
Have you had immunizations, as a child, and current influenza,
pneumonia, or chickenpox?
After your pregnancy how long was it before your menstrual
cycle returned? What birth control medication were you on
previously?
Have you missed a menstrual cycle recently or any thoughts you
could be pregnant? Do you exercise on a regular basis and what
activities do you do?
Do you feel bloated or distended in your bowels frequently?
What is your family history in terms of medical diagnosis?
(Bickley, 2016.)
· Are there any diagnostic studies that should be ordered on this
patient? Why?
The case study was geared toward the patients possible trauma
and abuse from her husband. I would agree there is a large
concern there and possibility that she has endured trauma due to
the multiple bruising at different stages of healing. With a
diagnosis of trauma I would want to first do an abdomen and
pelvic ultrasound to ensure there is not ongoing trauma to
organs in this area. I would perform an examination to assess
for a positive psoas sign, this would rule out her appendix. Due
to changes in bowels an occult blood test would be helpful in
assessing blood in the stool thus signalling a gastric intestinal
bleed or ulcer. Lab testing such as a CBC and CMP would also

help to evaluate blood loss, kidney and liver function or
infection, (Fischbach, & Fischbach, 2017.) A pregnancy test
should also be performed due to unprotected intercourse and not
using birth control. She is concerned about pain that comes and
goes in different areas of the abdomen to which signals me to
think there is some other pathology occurring. As stated above I
would like to rule out cardiac involvement with a EKG or
ECHO,
cardiac enzymes, and if these showed any abnormalities I would
investigate further with a heart catheterization, (Fischbach, &
Fischbach, 2017.)
Differential Diagnosis include:
Pelvic inflammatory disease with ongoing untreated
trichomoniasis infection:
Patient stated she has had a trichomoniasis diagnosis prior, the
treatment was unclear due to what the patent can recall. The
current pelvic exam was positive for the organism, prior
abdominal pap smear that was not addressed. Patient has had
ongoing pain for the last month, changes to menstrual cycle,
painful intercourse, and cervical tenderness. The patient does
not have any urinary concerns, has not had vaginal discharge or
spotting, no redness or swelling was observed on genitalia,
patient denies burning or itching symptoms, (Graesslin, Verdon,
Raimond, Koskas, & Garbin, 2019.)
Community acquired SARS-COV-2:
I realize this is not the correct diagnosis for this patient due to
the case study was developed prior but in the current moment

she does have some of the symptoms such as the increase in
headaches, a fever with no origin, abdominal pain, (Sheposh,
2020.) She is a teacher and her son is in daycare, her husband is
out at the bars drinking so exposure is likely, and her son is
having similar symptoms. She has prior chest pain and hives.
This could be ruled out quickly with a test, she does not have
any SOB, chest congestion or cold like symptoms or sensory
changes, (Sheposh, 2020.)
Abdominal aortic aneurysm related to trauma:
The patient has inconsistent pain to which is stated to be in her
upper and lower abdomen and aggravated by things that cause
pressure or distention. She is under increased stress and I
would assume her blood pressure fluctuates throughout the day.
She has had chest pain prior. There was only bruising observed
in her abdomen and it was at different stages of healing which
indicates she has had ongoing repeated trauma in that area. She
stated that her husband is usually intoxicated and pushes her
thus internal injury from the force or if she were to have impact
with objects is suspect. Pain has recently increased in severity.
She is a former smoker. There was no pulsating mass observed
in the case study and the patient did not complain of back pain,
(Belloch García, 2018.)
My primary diagnosis is:
Ectopic pregnancy with additional complication of
trichomoniasis:
The patient stated she thought she may be pregnant, has not had
a menstrual cycle in last four weeks, has had nausea and

vomiting, a fever with unknown origin, has had unprotected sex,
and no contraception measures in place. Abdomen trauma
observed to which could be self inflicted or by her husband to
cause miscarrage. She was positive with trichomoniasis which
would add symptoms of painful intercorse and variations to the
abdomen pain. Patient does not have rectal pressure, dizziness
or bleeding, (Layden, & Madhra, 2020.)
This diagnosis would be confirmed by an ultrasound and a
pregnancy test. Labs to address anemia or infection w ould
include a CBC and CMP. Treatment for this diagnosis would
include removing the products of conception that can be
accomplished a couple of different ways depending on what the
patient prefers or risks involved. Methotrexate is a medication
which causes destruction of fast growing cells, cells of a
growing fetus would be targeted thus eliminating the ectopic
pregnancy, (Layden, & Madhra, 2020.) Surgical laparoscopic
procedure can also be performed to remove the ectopic tissue
from the fallopian tube and repair any
damage that may have occurred by the mass, (Layden, &
Madhra, 2020.) The patient should be restarted on birth control
measures to prevent future pregnancies due to her not wanting
to have any more children. She should also have a gynecologist
follow up to monitor any further concerns after the pregnancy is
terminated. The patient will also need treatment for the
trichomoniasis and a followup with a primary provider for
monitoring of the medication and retesting to ensure the
infection is resolved, (Workowski, & Bolan, 2015.) Follow up
testing for the husband and any of his sexual partners to stop
further spreading. This patient also is in need of resources and
counseling in regard to the abuse to which is speculated to be
occurring in her current relationship. This abuse could also be
occurring to the child which may need further evaluation but I
don't feel there is evidence at this point to make a call to
authorities regarding the concern.

References:
Belloch García, L. (2018). Abdominal aortic aneurysm.
Prevalence and associated risk factors in a population of
patients hospitalised in Internal Medicine. Revista Clínica
Española (English Edition), 218(9), 455–460. https://doi-
org.su.idm.oclc.org/10.1016/j.rceng.2018.04.005
Bickley, L. (2016). Bates' Guide to Physical Examination and
History Taking (12th Ed.).
Philadelphia, PA: Lippincott,William & Wilkins. ISBN:
9781469893419
Fischbach, F., Fischbach, M. (2017). Fischbach's A Manual of
Laboratory and Diagnostic Tests, (10th Ed.). Philadelphia, PA:
Lippincott,William & Wilkins. ISBN: 9781496380111
Graesslin, O., Verdon, R., Raimond, E., Koskas, M., & Garbin,
O. (2019). Management of tubo- ovarian abscesses and
complicated pelvic inflammatory disease: CNGOF and SPILF
Pelvic Inflammatory Diseases Guidelines. Gynecologie,
Obstetrique, Fertilite & Senologie, 47(5), 431–441. https://doi-
org.su.idm.oclc.org/10.1016/j.gofs.2019.03.011
Layden, E., & Madhra, M. (2020). Ectopic pregnancy.
Obstetrics, Gynaecology & Reproductive Medicine, 30(7), 205–
212. https://doi-org.su.idm.oclc.org/10.1016/j.ogrm.2020.03.011
Sheposh, R. (2020). Coronavirus 2019 (COVID-19): Overview.
Points of View: Coronavirus 2019 (COVID-19), 1.
Workowski, K., & Bolan, G. (2015). Sexually Transmitted
Diseases Treatment Guidelines, 2015.

MMWR Recommendations & Reports, 64(3), 1–134.
Reply
differently with every patient. I felt it was important not to just
look at the obvious symptoms and ensure there were not other
underlying complications. Chest pain is always ruled out first,
for abdomen pain is an atypical symptom of a Myocardial
like to address cardiac in my examination. This patient has been
without medical treatment for the last four years to which was
specialized care of an active pregnancy. She does not have a
primary provider thus her medical history is incomplete. I
would agree with you addressing her past history in detail prior
to making a diagnosis. I think you were also thinking out of the
box when you suggested appendicitis. It is completely
reasonable to assess that. I do also realize domestic violence is
a concern for this patient due to many factors. This is why I
suggested trauma related abdominal aneurysm, do I think that is
her current concern no but blunt force trauma to her abdomen
can
cause significant damage. Great job on your post. It's nice to
see someone else giving ideas that are not all the same simple
diagnoses.

History Taking (12th Ed.). Philadelphia, PA: Lippincott,William
& Wilkins. ISBN: 9781469893419
differently with every patient. I felt it was important not to just
look at the obvious symptoms and ensure there were not other
underlying complications. Chest pain is always ruled out first,
for abdomen pain is an atypical symptom of a Myocardial
like to have addressed cardiac in my examination. This patient
has been without medical treatment for the last four years and
she does not have a primary provider thus her medical history is
incomplete. I would have liked to address her past history in
more detail, there is alot to which a patient does not indulge
unless asked and the information could be relevant to her
current concerns. I think you were also thinking out of the box
when you suggested abdomen trauma and gastritis. It is
completely reasonable to assess that. I do also realize domestic
violence is a concern for this patient due to many factors. This
is why I suggested trauma related abdominal aneurysm, do I
think that is her current concern no but blunt force trauma to
her abdomen can cause significant damage. Great job on your
post. It's nice to see ideas that are not all the same simple
diagnoses such as PID. This patient is a strong lady and she
would not be in the office if her concern was not acute, and
causing more pain then what she could handle.

History Taking (12th Ed.). Philadelphia, PA: Lippincott,Willia m
& Wilkins. ISBN: 9781469893419
(
Obstetrical History
)
Family Medicine 20: 28-year-old female with lower abdominal
pain
User: kenya leyva
Email: [email protected]
Date: July 21, 2021 11:22PM
(
Learning Objectives
)
The student should be able to:
Conduct a focused history and physical exam appropriate for
differentiating between the common etiologies for a patient
presenting with abdominal pain.
Elicit a full obstetric and gynecologic history.
Recognize "don't miss" conditions that present with abdomi nal
pain.
Propose a cost-effective diagnostic workup for a patient
presenting with abdominal pain. Discuss who should be
screened for intimate partner violence.
Develop a health promotion plan for patient of any age or
gender that addresses intimate partner violence. Demonstrate
active listening skills and empathy for patient.
Utilize effective listening skills and empathy for patient to help
improve patient adherance. Communicate effectively with
patients and families from different cultural backgrounds.

Describe the barriers to accessing and utilizing health care that
stems from personal barriers. Describe the barriers to accessing
and utilizing health care that stems from personal barriers.
(
Knowledge
) (
The
location
of
the
abdominal
pain
is
important,
as
it
can
help
narrow
your
differential

diagnosis.
For
example,
diffuse
abdominal pain
may
represent
gastroenteritis,
whereas
localized
right
lower
quadrant
pain
is
classic
for
but

not
limited
to
appendicitis.
Think about
what
is
in
the
various
quadrants
of
the
abdomen
when
considering
the
differential
diagnosis

of
abdominal
pain.
Significance of the Location of Lower Abdominal Pain
)
(
There
are
many
signs
and
symptoms
of
a
life-threatening
condition
in
a
patient

with
abdominal
or
pelvic
pain.
Examples
include: Abrupt onset of severe
pain
Shock with hypotension and tachycardia Distension
Peritoneal irritation signs Rigid abdomen
Pulsatile abdominal mass Absent bowel sounds Fever
Vomiting Diarrhea Weight loss
Menstrual changes
Trauma, prior surgeries, or operative scars History/presence of
blood in emesis History/presence of blood in stool
Severity of the pain
Ecchymoses/bruising
Rebound tenderness Mass or ascites
Red Flags of Life-Threatening Condition in Patient with Lower
Abdominal/Pelvic Pain
)
G
Gravida or number of pregnancies

T
Number of Term pregnancies
(
©
2021
Aquifer,
Inc.
-
kenya
leyva
([email protected])
-
2021-09-27
21:05
EDT
) (
1
/8
)
P

Number of Preterm infants
A
Number of spontaneous or induced
Abortions
L
Number of Living children
(
Documentation
of
attempts
to
schedule
follow-up
visits
and
inform
patients
of
laboratory
results

is
very
important.
Failure
to
reach a patient by phone or mail should also be documented. If
a provider is unable to reach a patient about an important test
result (e.g. an abnormal Pap smear), reaching out to emergency
contacts and sending a certified letter should be done to
document every effort to reach a
patient.
Documenting Follow-Up and Lab Reporting
)
(
Location Quality Severity Timing
Aggravating factors and alleviating factors
Abdominal Pain History
)
Some Common Causes of Lower Abdominal Pain Presenting in
Primary Care
Constipation: Patients may give a history of having small, hard
pellets for stools, decreased frequency of stooling, harder stools
than usual, or occasionally having loose stools, which may
actually signify an impaction, where the patient has soft stool
leaking around an impacted hard stool. This type of stooling
pattern is more often associated with irritable bowel syndrome.
Irritable bowel syndrome (IBS): Many patients will describe

abdominal pains of varying location, associated with either soft,
frequent, loose stools, or constipation, or an alternating stool
pattern. They may also describe abdominal bloating, increased
flatulence, and mucus in the stool. The symptoms of IBS are
frequently worse when the patient is under stress, anxious, or
depressed. Symptoms of IBS can be brought on initially by a
case of gastroenteritis and can be aggravated by stress, diet, and
change in activity—and the symptoms are often unpredictable.
Caffeine and dairy products can make symptoms worse. The
diagnosis is based on clinical history, physical exam, and
absence of alarming symptoms suggesting other pathology.
The Rome IV criteria is often used to aid diagnosis of adult
IBS:
Recurrent abdominal pain, on average ≥ 1 day per week in past
3 months with two or more of following features:
1. Related to defecation
2. Associated with change in stool frequency
3. Associated with change in stool form (appearance)
Endometriosis: Patients with endometriosis may begin to notice
increasingly more painful and heavier menstrual cycles as early
as late adolescence. A patient with endometriosis might indeed
have lower abdominal discomfort, often starting after ovulation
during most cycles and continuing through their menstrual
cycle. There may also be low back pain or painful stooling. It is
not uncommon for a patient with endometriosis to experience
pain with intercourse. Ultrasounds or MRIs may be needed in
order to help diagnose the problem. Laparoscopy may be needed
to definitively diagnose, treat, or alleviate symptoms. Hormonal
contraception often stops the pain and the process, thus
preserving the patient’s ability to become pregnant later.
Genetic factors are often involved.
Inflammatory bowel disease (IBD): Patients with IBD usually
have some combination of abdominal pain, bloody diarrhea, and
frequent stooling. The onset of symptoms frequently occurs in
the late 20s or early 30s. The patient may ultimately be
diagnosed with either ulcerative colitis or Crohn Disease.

Diagnosis is made through specific radiological findings on
barium enema, small bowel follow-through, and by
colonoscopy.
Muscular pain or musculoskeletal pain is generally
reproducible. On exam, there is usually point tenderness to
palpation of the affected muscles. The pain may recur during
certain activities or when the offending position is (re)assumed.
Psychosomatic pain: Symptoms from this type of pain are
variable and can be associated with or aggravated by other
etiologies such as IBS or gastritis. The pains can occur
anywhere throughout the abdomen. They usually present as an
atypical pain pattern, occur in a depressed or otherwise
mentally ill patient, and may point toward a psychogenic cause.
This is a diagnosis of exclusion.
Stress: The patient's symptoms and pains tend to be increased
when the patient is under increased stress or is involved in other
negative interactions. The patient may present with a whole
constellation of other stress-related symptoms, such as
headache, depression, anxiety, appetite changes, and sleep
disorders. Stress can also aggravate other conditions, such as
irritable bowel syndrome. This diagnosis, which is related to
psychosomatic disease, is one of exclusion.
Urinary tract infection (UTI): Symptoms may include lower
abdominal or suprapubic pain, urinary frequency, burning with
urination (dysuria) that is frequently worse at the end of the
urinary stream (terminal dysuria) and which can also involve
hematuria. There may even be lower back pain in severe
infections that involve the kidney. Among patients with female
genitalia, the onset of symptoms may be related to recent sexual
intercourse. UTI is a common condition and should always be
considered in patients with lower abdominal pain.
(
Screening recommendations:
The

American
College
of
Obstetrics
and
Gynecology
suggests
screening
all
patients
who
come
to
them
(family
planning
patients, all ob-gyn patients, and all prenatal patients) at first
visit, at each trimester, and at the postpartum visit. It may help
to preface asking

such
questions
with
a
statement
such
as:
"Because
intimate
partner
violence
(IPV)
is
so
common,
I
ask
all

of
my
patients about
this..."
The
U.S.
Preventive
Services
Task
Force
(USPSTF)
recommends
that
clinicians
screen
women
of
childbearing
age

for
IPV,
such
as domestic
violence,
and
provide
or
refer
women
who
screen
positive
to
intervention
services.
(Level
of

Evidence:
B)
This is routinely done at annual exams or when red flags are
present.
Here
is
a
good
resource
regarding
screening
for
intimate
partner
violence
.
Prevalence:
It is important to be aware of IPV when addressing our patients,
as approximately 25% of women in the U.S. report being
victimized
by
an

intimate
partner
at
some
point
in
their
lifetime.
While
the
majority
of
IPV
victims
are
women,
they
can

be
any gender,
occur
in
both
heterosexual
and
same-sex
relationships,
and
across
all
socioeconomic,
age,
and
ethnic
divides.
Complications:
In addition to the trauma incurred, the rates of chronic

disease—including heart disease, diabetes, depression, and
suicide—are significantly
higher
in
victims
as
well
as
in
adults
who
were
victimized
as
children
as
a
result
of

direct
abuse
and
exposure
to
IPV.
Intimate Partner Violence: Screening Recommendations,
Prevalence, and Complications
) (
There are several nonjudgmental ways to ask about intimate
partner violence. Examples include: "Do you feel safe at
home?"
"Because
violence
is
so
common,
and
there
are
so

many
forms
of
violence,
I
am
asking
all
my
patients
about
it.
Is
anyone now
or
has
anyone
in

the
past
hurt
you
emotionally,
physically,
or
sexually.
Is
anyone
threatening
you?"
"All couples disagree at sometime. What happens when you
disagree/fight/argue?"
"Does
your
partner
ever
force
you

to
do
things
you
do
not
want
to
do
or
keep
you
from
doing
things
you
want
to

do?" "How do you handle money issues in your
relationship?"
"I
often
see
the
type
of
symptoms
that
you
have
in
people
who
are
being
hurt

at
home
or
in
a
relationship.
Do
you
think
that this might be happening to
you?"
There are lots of things you can do to facilitate discussion about
IPV.
Facilitating Discussion About Intimate Partner Violence
) (
Vaginitis:
The patient's symptoms and concerns will vary depending on the
cause of the discharge. She can present with a vaginal
discharge
that
is
watery

to
pasty;
it
may
be
malodorous;
discomfort
can
vary
from
itching
to
burning,
and
there
may
or may not be pain with intercourse (dyspareunia) and pelvic
pain. Being at risk for sexually transmitted infections widens
the differential,

and
the
use,
or
lack
thereof,
and
the
type
of
contraceptive
used
impacts
that
risk.
An
expanded
history

is
needed
in this case. Examination of the discharge under the microscope,
or sending a vaginal swab and cervical cultures to the lab, is
generally
required.
)
(
Individuals who were victimized by their intimate partner are
more likely to experience:
Migraines, frequent headaches Chronic pain syndrome
Heart and blood pressure problems Arthritis
Stomach ulcers, frequent indigestion, diarrhea, constipation,
irritable bowel syndrome, spastic colon
Pain
during
sex
(dyspareunia),
dysmenorrhea,
vaginitis,
pelvic
inflammatory
disease,

chronic
pelvic
pain
syndrome,
and other gynecological
diagnoses
Invasive cervical cancer and preinvasive cervical neoplasia
Depression, anxiety, and post-traumatic stress Unexplained or
poorly explained findings on physical exam
Red flags for intimate partner violence include:
Delay in seeking medical care
Non-compliance with treatment plan
Partner insisting on staying close and answering questions
directed to patient
Hesitancy or not answering questions or inconsistent or
incorrect answers given to questions Shyness or reticence in
answering questions
Explanation of problem or incident does not match severity of
findings
Symptoms and Conditions Experienced More Frequently by
Victims of IPV Red Flags for Intimate Partner Violence
)
Ask screening questions
Many clinics will ask a screening question of all patients during
the triage process. Asking the patient, "Do you feel safe at
home?" follows the vital signs and questions about whether or

not the patient is having any pain. This open-ended question
allows the patient to share information they might have about
feeling unsafe at home, in their neighborhood, or where they
live, work, or shop, or feeling threatened or actually being
abused by someone. This question is appropriate for any age,
gender, or socioeconomic class. It may take several visits for
the patient to feel comfortable enough with the provider to
discuss such a sensitive issue.
Create a safe setting
Hang posters on the clinic walls and place brochures about
safety, particularly in private areas like bathrooms and exam
rooms. These should also contain information addressing
cultural differences and acknowledging varied relationships and
backgrounds.
Interview the patient alone
Never interview with the suspected perpetrator present. In order
to have the partner leave the room, you can cite protocols such
as, "I always do this part of the exam just with the patient. You
can join us again when we are done." Or, "I begin the visit with
the patient alone. If you have questions after, we can meet
together."
If the partner insists, then attempt to separate the two by taking
the patient to obtain a urine sample or another test outside of
the exam room.
Infants and toddlers three years old or younger can stay with the
parent, but it is recommended that if the child/children
accompanying the parent are older than three, you should meet
with the patient alone.

Ensure confidentiality
Update and review HIPAA forms and make sure that all staff
are aware of how to use them. Be sure to tell the patient that
anything discussed in the room will not be shared with anyone
not directly involved with their care, including their partner and
family members.
Direct assessment
Interviewing can begin with indirect questions such as, "Tell me
about your relationship," but should include a direct assessment
of safety, including questions regarding weapons in the house
and danger or possible harm to the children or pets.
Know your local laws
All states require reporting of child abuse and some require
reporting of intimate partner violence. Be open with your
patient about your legal constraints.
Facilitate impartiality
Consider using a telephone service for interpretation if an
appropriate professional interpreter is not present in the office.
Do not use a friend or relative.
Listen nonjudgmentally
Validate the patient's concerns and the fact that abuse is not the
fault of the victim.
(
It
is

generally
preferred
to
have
children
outside
the
room
during
a
pelvic
or
genital
exam
of
the
parent.
Depending

on
the
age
of the child, some parents may prefer to have the child sit in the
room in a corner and face away from the exam table, or keep a
sleeping child in a stroller in the room with them. The clinician
may have sensitive questions to ask; the parent-patient may not
want the child to see them undressed and undergoing this
exam.
There is frequently someone on staff who will watch or
entertain the child or children during this portion of the exam.
Or the parent
may
have
come
to
the
clinic
with
a
friend
or

relative
with
whom
the
child
can
stay
in
the
waiting
room
during
that
portion of the
visit.
It
is
also

important
to
have
a
chaperone
in
the
room
for
the
exam
for
legal
reasons
and
for
protection
of

the
clinical
staff.
This person should be named in the chart
note.
Handling Children During a Sensitive History and Exam
) (
Increasing severity of
violence
Presence of gun in the
house
Threats to kill or commit suicide by either victim or
abuser
Use of drugs or alcohol by victim or
abuser
Victim trying to leave or left
recently
Intimate Partner Violence Safety Assessment
)
(
Obvious physical signs of physical or sexual abuse
Behavioral
or
emotional

problems,
such
as
increased
aggression,
increased
fear
or
anxiety,
difficulty
sleeping
or
eating,
or other signs of emotional
distress
Chronic somatic concerns
30% to 60% of perpetrators of intimate partner violence also
abuse children in the household.
Symptoms of Exposure to Domestic Violence in Children and
Adolescents
)

(
Verbal abuse, insults,
yelling
Throwing things, punching
wall
Pushing victim or throwing things at
victim
Slapping
Kicking,
biting
Hitting with closed
fist
Attempting
strangulation
Beating up; punching with repeated
blows
Threatening with
weapon
Assault with
weapon
Increasing Severity of Intimate Partner Violence
) (
6. Harm to children
)
(

Intimate
partner
violence
is
a
pattern
of
increasing
episodes
of
violence
in
which
one
partner
exerts
control
over

another
through intimidation,
physical
and/or
emotional
violence,
and
threats.
It
is
common
for
there
to
be
a
tension-building
phase,

a
crisis
phase when overt violence is likely to occur, followed by a
calmer phase when the abuser might ask for forgiveness and
even be affectionate.
Unfortunately,
in
most
cases,
the
cycle
begins
again
and
often
the
violence
is
increasingly

severe.
Escalating Cycle of Intimate Partner Violence
)
(
When
documenting
a
history
of
abusive
behavior,
use
the
patient's
own
words
in
quotes
and
fill

in
names
after
pronouns
are
used. Example:
"then
he
(John
Smith)…".
Use
neutral
language.
Example:
"patient
states",
not
"patient

alleges,"
which
may
give
a
false impression of
disbelief.
Give a detailed description of the patient's appearance,
behavioral indicators, injuries and stages of healing, and health
conditions.
If
the
patient
consents,
use
photos
to
document
injuries;

one
with
a
face
included
in
the
photo,
and
then
close-ups
of the injury. If photos are not possible, draw and describe
injuries on a body map in blue ink as this is difficult to
alter/reproduce. Document
recommendations
for
support
and
follow-up

as
well
as
materials
given
to
the
patient.
Document abuse history as reported by patient in the subjective.
The subjective section is meant to document the patient's
experience and verification is not applicable. Include any
laboratory and radiology tests ordered with results to maintain a
complete
record
for
the
patient.
Document
results
of
health

and
safety
assessments
and
plans
for
follow-up
as
well
as
referrals and materials given to the patient. Document
recommendations for support. If the patient was referred for a
post-rape exam, document the referral site. Maintain strict
confidentiality and safeguard the chart rather than limit the
contents for best care practices.
Documenting a Case of Suspected Intimate Partner Violence
)
(
Clinical Skills
) (
It
is
a

common
scenario
to
see
a
patient
that
is
scheduled
for
an
acute
visit,
but
the
situation
requires
more

time
to
be
adequately addressed. Prioritize the most acute or high risk
issues raised during this visit and focus on these, and then
emphasize the importance of follow-up and schedule a follow-
up visit as soon as
possible.
Adequately Addressing Your Patient's Needs Within Time
Constraints
) (
Management
) (
The Role of the Health Care Provider in the Care of a Victim of
Intimate Partner Violence
)
Acknowledge the abuse and health implications
It is important to acknowledge the abuse, recognize the health
implications, and share this with your patient.
Support your patient's decisions
While you may not always agree with the decisions your patient
makes to stay or escape, it is important that you support their

decisions. They have a greater understanding of the complexity
of the problem, and have more information on which to base
their actions.
Address safety issues
Address the level of risk and safety issues for your patient.
Provide information for them to go to a safe haven if needed. As
lack of a telephone or computer (or monitoring of their use)
often make it unsafe or impossible for victims to contact IPV
resources from home, it is important not only to give contact
information to the patient, but also to offer a means for them to
contact services while in your office. One should be aware that
the person inflicting the violence might check the
patient's/victim's phone and computer for recent phone calls,
website visits, and emails.
Practice cultural sensitivity
Cultural differences can give the appearance of abuse, be
accepting of practices some might consider abusive, and can
inhibit the ability to interview or support a victim. Practicing
sensitivity in caring for patients from different backgrounds is
key to a supportive patient-clinician relationship.
Consider impact of abuse on children and other vulnerable
parties
When children or other vulnerable persons who are less able to
make decisions on their own behalf are in the home,
consideration must be given to the impact of the abuse on them
physically and mentally as well as their safety.
Even in states where reporting abuse towards a domestic partner

is not mandated, the impact or abuse on a child or other
vulnerable person may be and will supersede the desires of the
victim to not alert social services.
It is not possible for a clinician to solve the problem of IPV for
an individual. Statistically, the most dangerous time for a
victim is when they escape an abusive relationship. While it is
hard to accept, sometimes it may be safer for a victim to stay
with the perpetrator. Clinicians are not in a position to stop the
abuse. You can make recommendations in terms of decreasing
the victim's level of risk by providing resources to the patient,
limiting access to weapons, and developing an escape plan with
a victim's advocate. Safety planning takes time and expertise.
While some clinicians will take the time to be trained to be
effective at this, it is probably best to utilize experts who are
associated with IPV agencies if available or to train a staff
member to serve this role.
Reporting
Reporting laws differ from state to state, so you need to know
what the laws are where you are working. Whenever a child is
abused as a result of IPV, either intentionally or
unintentionally, state law requires health care providers to
report this abuse to child protection services. Mandated
reporters would also report any high-risk situation of IPV in
which children are at risk.
However, state laws are less clear about whether exposure to
IPV in the absence of injury or serious risk of injury to the
child would require a report to children's protective services.
In some states, stringent rules/laws require mandated reporters
to notify child protection services whenever a child is in the
home and has been exposed to a parent's abuse, whether or not
the child has been directly abused. Proponents of this definition
point to the ample documentation of the overlap between adult
IPV and child abuse and the adverse psychological effects on
children who witness IPV. Opponents of this policy believe it
penalizes women for abuse that they have no control over and
may discourage women from seeking help. It also could elevate

the level of risk for the victim.
In other states, a child's exposure to IPV does not automatically
require a mandatory child protection report. The provider has
wider discretion to assess whether a child has been directl y
involved and what other factors may exist to put the child at
risk. In these states, a provider would take into account the
existence of direct injury to a child, the potential danger of the
situation, and the capacity of the mother to keep her children
safe in deciding whether to notify Child Protective Services
(CPS).
(
Recommended Studies for Evaluation of Lower Abdominal Pain
)The rules for victims who are adults and are not disabled vary
dramatically from state to state, from mandatory reporting for
evidence of abuse to reporting only if the victim asks the
clinician to do so. Contact your local Domestic Violence
helpline and ask what the rules are for the community in which
you work. You can find out about your local resources by
calling the National DV Hotline at (800) 799-SAFE, TTY (800)
787-3224.
(
Studies
)
Pap test— thin prep
Recommended in the setting of previous abnormal results.
KOH/saline wet prep
This is a quick test which should be done as it could indicate
inflammation (white blood cells) or diagnose trichomonas,
bacterial vaginosis, or yeast vaginitis.

Chlamydia / gonorrhea DNA probe
Chlamydia and gonorrhea can present with a yellow discharge,
abdominal pain, and dyspareunia. This is the preferred method
for diagnosis of chlamydia and gonorrhea because both can be
performed using the same sample, and the sample can be
endocervical, urethral, vaginal, oral, or urine.
Urine dipstick
Helpful to rule out a urinary tract infection (UTI).
Urine pregnancy test
Should be performed on any patient who is physically able to be
pregnant.
RPR
Should be done as part of the STI screen to rule out syphilis.
HIV
Should be done as part of the STI screen.
HPV
Consider ordering a reflex HPV. Reflex refers to the fact that an
abnormal Pap will automatically be tested for HPV. If the Pap is
normal, the HPV testing will not be done.
Pelvic ultrasound

The pelvic exam, urine pregnancy test, and STI testing will help
guide the need for an ultrasound to evaluate a possible pelvic
mass, the size of uterus and ovaries, to confirm the location of a
pregnancy, or to rule out an inflammatory or infectious process.
Colposcopy
Colposcopy is not indicated until the results of the Pap are
back. If the Pap is abnormal, and/or if high-risk HPV is
positive, a colposcopy may be indicated. Follow the ASCCP
guidelines for follow up of abnormal PAP
Gonorrhea culture
While this is a good test for gonorrhea, a separate test needs to
be done on vaginal or urine samples. However, this is still the
preferred method for sexual assault tests, for tests of cure, and
for oral and rectal specimen.
HCG beta sub
This is generally not indicated because of the sensitivity of the
urine pregnancy test. If the results of the urine pregnancy test
were inconclusive, a blood test such as HCG Beta Sub would be
needed.
(
Clinical Reasoning
) (
Severe / Life-Threatening Causes of Abdominal Pain
)
Appendicitis

Patients with appendicitis often start with visceral pain that is
dull and in the periumbilical region; within a short time the pain
classically localizes; presentation is usually of fairly acute
onset with moderate to severe right lower quadrant pain. There
is often a history of nausea and/or vomiting. There are usually
some changes in the patient's bowel movements.
Ectopic pregnancy
Ectopic pregnancy is a medical emergency. Early medical
treatment reduces the need for surgery, but if the fallopian tube
is in danger of rupture, surgical intervention may be necessary.
Patients present with divergent symptoms ranging from no pain
and normal menses to intense pain and irregular or absent
menses. A good history, the physical exam and lab testing
(always get a pregnancy test if the patient has a uterus) are
crucial for this diagnosis. Imaging is also usually needed. You
need the date of the patient's last menstrual period (LMP), her
menstrual history, most recent intercourse dates, the types of
contraception used currently and used in the past
/ever used, history of any vaginal or pelvic infections, and
history of previous ectopic or normal pregnancies.
Endometriosis
While endometriosis is not typically life-threatening, it can be
severe. The majority of patients are of reproductive age and
present with cyclical pelvic pain, following the menstrual cycle
in patients with regular menses. The location and pattern of the
pain can vary widely, depending upon which organs have been
affected. For example, those with bladder involvement may
present with urinary frequency, urgency or dysuria.

Endometriosis may also present as infertility in an otherwise
asymptomatic patient or as an incidental finding during surgery.
Ovarian pathology
Patients with ovarian problems generally have lower abdominal
or pelvic pain. Pain from ovarian torsion or ruptured cyst or
ectopic pregnancy may be very severe and usually has a sudden
onset. Patients often present to the emergency department due
to the pain, and this is appropriate since imaging is usually
necessary to determine the exact cause of the pain. In several
cases, the pain from ovarian problems may persist for several
weeks. It is often aggravated by intercourse or strenuous
activity.
Pelvic inflammatory disease
Patients with pelvic inflammatory disease (PID) might have
abdominal or pelvic pain, which is worse with sexual
intercourse or with activities such as running or jumping, which
cause jarring of the pelvic organs. This diagnosis has significant
morbidity, which increases with the severity of the disease and
with the length of time to diagnosis. Studies show that
approximately one in four patients who had a single episode of
PID later experienced tubal infertility, chronic pelvic pain, or
an ectopic pregnancy, as a result of scarring and adhesions.
Tubal adhesions leading to infertility have been reported to
occur in 33% of patients after their first episode of PID, and up
to 50% after the second pelvic infection.
Normal pregnancy
Patients who have normal pregnancies may experience some

lower abdominal discomfort or pain as the uterus undergoes
normal growth. This is more a diagnosis of exclusion, but you
would not want to miss a pregnancy. Certain medications should
not be given to patients who are pregnant. Fetuses should not be
exposed to radiation.
Trauma
A careful history is important in regard to trauma. Be aware of
the patient's body language and response to touch. Consider the
consistency of the history with the exam. Have the patient
undress and examine the patient thoroughly in a gown so that all
areas can be visualized. Consider taking a photograph of any
injuries and bruises if there is a way to appropriately attach
them to the patient's medical record, and if the patient gives
consent.
(
References
)
American College of Obstetricians and Gynecologists (ACOG).
Sexual Misconduct. https://www.acog.org/Clinical-Guidance-
and-Publications/Committee-Opinions/Committee-on-
Ethics/Sexual-Misconduct Accessed June 9, 2020.
American Society for Colposcopy and Cervical Pathology.
Updated Consensus Guidelines for Managing Abnormal
Cervical CancerScreening Tests and Cancer Precursors. Updated
2013. Accessed February 8, 2020.
Cartwright SL, Knudson MP. Evaluation of acute abdominal
pain in adults. Am Fam Physician. 2008;77(7):971‐ 8. Connor
VF. Essure: a review six years later. J Minim Invasive Gynecol.
2009;16(3):282‐ 90.
Dicola D, Spaar E. Intimate Partner Violence. Am Fam
Physician. 2016;94(8):646‐ 51.

Edelson, J.L. (1999). "The Overlap Between Child Maltreatment
and Woman Battering." Violence Against Women. 1999;5:134-
54.
Family Violence Prevention Fund. Compendium of State
Statutes and Policies on Domestic Violence and Health Care.
Produced 2010. Accessed August 16, 2021.
Futures Without Violence(formerly The Family Violence
Prevention Fund). First Printing: September, 2002. Updated:
2020. Accessed February 8, 2020.
Futures Without Violence. The Facts on Domestic, Dating and
Sexual Violence. Released 2009. Accessed February 8, 2020.
Futures Without Violence. The Facts on Women, Children and
Gun Violence. Released 2013. Accessed February 8, 2020.
Futures Without Violence. The Health Care Costs of Domestic
and Sexual Violence. Updated March 2010. Accessed February
8, 2020.
Hatcher RA et al. Contraceptive Technology 19th edition,
Ardent Media, 2007.
http://www.contraceptivetechnology.org/table.html. Accessed
February 8, 2020.
Institute for Clinical Systems Improvement (ICSI). Initial
management of abnormal cervical cytology (Pap smear) and
HPV testing. Algorithm. Bloomington (MN): Institute for
Clinical Systems Improvement (ICSI); Oct 2008;32:63.
Accessed February 8, 2020.
Katz VL et al, Infections of the Upper Genital Tract:
Endometritis, Acute and Chronic Salpingitis In: Comprehensive
Gynecology, 5th edition. Philadelphia, PA: Mosby; 2007.
Marsicano E, Vuong GM, Prather CM. Gastrointestinal causes
of abdominal pain. Obstet Gynecol Clin North Am.
2014;41(3):465-89.
National Consensus Guidelines on Identifying and Responding
to Domestic Violence Victimization in Health Care

Settings.Produced by The Family Violence Prevention Fund,
383 Rhode Island Street, Suite 304, San Francisco, CA 94103-
5133. (415) 252-8900. TTY (800)
595-4889. First Printing: September, 2002. Updated: February,
2004.
Planned Parenthood Interactive website. Birth Control Methods
and Options | Types of Birth Control. Accessed February 8,
2020.
Reproductive Health Access Project. Your Birth Control
Choices Fact Sheet.
https://www.reproductiveaccess.org/resource/bc-fact-sheet/.
Updated July 2021. Accessed August 16, 2021.
Shian B, Larson ST. Abdominal Wall Pain: Clinical Evaluation,
Differential Diagnosis, and Treatment. Am Fam Physician.
2018;98(7):429-36.
Silverman JG, Decker MR, Reed E, Raj A. Intimate partner
violence victimization prior to and during pregnancy among
women residing in 26 U.S. states: associations with maternal
and neonatal health. Am J Obstet Gynecol. 2006;195(1):140‐ 8.
Trigg BG, Kerndt PR, Aynalem G. Sexually transmitted
infections and pelvic inflammatory disease in women. Med Clin
North Am.
2008;92(5):1083‐ 113.
Wet Mount. Military Obstetricts & Gynecology.
http://www.brooksidepress.org/Products/Military_OBGYN/Text
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