Marcia Anne Giancomello
Facilitator Guide
Marcia Giancomello
Facilitator Guide
Case Authors:
 2006
Jacqueline Anne Bartlett, MD, Department of Psychiatry, NJMS
Linda Boyd, DO, Department of Family Medicine of Medical College of
Georgia
Revised:
© 2010
Neil Kothari, MD, Department of Medicine, NJMS
Sophia Chen DO, MPH, Department of Pediatrics, NJMS
Primary Learning Objectives:
At the end of this case, students will be able to:
 Elicit a comprehensive sexual history
 Demonstrate the ability to discuss domestic violence issues with a patient
 Describe different presentations of patients in domestic violence situations
 Develop a support plan for patients with domestic violence issues
Secondary Learning Objectives:
At the end of this case, students will be able to:
 Identify common behavioral characteristics of patients who have been sexually
abused in their past.
 Describe the presentation of common sexually transmitted diseases
Completed before case begins:
 Lecture delivered on sexual history taking
Recommended Readings:
 Tomlinson, J. (1998). ABC of Sexual Health. BMJ, 317: 1573-1576.
 Taking A Sexual History - Skills Checklist
 Elements of a Sexual History: Asking the Questions
For completion before the second session:
 Lecture delivered on domestic violence
Recommended Readings:
 Smith, M. & Segal, J. (2010 March). Domestic Violence and Abuse: Signs of Abuse
and Abusive Relationships. Retrieved July 31, 2010 from the “Help Guide” website:
http://www.helpguide.org/mental/domestic_violence_abuse_types_signs_causes_eff
ects.htm
 Rhodes, H.V., Frankel, R.M., Levinthal, N., Prenoveau, E., Bailey, J., Levinson, W.
(2007). You’re Not a Victim of Domestic Violence, Are You? Annals of Internal
Medicine, 147:620-627.
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Marcia Anne Giancomello
Facilitator Guide
Facilitator Notes:
This is designed to be the third case of the Advanced Communication Skills course. As with
all Problem Based Learning (PBL) cases, there will be opportunities to develop hypotheses
about the patient’s medical problems. We do want to focus attention, though, to details of
the development of a good doctor-patient relationship.
This case is intended to take 2 sessions. A student should be selected (volunteer or
chosen) to assume the patient role if a Standardized/Simulated Patient (SP) is not assigned
for that session. If a student is selected, s/he should be given the script that is included in
the facilitator guide in advance.
There may be students in your group that have experienced sexual and/or physical
abuse, or know someone who has, and this case could cause emotional pain. Please
look out for students who seem unusually quiet or anxious during this case and try to
talk with them after class. Feel free to call a Course Director with any concerns.
Students can be referred to Student Health and Wellness where they can be assessed
and referred for counseling.
Standardized Patient Vitals:

A female patient (18-30 years old)
Symbols to help you navigate the facilitator guide:
1.
No symbol before the bolded question means the question is for small
group discussions.
Student
Task
2. Student must interview the patient
SP
PP
3. Standardized Patient’s script
There will be learning issues as the case unfolds. Please have the students keep
track of their own learning issues as they will need to research them and present their
findings at the next small group session
Overview of Case:
Marcia Anne Giancomello is an 18 year old sexually active female who presents to a primary
care doctor with a complaint of abdominal pain for several days. She is given a diagnosis of
Pelvic Inflammatory Disease and is instructed to notify her partner. On subsequent visits,
she admits to being sexually abused, and physical examination reveals that she is also
physically abused. Students will need to address domestic violence at the end of this case.
2
Marcia Anne Giancomello
Facilitator Guide
Overview of First Session:
The goal of this session is to have the students obtain a full history with emphasis on the
sexual history from the standardized patient. It is expected that students will develop
learning issues relating to the case. Other crucial issues that will come up with this
encounter are the student’s comfort level when inquiring about the sexual history.
Please make sure all students are scribing while they listen to the standardized patient’s
history. They will be asked at the second session to identify any information that was
missing from the SP’s history.
Standardized Patient’s Instructions:
Standardized patients are told that the facilitators will let them know how they will be used
during the session(s). For example, you may choose to ask the SP to enter the room only
when the students are instructed to interview him/her. You may ask the SP to leave the
room and sit on a chair by the door for the remainder of the case. You may also choose to
keep the SP in the room through the entire session, only asking him/her to speak during the
SP activities. In addition, the SP should be encouraged to provide direct feedback to the
students at the end of each session. The bottom line is the SP will play his/her role as
instructed by the facilitator.
DISTRIBUTE STUDENT CASE PAGE 1
Scenario:
You are student working with a primary care doctor. Dr. Ellis is expecting you to obtain the
pertinent history and physical first (except for the GYN exam – you’ll do that together) from a
new patient and to formulate a differential diagnosis and management plan.
What do you do first?
Facilitator Notes:
Students might discuss reviewing the history taking section of their textbook. They should
also discuss the proper etiquette for entering the exam room and initiating the interviewing
process.
Prompting Questions
Which can be used to facilitate this discussion include:
1. How do you feel about taking a complete Gyn and sexual history from a patient?
2. What is the best way to enter the patient’s room? (Knocking first, etc.)
3. How should you introduce yourself as a student?
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Marcia Anne Giancomello
Student
Task
Facilitator Guide
Select Student to begin taking the history from the Standardized “Patient” (SP), Ms.
Giancomello.
Facilitator Notes:
Arrange the room so the SP can sit at the front of the room and have one other chair for
students to take turns as they assume the role of the health care professional asking
questions.
Only the SP and the facilitators have the full history information. The students will not get
this information until later unless they specifically ask for it during the history.
Feel free to prompt the students if they get stuck during parts of the history. This session will
serve as practice for taking a complete sexual history.
[You and the SP are given the full history, even though the students are only asked to
elicit the “pertinent” history from the patient.]
Marcia appears a bit older than her age of 18, is very attractive, is dressed in a tight low-cut
blouse, tight jeans and stiletto heels, and wearing lots of make-up. She is tall, underweight,
with long dark hair.
SP
PP
SP Notes:
Marcia Anne Giancomello is an 18-year old female
SIMULATED PATIENT: Act high strung. Talk quickly. Smile a lot even when talking about
symptoms and pain. Seem eager to please. Marcia appears a bit older than the stated age,
is very attractive, dresses provocatively (low cut blouse and tight jeans), and wears lots of
makeup. She is single, tall, with long hair. Give brief answers, which are specific to any
questions asked. Stop until more questions are asked by the student. DO NOT
VOLUNTEER ANY INFORMATION regarding anything not asked by the student
interviewing you. Make it difficult, but not impossible. You are given the full history, even
though the students are only asked to elicit the “pertinent” history from the patient.
CHIEF COMPLAINT: Lower abdominal pain for several days
HISTORY OF PRESENT ILLNESS:
Pain started several days ago. Started off and on but has become constant.
Describes pain as initially sharp and intermittent, but now pain is dull, aching and
constant.
Pain is across the lower abdomen. Intensity of pain is about 7/10 most of the time,
but sometimes goes up to 9/10 now.
4
Marcia Anne Giancomello
Facilitator Guide
Heating pad helps and nothing really makes it worse. You have mild nausea, no
vomiting, no diarrhea. Vaginal discharge for about one week. Not really able to do
anything now because of the constant pain, so you decided to see the doctor.
Facilitator Notes:
At various points while the student is taking the HPI, ask why they are asking specific
questions.
Prompting Questions:
1. Why is it important that you are asking about the character of the abdominal pain?
2. At the end of the HPI, stop the student taking the history and ask the group to begin
to develop ideas about what might be wrong with this patient. (Begin to develop
differential diagnosis)
SP
PP
PAST MEDICAL HISTORY:
Hospitalizations:
Surgeries:
Childhood Illnesses:
Injuries:
Past Illnesses:
GYN:
Transfusions:
Meds:
Allergies:
None
None
None
None
Used to get a lot of abdominal pain when in middle school.
Was diagnosed with possible irritable bowel syndrome then.
No meds were prescribed, just dietary treatment
One pregnancy – fetus aborted at 12 weeks (patient was 14
years old). No other pregnancies.
Menarche age 11, periods usually regular about the same time
every month, flow lasts 5 days with a moderate flow. Used to
have bad cramps when in middle school – even had to miss
school sometimes, but cramps are much better now. Manages
them with Midol or Advil.
Last menstrual period 3 weeks ago. Last period was late and
very light. Wonders if she could be pregnant.
None
Recently has been trying Advil and Tylenol for abdominal
pain. Otherwise, no other medicines.
[Tell only if asked what meds you took today] Took two
Tylenol 2 hours ago.
None
5
Marcia Anne Giancomello
Facilitator Guide
Prompting Questions:
At any point in the history, stop and ask:
1. Why did you ask this question?
2. Why did you ask it now?
3. How does this question help you to develop the differential diagnoses?
SP
PP
FAMILY HISTORY:
Father – alive with hypertension (age 42), on medicine for hypertension
Mother – alive (age 40). On Zoloft for irritable bowel syndrome
Half-sister (father’s child) – in 5th grade (age 11)
2 half-brothers (mother’s) – in High School (ages 7 and 5 )
Maternal Grandmother – has irritable bowel syndrome
All other grandparents are dead:
Maternal grandfather – died of a stroke at age 62. He smoked heavily.
Paternal grandfather – died at age 57 of a heart attack. He smoked and drank.
Paternal grandmother – died of breast cancer at age 67.
CURRENT HEALTH/RISK FACTORS:
Exercise:
Goes to gym about 5 times per week for about an hour treadmill and weights. Also takes dance classes a couple of
times per week.
Nutrition:
Eats out 2-3 meals per day.
Smoking:
Smokes every day. Started at age 13. Never quit. Loves
smoking. Smokes every day after school, while hanging out
with her friends. 5 to 10 cigs/day
Alcohol:
Has had occasional drinks at parties – most ever was 3-4
drinks, made her feel very woozy and sick, so never did that
again. Answer negative to the CAGE1 questions. (C=Have
you felt you should Cut down on your drinking? A=Have
people Annoyed you by criticizing your drinking? G=Have
you ever felt bad or Guilty about your drinking? E=Have you
ever had an Eye-opener (a drink first thing in the morning) to
steady your nerves or to get rid of a hang-over?)
Drugs:
Tried just about everything starting in High School – has been
pretty wild. Now only smoking marijuana. Denies intravenous
drug use – is “deathly afraid” of needles
Sleep pattern:
Stays out late weekend nights at clubs (uses a fake ID).
Getting only about 5 hours of sleep at night.
Recent health exams:
Had a Pap smear last year at Planned Parenthood.
Immunizations:
Remembers getting shots before high school, but doesn’t think
she has had any since then.
Injury prevention:
Has a smoke detector in her house. Wears seat belts when
her mother makes her.
1
Ewing, J.A. (1984). Detecting Alcoholism: The CAGE Questionnaire, Journal of the American Medical
Association, 252: 1905-1907.
6
Marcia Anne Giancomello
SP
PP
SOCIAL HISTORY:
Personal Status:
Culture and Religion:
Support system:
Socioeconomic:
Domestic Violence:
Occupation:
Sexual Behavior:
Military:
Travel:
Facilitator Guide
Single. Lives with family in 3 bedroom house.
She “hooks up” with guys when she feels like it. She is seeing
one guy pretty regularly.
Born in NJ and attended Catholic school for grade school.
Parents separated when she was 4 and divorced when she
was 7. She saw her father intermittently. Her mother remarried
at age 8. Stepfather is OK – a cop. Mother had 2 more kids.
Mother is a grade school teacher. Father is now a Principal of
a high school near where she grew up (South Jersey).
Raised in an Italian Catholic family that went to church
regularly. She stopped going to church in early high school
and does not consider herself religious.
Friends.
Parents are middle class, have health insurance and she is
making enough money to buy clothes and go out to clubs. Not
saving anything.
Denies
Works as receptionist for a tanning salon part-time.
Frequent sex with different partners (male AND female, but
give information about female partners only if specifically
asked)
Uses condoms with spermicide (“most of the time” – give this
information only if specifically asked).
Total lifetime partners (about) 10. Age of 1st intercourse
13 years old.
Oral sex partners (about) 10. Does not consider oral sex
really having sex.
Used birth control pills for a while in early high school (mother
made her start after she got pregnant), but she recently
stopped in college because she thought it made her gain
weight.
[Only if specifically asked] Has been having pain with
intercourse for that past couple of weeks.
[Only if specifically asked] Engages in oral sex, vaginal
intercourse, and anal intercourse. You do not use condoms for
oral sex, anal intercourse, and female partners because no
risk of pregnancy.
None
None
REVIEW OF SYSTEMS: (info given only if you are asked about each system)
General:
Very tired for the past 2 weeks. No weight changes. Eating
OK.
Heent:
Occasional sneezing in am
Pulmonary:
No complaints
Heart:
No complaints
GI:
See Chief Complaint and History of Present Illness
GU:
See GYN history
Neuro:
No complaints
Musc-Skel:
No complaints
7
Marcia Anne Giancomello
SP
PP
Psych:
Facilitator Guide
Has always been nervous and high strung since a kid. No
counseling and no psychiatric treatment or medications.
Has been kind of wild in high school. Parents are always angry
at her. She tried a lot of drugs and stays out late and has had
lots of boyfriends. Got pregnant at age 14.
Facilitator Notes:
If the students do not take a sexual history, then prompt them to do that. If you don’t think it
is adequate, then have a group discussion about what else should be asked.
Prompting Questions:
1) How did you feel asking personal questions in the sexual history?
2) How would you educate the patient on her risky sexual behavior?
Facilitator Notes:
Encourage the students to explore their own judgments about this patient who is
promiscuous and engaging in high-risk sexual behavior. How would they approach a patient
engaging in high-risk sexual behavior? Talk about how personal judgments need to be
separated from our professional behavior.
Prompting Questions:
1. What are your reactions to this patient?
DISTRIBUTE STUDENT CASE PAGE 2
Now that you have taken the pertinent history, what problems have you identified with
this patient?
What are the hypotheses/ differential diagnoses for the problems that you have
identified?
8
Marcia Anne Giancomello
Facilitator Guide
Facilitator Notes:
Some of the diagnoses the students may be considering at this time are:





Ectopic (tubal) pregnancy
Sexually transmitted disease
Pelvic inflammatory disease
Irritable bowel syndrome
Eating disorder




Diverticulitis
Urinary tract infection
Ovarian cyst
Appendicitis
Prioritize the hypotheses based on what problems you know so far.
What parts of the physical exam do you want to do and why?
DISTRIBUTE STUDENT CASE PAGE 3
Vitals: Height 5’10”, Weight 125 lbs, Temp 99.6, BP 110/70, Pulse 94, RR 16
General appearance: Well developed and thin young woman in moderate distress and
discomfort
Heart:
Regular rate and rhythm without murmurs, rubs or gallops
Lungs:
Clear to auscultation
Abdomen:
Normoactive bowel sounds x 4 quadrants, tenderness in the left lower
quadrant and suprapubic area with guarding, no rebound tenderness, no
masses palpable
Skin:
No rashes present
Mental-Status: Orientated x 3, memory intact, slightly anxious mood/affect
Neuro:
Deep tendon reflexes 2/4 B/L, muscle strength +5 all extremities, cranial
nerves intact
What problems did you identify during her physical?
9
Marcia Anne Giancomello
Facilitator Guide
DISTRIBUTE STUDENT CASE PAGE 4
You go present your findings to Dr. Ellis and then go back in to perform the Genitourinary
(GU) exam together.
GU:
Vaginal vault with yellowish white discharge present, + yellowish cervical
discharge, cervix appears normal, negative Chadwick’s sign, + cervical
motion tenderness. No distinct right lower quadrant tenderness. No masses
palpable in the adnexa. No tenderness elicited during recto-vaginal exam.
Rectal exam negative for masses, tenderness, or blood.
Who should be in the room during the physical exam? Why is this important?
Facilitator Notes:
There should always be a chaperone present in the room during a GYN exam. If the
student accompanying the physician is female, then she could potentially serve as the
chaperone. A male doctor should not perform a GYN or breast exam without a chaperone to
protect himself from claims of inappropriate sexual behavior as well as protect the patient.
More controversial is the need for same-sex providers to have a chaperone present. In our
opinion, all providers should have a chaperone present during any sensitive exam.
What are your Differential Diagnoses (hypotheses) now? Go through your previous
list, and rule in or rule out based on the physical findings.
Facilitator Notes:
Use the VINDICATE SLEEP2 mnemonic for use with generating hypotheses.
Some of the diagnoses the students may be considering at this time are:
 Ectopic pregnancy
 Sexually transmitted disease – likely with yellow discharge and cervical motion
tenderness
 Pelvic inflammatory disease (PID) – very likely with fever, cervical motion
tenderness, cervical mucous
 Bladder infection – still possible
 Irritable bowel syndrome – less likely with pelvic pain and cervical motion tenderness
 Diverticulitis – less likely
 Ovarian Cyst
 Appendicitis – less likely but still possible
2
Collins, R.D. (1981). Differential Diagnosis in Primary Care. Philadelphia: J.B. Lippincott Company.
10
Marcia Anne Giancomello
Facilitator Guide
What lab tests or other diagnostic studies would you like to order? (You must give
justification for each test.)
Facilitator Notes:
The following lab tests might be ordered:
 CBC (Complete Blood Count) with differential - evaluate for anemia, and serious
infection
 Pregnancy test – since her period was not normal last cycle, it is important to R/O
pregnancy. If + could lean towards diagnosis of ectopic pregnancy
 Urinalysis and/or urine culture – to rule out acute bladder infection
 Sedimentation rate (ESR) – elevated ESR is one of the additional criteria for PID,
can detect infection and inflammation (not specific)
 C-reactive protein – a non-specific screen for inflammation and infection (also one of
the additional diagnostic criteria for PID)
 Cervical cultures for gonorrhea and Chlamydia
Facilitator Notes:
Students should be expected to have learning issues that include treatments of their top
hypotheses. This should include sexually transmitted diseases and pelvic inflammatory
diseases.
END OF SESSION 1
11
Marcia Anne Giancomello
Facilitator Guide
Marcia Giancomello - Session 2
Overview of Second Session:
During this session, students will recommend a treatment plan for Pelvic Inflammatory
Disease. They will also need to address the issue of domestic violence with the patient.
Facilitator Notes:
1. Have each student review their learning issues – each student should only take 3
minutes or less to summarize their findings for the group. Note if they use what they
have learned as the session progresses. Students should note which resources they
use each week on the resources grid.
2. After the learning issues are presented, have one student summarize the case and
the group should re-evaluate and prioritize their hypotheses based on the new
information from the learning issues.
Facilitator Notes:
This information is for facilitator knowledge only as this is the case diagnosis. One of the
students should have researched and presented PID as a learning issue, so all of the
students in the group should now have this information.
PELVIC INFLAMMATORY DISEASE
Minimum criteria for diagnosis of Pelvic Inflammatory Disease, or PID:
 Lower abdominal tenderness
 Adnexal tenderness
 Cervical motion tenderness
Additional criteria for diagnosis:
 Pyrexia > 38.3oC (101oF)
 Abnormal cervical or vaginal discharge
 Elevated WBC count
 Elevated erythrocyte sedimentation rate, C-reactive protein
 Confirmed Chlamydial infection of cervix
- Culture or antigen test for Chlamydia trachomatis positive
Definitive criteria for diagnosis:
 Endometrial biopsy reveals endometritis
 Ultrasonography shows tubo-ovarian abscess or fallopian tube abnormalities
Abnormal Ultrasound Findings:
- Fluid filled tube
- Pyosalpinx
- Tubo-ovarian abscess
- Free pelvic fluid
12
Marcia Anne Giancomello
Facilitator Guide
Pelvic Inflammatory Disease (continued)
Endocervical mucus should be examined:
 Microscopy for presence of WBCs
 Gram stain for Gram-negative intracellular diplococci
 Culture of Neisseria gonorrhoeae
 Culture or antigen test for Chlamydia trachomatis
Additional information regarding diagnosis:
 Pregnancy testing should be routine where PID is suspected in order to exclude
ectopic pregnancy and identify the rare case of PID in the pregnant patient
 Endometrial biopsy may be considered in cases of pelvic pain where a diagnosis of
PID is being considered
 Ultrasonography and computed tomography may help in assessing presence and
progress of tubo-ovarian abscess
 Magnetic resonance imaging used in some centers as alternative to laparoscopy
 Laparoscopy may provide definitive diagnosis but usually individualized
DISTRIBUTE STUDENT CASE PAGE 5
Based on the physical exam findings, Dr. Ellis suspects pelvic inflammatory disease.
She discusses with you the empiric treatment option:
Ceftriaxone 250 mg IM + Doxycycline 100mg orally BID x 14 days
Given the fact that Marcia is “deathly afraid” of needles, do you think Marcia will
agree to this treatment plan? Are there any alternative treatments you could offer to
Marcia?
13
Marcia Anne Giancomello
Facilitator Guide
Facilitator Notes:
Promote a discussion of what to do if your patient adamantly refuses your treatment plan.
You should also discuss if your treatment plan will change if the patient has health insurance
with prescription drug coverage vs. a patient who does not. What is the likelihood of
compliance with a weeklong prescription vs. immediate one-time treatment? With a patient
(like Marcia) who has a fear of needles (as previously stated in her history) – choosing oral
meds instead might be better for her.
According to the 2010 CDC STD treatment guidelines**, the recommended regimens for
outpatient treatment of PID are as follows:
Recommended Regimen:
1. Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice a day
for 14 days
OR
2. Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently
in a single dose PLUS Doxycycline 100 mg orally twice a day for 14
OR
3. Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) PLUS
Doxycycline 100 mg orally twice a day for 14 days
Alternative Oral Regimens:
1. Amoxicillin/Clavulanic acid and Doxycycline were effective in a single clinical trial,
however, gastrointestinal symptoms may prevent patients from completing this
regimen.
2. Levofloxacin 500 mg orally or ofloxacin 400 mg twice daily for 14 days and
Azithromycin 2 g orally in a single dose could be used if parenteral cephalosporin
therapy is not feasible.
** http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf
14
Marcia Anne Giancomello
Facilitator Guide
What else do you need to educate the patient about?
Facilitator Notes:
Partners need to be advised if the cultures come back positive for an STD. Patient should
be informed about the importance of using safer sex practices. (eg. Wearing condoms all
the time, including during anal intercourse since this practice carries a very high risk for
transmission of infection. Partners should be tested for STD’s before having sexual
relations.)
Student
Task
Select Student to tell the patient her diagnosis and provide education about her
treatment regimen. Advise her that your office nurse will call in two days to check on
how she is feeling and give her the lab test results. Ask her to come back in 2 weeks.
Facilitator Notes:
After the student finishes giving the diagnosis and providing education, the SP should leave
the room in preparation for her next “visit.” Facilitators should lead a short discussion with
the students as to how the encounter closed. Did the SP clearly understand all of the
directions?
DISTRIBUTE STUDENT CASE PAGE 6
Marcia returns to the office 4 months later, having not shown up for her previous follow-up.
Reviewing her chart, you see that her previous blood work came back with:
An elevated white blood cell count of 22 T/ul with a left shift of 76% neutrophils.
Endocervical mucous was positive for Chlamydia by antigen.
ESR(Sedimentation Rate) was elevated at 42
UHCG (Urine human chorionic gonadotropin or Urine pregnancy test) was negative
Patient was notified of results by nurse 3 days after the last visit and the patient told the
nurse that she was feeling better at that time.
Student
Task
Select Student to go in and take the SP history for today.
15
Marcia Anne Giancomello
Facilitator Guide
SP Notes
SP
PP
[Appear very anxious and hyper]
CC:
Lower abdominal pain – just like last time
HPI:
Pain started about a week ago with mild aching on and off. Now the pain is constant,
about 8/10 intensity and she had to miss work and school yesterday and today
because of it. Has some vaginal discharge, but not more than usual.
GYN: LMP 2 weeks ago and that was a normal period.
Has had 2 partners since last visit. Never told them about her infection. She planned
to use condoms all the time, but on a couple of occasions, her partner talked her out
of it (both partners).
She did feel better after the last treatment within a few days, and then normal after a week.
Avoided partners for a month, then started dating again.
Facilitator Notes:
Prompting Questions
1. What do you think about the patient at this point?
a. Students might think she is stupid, self-destructive, dysfunctional,
endangered
SP
PP
[If asked about why she is anxious or upset or if responded to in an empathetic way,
share this information]
Has a history of being sexually abused at age 8 to 10 by half-brother (step-father’s son from
a former marriage)
She never told anyone in her life. (At this point act very upset or cry) He was using drugs
and went to jail when she was 10 (He was 22.) He had threatened to torture and kill her and
her mother if she told anyone.
He got out of jail 2 years ago, but she hasn’t seen him. He was ‘disowned’ by his family for
substance use and criminal behavior.
[If asked by doctor] Still afraid of him - is afraid he will come looking for her.
16
Marcia Anne Giancomello
Facilitator Guide
Facilitator Notes:
If the students do elicit the information about the sexual abuse history, take a break and talk
about how to respond to a patient that reveals this kind of personal information. Some
examples of what a doctor could say:
a)
b)
c)
d)
“I’m sorry that you went through that.”
“That must have been really hard for you.”
“Thank you for sharing that information with me. I know it must be hard to talk about.”
“You’ve been through a lot – I can understand why you are so upset.”
You should also talk about whether it would be appropriate to touch the patient in
consolation. This is a controversial topic. Some doctors do use touch in consolation, but
when used, should be limited to shoulder or elbow or hand. Only use touch if you, as the
practitioner, feel comfortable with it – otherwise it will come off as stiff and awkward. Also
only use it if you sense that the patient would be comfortable with it.
In this case, since she is reporting a history of sexual violence, and she is not a long-term
patient of this doctor, it is probably safest to avoid touch.
DISTRIBUTE STUDENT CASE PAGE 7
You present your history to Dr. Ellis and go in with her to examine the patient.
Vitals: Ht: 5’10”, Wt: 120 lbs., Temp: 101.6, Pulse: 116, RR: 16
Patient appears thin and in moderate distress and has been crying.
Heart:
Lungs:
Abdomen:
GU:
Tachycardic, regular rhythm, no murmurs
Clear to auscultation
Normoactive bowel sounds x 4 quadrants, tenderness diffusely in the lower
quadrants and suprapubic area with guarding, no rebound tenderness. Bruise
on the right lower quadrant of the abdomen measuring about 4 inches by 3
inches. (When asked about it, she says that she bumped into the corner of
her dresser.)
(+) cervical mucous and (+) cervical motion tenderness (more this time than
last) – patient jumps when you do the bimanual examination. No adnexal
masses palpable.
What do you think is going on with the patient?
Is your treatment choice different this time?
What are some reasons that a patient might not be compliant with a doctor’s
suggestions?
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Facilitator Notes:
Students should be discussing how to manage the patient’s report of past sexual abuse.
They should be wondering about the bruise and how it got there, and they should ask about
it.
Prompting Questions:
1) What can sexual abuse do to a person?
2) What are some of the associated problems with sexual abuse?
 Hypersexuality
 Can present as a seductive patient
 Post-traumatic stress disorder (PTSD)
 Depression
 More prone to select abusive partners
3) What do you think about that bruise on her pelvic area? How do you deal with a
patient when you are suspecting domestic violence, but the patient denies it?
Student
Task
Select Student to tell the patient what your treatment plan is and have her return to
the clinic in one week.
Facilitator Notes:
After the student finishes this 2nd visit, the SP should leave the room in preparation for her
final “visit.” Facilitators should lead a short discussion with the students as to how the
encounter closed. Did the SP understand the new treatment plan? Did the student talking
with her provide adequate emotional support?
DISTRIBUTE STUDENT CASE PAGE 8
Student
Task
Patient returns one week later. Dr. Ellis sends you in to get a history.
Select student to obtain a focused history.
SP Notes:
SP
PP
You told both partners about the Chlamydia in the past couple of days. One of your partners
seemed OK with the news. However, he did not show up for a scheduled date and is not
returning phone calls.
You told your other partner (single, age 20, in college) after going to his apartment after
dinner last night. He cursed you out, called you a ‘whore’, and then hit you several times
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Facilitator Guide
knocking you down. [If asked] admit that he has hit you several times in the past month,
including causing the bruise on the abdomen noted at last visit.
You complain of soreness of the left eye where he hit you, and soreness and bruising in
several spots on the left side where you fell when he hit you.
Your abdominal pain is gone.
(If you were put on the oral medication, you stopped after 5 days when you felt better)
How do you respond to the patient?
Facilitator Notes:
There should be some empathic response to her admission of abuse. It is important not to
say anything that blames the victim, no matter how well intended it may be. For example,
saying “You shouldn’t have put up with that” only places more blame on the victim, as does,
“Why would you stay with a man like that?”
Some examples of supportive and empathic responses are:
 “I’m sorry that happened to you.”
 “You don’t deserve to be treated like that.”
 “That sounds pretty frightening. How afraid of him are you?”
DISTRIBUTE STUDENT CASE PAGE 9
You present the history to Dr. Ellis and you go back in together to see the patient.
Vitals: Ht: 5’10”, Wt: 115 lbs., Temp: 98.6, Pulse: 88, RR: 16
Pupils equal round and reactive to light
Left eye upper and lower lids swollen with ecchymosis
Fundus normal, no hyphema (blood in the front area of the eye)
Vision 20/20 for distant and near vision
Extraocular movements intact bilaterally, no step-up lesion of the orbit
No crepitus or deformity of the zygomatic bones bilaterally
Tympanic membranes intact bilaterally, No Battle’s sign
Left wrist is swollen and tender with decreased range of motion, but no point tenderness
Ecchymosis of the left hip
Abdomen is soft and non-tender with no guarding.
Discuss each question one at a time…
Did you give her good advice last time?
How do you feel about what happened to her?
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Facilitator Guide
Facilitator Notes:
Sometimes you will do the right thing as a health care provider, but there is a negative
outcome. It certainly won’t feel good. When there is a bad outcome, you should always go
through a process of analysis of the situation, to see if you should have done something
differently. It is often helpful to use trusted colleagues as a sounding board to discuss these
situations.
What is the differential diagnosis for her injuries?
Facilitator Notes:
Soft tissue injury, like bruising or sprain.
Rule out fracture.
What do you do now?
Facilitator Notes:
1. Need to discuss intimate partner violence (domestic violence). Ascertain patient’s risk for
further injury.
2. Do health care providers need to report this assault? In this case, it would have to be the
patient’s decision if she wanted to press charges. It would be important to document her
injuries and reporting of the incident. If possible, offer to photograph her injuries, in case
she decides to press charges.
3. What if the patient had a gun shot wound, or was cut with a knife and simply took care of
herself? Would the doctor’s responsibilities be any different?
4. Should order an x-ray of the left wrist at a minimum. May want to order an x-ray of the
left orbit and left hip, too.
5. Probably not necessary to send to the ER or an orthopedist, unless the x-ray is positive.
6. Encourage her to call police or inform family.
What will you recommend for the patient?
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DISTRIBUTE STUDENT CASE PAGE 10
Student
Task
Select Student to talk to the patient about your recommendations.
SP
PP
SP Notes:
You are uncomfortable with reporting this incident to the police. The young man is a friend of
many of your friends. You are afraid he will tell them. You’ll just stop seeing him. In fact,
you say that you are not going to see any guys for a while.
If the doctor recommends counseling for the abuse (either the previous sexual abuse or
this recent domestic abuse) you should say that you will consider it, and it sounds like it
might be a good idea.
If the doctor doesn’t offer counseling, say something like, “Why does this keep
happening to me? What did I do to deserve being treated like this?”
Facilitator Notes:
The group should discuss how to respond to her comments.
It may be helpful to tell the patient that women who have experienced abuse often get into
abusive relationships unintentionally. Counseling can help to come to terms with the abuse
and reverse destructive relationship patterns.
What if her partner was a patient of yours? How would you deal with him?
END OF CASE
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