Assignment: Family Medicine Treatment

Assignment: Family Medicine Treatment

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Assignment: Family Medicine Treatment

This week, complete the Aquifer case titled Family Medicine 20: 28-year-old female with abdominal pain.

After completing your Aquifer Case Study, answer the following questions using the latest evidenced based guidelines:

• Discuss the questions that would be important to include when interviewing a patient with this issue.

• Describe the clinical findings that may be present in a patient with this issue.

• Are there any diagnostic studies that should be ordered on this patient? Why?

• List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.

• Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.


You are working in Dr. Nayar’s family medicine office. He informs you, “The next patient on the schedule is Ms. Amanda Bell. She is a 28-year-old, cisgender, female here with a chief concern of lower abdominal pain of a few weeks’ duration. I’m going to have you go take her history and start her physical exam. Before you see her, let’s take a moment to think about the questions you will want to ask her. How would you approach someone with a chief concern of abdominal or pelvic pain?”


Significance of the Location of Lower Abdominal Pain

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.


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


Dr. Nayar suggests, “Before you go and meet Ms. Bell, let us take a look at her chart in the electronic medical record (EMR) together.”

Because you are aware of the importance of a patient’s surgical history in the evaluation of abdominal pain, you review her chart for prior surgeries and find that her only past surgeries were a tonsillectomy and adenoidectomy at age 17.

You investigate the chart further and find that Ms. Bell is “G1P1001.” Her pregnancy was four years ago, and Dr. Nayar had performed the vaginal delivery of a full term male infant without complications.


Obstetrical History

G Gravida or number of pregnancies
T Number of Term pregnancies
P Number of Preterm infants
A Number of spontaneous or induced Abortions
L Number of Living children


You also note that Ms. Bell has not been seen in your clinic for over four years. She was last seen for her postpartum check, at which time she was found to have an abnormal Papanicolaou (Pap) test.

When you mention this to Dr. Nayar, he sighs and explains, “Follow-up of an abnormal Pap test is important because it may prevent later progression to cervical cancer. The early stages of this disease are very treatable. Thus, it is important for the practitioner to document that every effort that has been made to follow-up on an abnormal Pap test. The patient’s chart shows that efforts were made to contact Ms. Bell but that she did not follow through on further evaluation of her abnormal Pap test. We don’t know why she didn’t come back; it could be one of many reasons. Perhaps she moved and did not receive our letters; maybe her insurance changed or ended; life may have gotten too busy with a new baby; maybe she didn’t understand the importance of following up on an abnormal Pap; or maybe it was just plain fear. I would not like to think that she was just not interested.”

Sure enough, despite Dr. Nayar’s notation in the chart of the need for a follow-up appointment, there is no record of a repeat Pap in Ms. Bell’s chart. There are, however, multiple entries documenting Dr. Nayar’s repeated attempts to schedule follow-up care via letters, phone calls and even certified mail.

He tells you, “Documentation is very important; if something is not documented, it did not happen. In Ms. Bell’s case, I noted each time I attempted to contact her. I placed a copy of the lab result letter that was sent to her, in her chart. If her mail had been returned to the clinic, we would have placed that envelope in her chart, too. If you are at all concerned about a patient receiving an important lab result, it is best to send that result by certified mail, if you cannot get them in for a follow-up visit.”

When you and Dr. Nayar have finished your review of the patient’s chart, you go in to see Ms. Bell, with the instructions to return to Dr. Nayar with a report of her history and physical exam.


Documenting Follow-Up and Lab Reporting

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.


You introduce yourself to Ms. Bell and her 4-year-old son, Cooper, who is accompanying her. Cooper is seated on Ms. Bell’s lap and is trying to hide his face in his mom’s jacket. Both the patient and son are neatly dressed, well nourished, and in no apparent physical distress.

You begin to take a history of the present illness:

“The nurse has written in your chart that you have been having some pain in your lower abdomen. Can you tell me more about this?”

Ms. Bell states, “Yes, the pain started to get pretty bad about two weeks ago. I have probably been having pain for the past month or so, off and on. The pains feel sore, achy, and crampy. Anyway, I missed some days at work because of these pains, whatever they are, and now I need a work slip in order to go back.”

“Does the pain seem to stay in the lower part of your abdomen, or does it move anywhere else?”

“No, it seems to stay in the lower part.”

“How bad would you say your pain is, on a scale of 1–10, with 10 being the worst pain you can imagine?”

She answers, “It’s usually about 3 out of 10. But it can be worse, maybe up to a 5, but when it gets that bad it only lasts for a few seconds.”

“What makes the pain better or worse?”

“Being still helps.

But the pain can just come and go on its own. Moving around, like walking or exercise, seems to make the pain worse. I can’t seem to make sense of it all. Sometimes when my husband and I have relations, you know, sex, or even when I just do mild exercise, the lower part hurts. Maybe it’s just sore muscles from my starting back with trying to exercise.”

“Does the pain come at any particular time of day?”

“No, not really.”

“Do you get the pain during the night? Does it wake you up from sleep or prevent you from going to sleep?”

“No. I sleep okay most of the time. My son occasionally wakes up at night with bad dreams, so I get up with him for a while, but I don’t think the pain wakes me up.”

“Did anything happen a month ago when these pains started?”

“No, not really, although I have been under some extra stress, I guess, but that has been for longer than a month.”

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Pain scale

When you ask her about associated symptoms, she notes occasional nausea, vomiting, loose stools, and constipation. She adds that the changes in her bowel movements come and go; between times, her bowel movements are normal. Upon further questioning, she tells you that her stools are a normal brown color, not bloody or black. She also informs you that she had a mild temperature elevation about a week and a half ago. She did not know what caused that.

She has medicated the abdominal pain with two 200 mg tablets of over-the-counter ibuprofen a few times over the past couple of weeks but, “They really didn’t do anything much for the pain.” She reports not taking any regular medications, vitamins, or supplements. She’s never had an allergic reaction to any medicines.


Abdominal Pain History

· Location

· Quality

· Severity

· Timing

· Aggravating factors and alleviating factors

· Ms. Bell’s son, Cooper, has been very quiet. Now he climbs down from his mother’s lap. You hand a couple of picture books to Ms. Bell, who in turn, gives them to her son. Cooper climbs back into his mom’s lap and looks at the books.

· “I have a few more questions for you,” you tell Ms. Bell.

· “What can you tell me about your last Pap test and pelvic exam?”

· “My last exam was done here, about four years ago, shortly after I had my son. I got a letter from the clinic saying I had abnormal results: “ASK” or “ASC” something. I was supposed to come back to the clinic to check this out, but there was always a reason I couldn’t make it back here. First, I was changing jobs and didn’t have insurance. Then, when I got my new job, I was afraid to take the time off work to come in.”

· “Yes, those things can make health care difficult, I understand,” you reply. “However, it is very important for you to follow up on this. Have you ever had a sexually transmitted infection (an STD or an STI)?”

· “I’ve had vaginal infections; some kind of a trich-something infection and a yeast infection. Are they STIs?”

· You tell her that yes; trichomonas is actually considered a sexually transmitted infection, although it is generally not dangerous. A yeast infection is not an STI. You want to be thorough and make sure that you don’t miss the infections most likely to cause abdominal pain, so you ask her specifically about gonorrhea and chlamydia. She does not remember having been told that she had either of these. She is vague but states that she hasn’t ever been given a shot for treatment of an infection and that aside from the trichomonas, she is not aware that her husband has had to be treated for any infection.

· “Have you been experiencing any vaginal discharge, burning, itching, odor, or pain?”

· She replies, “No discharge; nothing like that, just the pain right here,” and she points just above her pubic bone.

· “When was the start of your last menstrual cycle?”

· “It started one month ago.”

· On further questioning, she reports no pain on urination (dysuria) or frequent urination.


Which of the following conditions are very important not to miss as they might be severe or life-threatening? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Appendicitis

· B. Ectopic pregnancy

· C. Endometriosis

· D. Ovarian cyst

· E. Pelvic inflammatory disease (PID)

· F. Pregnancy

· G. Trauma

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.

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.



You decide to complete your ob/gyn history:

“When did you say your last period started?”

“I think it is due now. I surely hope so. I don’t need another child now or anytime soon.”

“It sounds like you don’t want to get pregnant?”

“Definitely not!”

“Are you using any form of birth control?”

“I was taking birth control pills, but I have been out of them for over two years since I missed my follow-up Pap appointment. Since I ran out of pills, we haven’t been using birth control since my husband won’t wear condoms. I try to avoid having sex whenever I can.”

You suggest, “We have to do a pregnancy test today as part of your workup. If it is negative, we can probably restart you on birth control pills at this visit. We can also discuss other possible methods of contraception, if you would like.”


You ask Ms. Bell a few more questions in order to complete her social and family history and the review of systems:

Social history

Patient has been married for five years. She reports that her relationship with her husband is “so-so.” She is a college graduate; majored in education. She met her husband while they were in college, but he did not finish his college education; he only has a year to go to finish. He works in construction. It bothers the patient that he occasionally drinks a lot and stays out late.

· Alcohol/drug use: Ms. Bell admits that she may drink alcohol with her girlfriends when she does go out, but she can’t remember the last time she did that. She almost never drinks at home and she has never done any kind of drugs—including marijuana. “I just wasn’t brought up that way,” she says.

· Tobacco use: She is a former smoker; she quit a few years ago. She reports, “I don’t have enough money to smoke, and besides, it isn’t good for my son to see or to be around people smoking. My husband smokes though, but not in the house.”

· Sexual history: When asked about sexual partners besides her husband, she responds, “Not me! When would I have time? Besides, I just wouldn’t do that.”

· Spiritual: Ms. Bell is Methodist and she attends church regularly. She elaborates, “Church is my one social outlet. At least I don’t get questioned as much about my going to church.”

Family history

Father is alive and well; has hypertension and mild arthritis. Mother is alive and well; overweight, used to have mild asthma but outgrew it; does have breast lumps (fibrocystic breast disease) but no cancer. Patient is an only child.

· Cancers in family: Maternal grandmother treated for breast cancer at 70. Paternal grandfather diagnosed with prostate cancer at 68. Both are living and doing well.

Review of systems

· Head, eyes, ears, nose, throat: Itchy, tearing eyes during spring allergy season; more headaches recently.

· Respiratory: Okay; no problems.

· Cardiovascular: Occasional chest pains and rapid heartbeat, especially when nervous or anxious.

· Gastrointestinal: Stomach pains; occasional intermittent diarrhea/soft stools more than constipation.

· Genitourinary: Okay; no problems.

· Musculoskeletal: May ache a bit if she exercises too much.

· Neurological: Reports being nervous a lot! Not sure if she is having panic attacks.

· Skin: Occasional hives, not sure what she is allergic to; thinks she bruises easily. Seems to itch more when she is upset about something. Wants to know if hives are related to nerves or stress.

The correct answer is B.

Incorrect answers:

· A: Although Ms. Bell is only 28, a complete exam is necessary. She has not been seen for several years, she has not had follow-up for an abnormal Pap test, and she needs complete evaluation of her presenting symptoms. Furthermore, even for a patient as young as Ms. Bell, there are several recommended screening procedures during a preventive visit.

· D: It is tempting to talk to the nurse and reschedule the next couple of patients to accommodate the need for Ms. Bell’s complete physical exam. But you and Dr. Nayar have a full day scheduled. If you rearranged the schedule every time additional time is needed during a visit, you would never be on schedule, and this would make it very difficult for the staff to run the clinic effectively.

· C and E: On the other hand, asking Ms. Bell to reschedule her visit without addressing any of her issues today would be problematic, especially considering that Ms. Bell has a history of poor follow-up and you are not sure she will actually return for a complete physical. Furthermore, given what she has been telling you, you have concerns about her safety and about what might actually be occurring at home.

· Ms. Bell has indicated that she is under a lot of stress, and you think this is an important aspect of her history because she notes her abdominal symptoms are aggravated by stress.

· “I have heard you mention stress several times today, saying that all of the stress you are under makes it worse? Tell me more about the stresses in your life.”

· “Oh, I don’t know. Everything is stressful! Work, marriage, child care. Life is stressful!”

· “Describe your day to me. Tell me about your life.”

· “I work full time and thank goodness for the job. I need to work; we need the money. I am up early to take my son to daycare, and I have to pick him up by 6:30 p.m. I am always rushing somewhere. My job is getting more and more stressful. Everyone is afraid of being laid off. We have bills and money problems. Beyond that, there’s housework—cooking, cleaning, laundry. And then there are all the relationships! Family, friends and marriage are just, you know, it’s all stressful!”

· “How do you and your husband get along? Do you feel safe around him?”

· “We are normal, I guess, whatever normal is. My husband works in construction, so he is away from home a lot. But that’s okay, too. We argue when he is home.”

· “Does he help you with the childcare, the meals, or the housework when he is home?”

· “No, not really. That’s my job—the wife’s job.”


Intimate Partner Violence: Screening Recommendations, Prevalence, and Complications

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.


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.


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.


Symptoms and Conditions Experienced More Frequently by Victims of IPV Red Flags for Intimate Partner Violence

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

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

In the hallway, you take a moment to review what you have discovered so far. You are concerned about Ms. Bell’s marital relationship and her responses to your questions, but you are aware that she has signaled that she doesn’t want to talk about it right now. You plan to follow up on the matter after the exam.

Because the presentation is complicated, you decide you should review the case with Dr. Nayar before doing the physical exam. You find him and relay to him what you’ve gleaned from your discussion with Ms. Bell, including your recommendation for further evaluation via both abdominal and pelvic exams.

Dr. Nayar concurs that Ms. Bell will need both an abdominal and pelvic exam. He tells you, “the pelvic exam will be helpful in localizing pain, assessing severity of symptoms, ruling out masses, and evaluating the size of the uterus and ovaries.”

He also asks you, “Based on what we know so far, what tests would you recommend for Ms. Bell?”

You discuss your options and decide on:

Indicated Studies:

· Pap test—thin prep with HPV testing: In this case, a Pap test should be done with HPV testing because Ms. Bell’s last Pap test, three years ago, showed ASCUS.

· KOH/saline wet prep; with the presence of abnormal vaginal discharge. May have to send vaginal swab to the lab. This decision depends on the availability of a microscope at the clinic.

· Chlamydia / gonorrhea DNA probe: Chlamydia and gonorrhea are both possibilities in this case.

· Urine dipstick

· Urine pregnancy test: A urine pregnancy test is necessary, as Ms. Bell’s last menstrual period (LMP) was one month ago and she is currently sexually active without birth control. Her symptoms of nausea, vomiting, and pelvic pain could be caused by pregnancy. Generally, a practitioner should always consider getting a pregnancy test if the patient is biologically able to be pregnant.



· 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.


· Should be done as part of the STI screen to rule out syphilis.


· Should be done as part of the STI screen.


· 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.


You and Dr. Nayar return to the exam room. After Dr. Nayar has greeted Ms. Bell and Cooper, you tell her, “We are going to examine you together. Is that all right with you?” She nods in agreement. “One of our staff members can watch Cooper if you would like,” you say. Ms. Bell says, “It’s okay, he can stay here.”

You and Dr. Nayar perform your physical exam.

Vital signs:

· Temperature is 36.8 C (98.3 F)

· Pulse is 80 beats/minute

· Respiratory rate is 14 breaths/minute

· Blood pressure is 128/76 mmHg

· Weight is 58.3 kg (128 lbs)

· Height is 160 cm (63 in)

· General: Well-developed, well-nourished, young female adult in no acute distress. Four-year-old son is in the room with her; patient is in the examination gown; she moves to sit on the table for the exam.

· Pain: 3/10 (abdomen)

· Neck: Supple, no bruits, lymphadenopathy, or thyromegaly.

· Lungs: Clear to percussion and auscultation.

· Heart: Regular rate and rhythm, no murmurs, rubs, gallops, or ectopy.

· Abdomen: Bowel sounds positive in all quadrants. Mid-epigastric area nontender; bilateral lower abdominal tenderness to palpation. Some areas of ecchymosis present, across mid and lower abdomen in varying shades—purple to blue, yellow, and green. No masses or organomegaly; no rebound tenderness or guarding, although she does flinch at initial touch.

· Back: No costovertebral tenderness or spine tenderness.

· Pelvic Exam: External genitalia normal without lesions; small amount of yellowish discharge with mild malodor in vagina. Cervix parous without obvious discharge; No cervical motion tenderness. Uterus is possibly borderline enlarged, without palpable masses or significant tenderness. Adnexae slightly tender to palpation bilaterally; ovaries palpated, no masses noted.

· Rectal exam: No masses; normal brown stool, negative hemoccult.

· Neurological: Normal gait and speech; deep tendon reflexes (DTRs) 2+ and equal.

· Extremities: No deformities, pulses 2+ and equal, ecchymoses on upper thighs and extensor aspects of forearms.

· Skin: No rashes; bruises as noted, from purple to bluish to green to yellow, in various stages of resolution.

When you have finished performing the physical exam, you and Dr. Nayar leave the room so that Ms. Bell can get dressed again.


Handling Children During a Sensitive History and Exam

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.


Ms. Bell is a 28-year-old female who presents with lower abdominal pain for two weeks: achy pelvic pain worsened by activity and sexual intercourse. She reports associated nausea, vomiting, and alternating loose stools and constipation. Her last menstrual period was four weeks ago; she is sexually active without birth control and has many psychosocial stressors and reports her husband drinks alcohol frequently but she rarely drinks. Physical examination is notable for lower abdominal tenderness, numerous ecchymoses across her abdomen and extremities, a small amount of yellowish, malodorous vaginal discharge, and no cervical motion tenderness.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

1. Epidemiology and risk factors: 28-year-old female, LMP four weeks ago, sexually active without birth control

2. Key clinical findings about the present illness using qualifying adjectives and transformative language:

· Achy lower abdominal and pelvic pain worsened by activity and sexual intercourse

· Alternating loose stools and constipation

· Many psychosocial stressors

· Reports her husband drinks alcohol frequently but she rarely drinks

· Lower abdominal tenderness

· Numerous ecchymoses across her abdomen and extremities

· Absence of cervical motion tenderness

· Small amount of yellowish, malodorous vaginal discharge

The correct answers are B, C, G, and H.

In this patient with lower abdominal pain, vaginal discharge, and unprotected sexual intercourse, the most likely or important diagnoses to consider are:

· Cervicitis: Most commonly caused by chlamydia or gonorrhea, cervicitis may present with lower abdominal pain and can cause vaginal discharge. Both of these bacteria can also cause asymptomatic infection.

· Urinary Tract Infection (UTI): UTIs classically present with urinary symptoms such as dysuria and urinary frequency, which Ms. Bell does not report. That said, UTIs can have a broad range of clinical presentations and may present with lower abdominal pain. Furthermore, they are very common in patients with female pelvic anatomy, so this diagnosis must be considered. The diagnosis of UTI would not explain her vaginal discharge.

· Vaginitis: Yeast vaginitis, trichomonas vaginitis and bacterial vaginosis all present with vaginal discharge and are all fairly common conditions. Yeast vaginitis more typically presents with vaginal itching with thick, white discharge, whereas the other two conditions more commonly present with pelvic discomfort and thinner discharge. These may be diagnosed with microscopy of a vaginal swab or through a DNA probe test.

· Ectopic pregnancy: This is not the most common or, therefore, likely diagnosis in Ms. Bell’s case. That said, it is a potentially deadly condition if missed. Thus, it is essential to rule out pregnancy in a patient capable of pregnancy who is experiencing lower abdominal pain.

· Just as you and Dr. Nayar finish discussing how the symptoms support or refute the various items on the differential diagnosis, there is a knock at the office door.

· Ms. Bell comes in and asks, “By the way, do you think that Cooper could get checked today, also? I didn’t want to mention anything in front of him, but he has been complaining of stomach pains, too. Plus he has been wetting the bed again and he has been toilet-trained for almost a year. He wakes during the night and wants to get in the bed with me. Something is just not right. This week, he has not even wanted to leave me when it is time for him to go to nursery school, and he used to like his school. And they are telling me that he has been hitting some of the other children in daycare. Something is just not right.”

· Dr. Nayar tells Ms. Bell that he appreciates that she has brought this to his attention. He asks her to return to the exam room with Cooper and assures her that the two of you will join her in just a moment.

Top health concerns about Cooper include:

1. Possible urinary tract infection.

2. Psychosomatic pain because mom has pain.

3. Traumatic situation causing this behavior in the child.

4. Change in behavior at nursery school/daycare.


Symptoms of Exposure to Domestic Violence in Children and Adolescents

· 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.

Possible IPV

You say that while you need to rule out physical causes for Cooper’s abdominal pain, the combination of behavioral and somatic symptoms along with Ms. Bell’s presentation make exposure to IPV high on the differential.

Several of Ms. Bell’s statements warrant further investigation, including:

· Cooper wakes in the middle of the night frequently.

· Ms. Bell has stated that the child is very clingy; confirmed by behavior in the exam room, but within the realm of normal behavior for a four-year-old.

· Secondary enuresis/bed-wetting.

· Change in behavior regarding nursery school.

· Cooper has missed regular/routine healthcare visits.

You conclude by telling Dr. Nayar that although you feel it is necessary to address these issues for Cooper, you are not sure the best time to do it. Should you work him in for an appointment today, have Ms. Bell schedule a later appointment, or address the concerns today while Ms. Bell is being seen?

Dr. Nayar tells you that you are right to be concerned given the information you have. He informs you that doing a risk assessment in terms of IPV, finding out about local laws in regard to reporting exposure to IPV, and giving Ms. Bell access to resources is the key. He reassures you that scheduling a follow-up for evaluation of Ms. Bell’s physical symptoms would be appropriate and would give an opportunity to reevaluate Cooper’s level of safety.


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 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 directly 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).

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.


You and Dr. Nayar go to the lab to process Ms. Bell’s samples and find:



Color Yellow
Clarity Clear
Specific Gravity 1.010
Glucose Negative
Ketones  Trace
Protein Negative
Urobilinogen 0.2 Ehrlich units
Blood Negative
Nitrate Negative
Leukocyte Esterase Negative

UCG: Negative

Wet prep:

· Scant light yellow, frothy discharge; trace malodor

· No hyphae or yeast

· Few motile trichomonads

· White blood cells 10–15 per high power field

After discussing the results, you ask, “Dr. Nayar may I continue the visit? I feel like I have developed a rapport with Ms. Bell and I would like to discuss my concerns with her.” He agrees and the two of you proceed to the exam room.





The nurse has taken Cooper with her to find some crayons and Ms. Bell looks nervous.

You take care to make sure that you are sitting down at Ms. Bell’s level because some of the topics you want to discuss with her are sensitive and you don’t want her to feel intimidated by you. You begin, “We have the results of the tests that we did. Your urine pregnancy test is negative.” Ms. Bell sighs and says, “Thank goodness!” You respond, “I thought you would be relieved about that.”

You continue, “Your urine test is normal; it does not show any signs of an infection. However, when we did your pelvic exam, you did have a small amount of vaginal discharge. I checked it under the microscope and it showed that you have a trichomonas infection again. This would only partially explain your pain with intercourse and pelvic pain. We can treat this. We need to treat your husband, too, as this is considered a sexually transmitted illness (STI).”

“Oh boy,” she sighs.

You also tell Ms. Bell, “Especially since you likely have an STI, we need to make sure you do not have other STIs as well, which could also be contributing to your symptoms. We did tests for gonorrhea and chlamydia and they should be back in a few days; the Pap test should be back in about a week. We would like to get some blood tests to check you for other STIs. I know that this is a lot, but we want to be thorough for you—to protect you. We will give you some written information about this as well.”

Ms. Bell looks pale and strained.


You mention, “You said you don’t have any other sexual partners, but is it possible that your husband has had other sexual partners?”

You pause and give her time to think. She says in almost a whisper, “I wouldn’t be totally surprised if Jerry was sleeping with someone else.”

You ask gently, “It sounds like you have some concerns about your relationship and if it is okay I would like to talk to you more about this. We want you to know that everything we talk about here is confidential and will not be shared with anyone without your permission. That includes your husband. Do you understand?”

She nods.

“Can you tell us a little more about your relationship with your husband? You mentioned that he yells a lot and that he has pushed you sometimes. We also noticed the bruises on your abdomen, which are not in an area that is typically injured in a fall or other accident. Is he hurting you?”

Tears begin to show in her eyes.

You reassure her. “You are not alone. This is a safe place to talk about what is going on and to discuss your options.”

Ms. Bell tearfully explains that her husband has pushed her in anger and the bruises on her abdomen came from him hitting her when she mentioned that she might be pregnant. He had been drinking, though, she explained.

You are careful not to appear shocked about her admission. You look into her eyes and assure her, “I want you to know that this is not your fault. No one deserves to be treated like this.”


You remember reading about the increasing severity of intimate partner violence.

“Often these situations have a way of escalating. It may start out with yelling, become slapping, then turn to punching. Have things become worse or more frequent at home?”

You pause for a moment, considering how to ask your next several questions. You are concerned that Ms. Bell may feel that you are needlessly prying into her personal business. But, you know that as a medical professional, once you have dealt with her current injuries, your most pressing concern, is to assess Ms. Bell’s level of risk and safety.

“Because I’m concerned about you, I’d like to ask you a few more questions so I can understand what things are like for you at home. You said that your husband has pushed you at times, and that he has hurt you. Has he ever used a weapon, to hurt or threaten you with?”

“No, never that.”

“Are there any weapons or guns in your home?”

“Yes, my husband has a gun but it is locked up because of my son. Cooper does not know where it is. He’s had it for years; he says he needs to be able to protect his family and himself. In fact, he moves it around and I don’t always know where he keeps it.”

“You said that you rarely drink alcohol, and that you haven’t used any other drugs; but your husband does drink, at times a lot. Do you know if he uses any other drugs?”

“That’s right, I hardly drink at all. And if my husband is drinking, I definitely don’t drink. He can drink a lot once he gets going, but I don’t think my husband uses drugs. Maybe he has smoked pot in the past.”

“Has your husband ever threatened or harmed your son?”

“NO! I would never let him do that.”

“Has he ever threatened to kill you or your son or himself?”

“No, he has never threatened to kill me or our son, and he hasn’t ever suggested suicide.”

“Have you ever thought of escaping?”

Now Ms. Bell’s tears are freely flowing. She’s having a hard time talking, but she tells you, “I don’t have anywhere to go if I were to leave him. His check definitely helps with the mortgage, and I want my son to grow up with his father around. I don’t know how upset he would be if we left; I have never brought it up. The problem is only really bad when he has been drinking, and I certainly am not going to mention it then. I don’t have many close friends anymore; my friendships seem to have gone away since I have been married. My parents live in Massachusetts, and besides, they think Jerry is the greatest. I will let them think that for the time being. I don’t want to disrupt my life or my son’s life by moving so far away. Besides, I don’t want to get anyone else involved. It might even be dangerous for anyone I moved in with.”


Intimate Partner Violence Safety Assessment

1. Increasing severity of violence

2. Presence of gun in the house

3. Threats to kill or commit suicide by either victim or abuser

4. Use of drugs or alcohol by victim or abuser

5. Victim trying to leave or left recently

6. Harm to children


Increasing Severity of Intimate Partner Violence

1. Verbal abuse, insults, yelling

2. Throwing things, punching wall

3. Pushing victim or throwing things at victim

4. Slapping

5. Kicking, biting

6. Hitting with closed fist

7. Attempting strangulation

8. Beating up; punching with repeated blows

9. Threatening with weapon

10. Assault with weapon

Ms. Bell is at significant risk because of the history of violence, alcohol use, and weapons in the house. It isn’t clear whether the level of violence is increasing as it is common for there to be a “honeymoon period” after an episode of violence. Providing information on resources and options for the victim (D) allows the victim to make the best choices for themselves. Make sure the patient is aware that some people who inflict violence become angry when they see these kinds of resources or brochures in the home, on phones, or on browser histories on computers. The patient may want to make the call before leaving the doctor’s office.

· A: Couples therapy has been shown to increase the level of risk for the victim. The victim exposes the abuse, and the perpetrator feels like they are losing control and tries to regain it through further violence.

· B: Staying with family could be a good option, but would also be an obvious place for a victim to go and might place the victim and their family at increased risk.

· C: Having someone remove a gun from the house could increase the sense of loss of control on the part of the perpetrator and accelerate the abusive behavior.

· E: The clinician’s legal responsibility in regard to reporting intimate partner violence varies from state to state and is highly controversial because of concern that it might increase the level of risk for the victim. Mandatory reporting is more consistent in terms of child abuse and contacting social services. Experts in this field should be sensitive to risks and aware of appropriate responses.

· You tell Ms. Bell, “We want you to understand the impact that your marriage and relationship seem to be having on your health. You have trichomonas, which is considered a sexually transmitted disease. We are treating you for a possible pelvic infection because of the tenderness that was noted on your pelvic exam. This may partially explain your symptoms.

· “You also have bruises, which can explain some of your physical pain, and we suspect that you may have a lot of emotional pain. You are obviously under a lot of stress in your marriage, which can exacerbate pre-existing conditions or cause symptoms similar to the ones you are experiencing on its own. Cooper also seems to be responding to your stressful situation. This may be getting pretty dangerous for you and your son.”

· Ms. Bell says “You know, I think that things will be better now; he will be relieved that I am not pregnant. I don’t think it will be a problem. My husband has been saying he is sorry. I know he loves us. I really think he wants to change. He wants it to be better.”

· You respond, “It would be great if that happens, but I am concerned that things might not get better, and I want you to know your options and have resources if you ever don’t feel safe.”


Escalating Cycle of Intimate Partner Violence

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.


Dr. Nayar has suggested that you do the talking and discuss your assessment and plans with the patient.

You say: “First of all, we would like to treat your trichomonas infection with an antibiotic, metronidazole. It is important that you and your husband both take these pills, but he cannot drink any alcohol while the medicine is in his system. Beyond this, Dr. Nayar and I have talked about the things we have heard you say today. We have discussed ways that we think might be helpful to you, but now we want to discuss these options with you. We believe that you are at high risk of your husband hurting you again when you return home because of the violence that has already occurred, the fact that he drinks, and the presence of a gun in your home.

We know that you are in the best position to assess your levels of danger, so if you decide to return home, we respect your decision. We are not here to make decisions for you, but to facilitate your ability to think through alternatives and seek an acceptable course of action for yourself and your child.”

Dr. Nayar adds, “No one, including you, deserves to be injured by their partner.”

She responds, “I think things will be better, I don’t think he’ll hurt me or Cooper.”

“All right,” you acknowledge. “If you decide to go home, we support your decision, but we want you to know that you are not alone. We are concerned that it might not be safe for you to make phone calls to support agencies from your home. I have the phone number to a shelter that I want to give you today so that you can call and talk to the counselor there. We have a quiet room where you can be by yourself so that you can speak with this counselor today if you would like. We can have the staff member continue playing with Cooper while you are talking on the phone. We don’t want your husband coming home, checking the phone, and finding that you have been calling around to various shelters.”

“Well, it is true that my husband would find out if I was calling these numbers from home. He checks the computer at home to see what websites I’ve looked at. He checks the cell phone log to see my outgoing calls. And, after he has been drinking, he even checks *69 on the home phone to see who has called me. But I don’t want to go to a shelter,” she says.