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. 1 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? 3 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? 17 Marcia Anne Giancomello Facilitator Guide 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 18 Marcia Anne Giancomello 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? 19 Marcia Anne Giancomello 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? 20 Marcia Anne Giancomello Facilitator Guide 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 21