Module 2: Training Materials for self-study

Sabrina is an accountant, 30 years old, married to a construction worker for 8 years now. She tells her primary care physician about her low energy level and headaches that have affected her for over a year. The headaches have gotten worse in the past month, affecting her mostly at the end of the day and she gets hopeless and feels down.

She has trouble sleeping and reports pain all over. She has been to several physicians in the past year but has not found anything that could help her. She has had blood tests, been prescribed painkillers, been advised to get more exercise and change her diet. She tells her physician that she desperately needs something to be done for her today as her husband is getting impatient with the lack of results.

When Elyse, a 28-year-old nurse developed debilitating irritable bowel symptoms (IBS), she went to a new primary care physician. In response to the physicians detailed questions as part of initial assessment, Elyse told her that work was okay but she was having a few problems with her boyfriend. Sex was sometimes painful, but she tried not to show it. She had occasional migraines, her periods were heavy and painful and she was treated with antidepressants for 3 years in her early twenties. She was a binge drinker as a teenager. She’d only ever had one Pap smear 8 years ago and it was excruciating.

Case adapted from The Medical Women’s International Association’s Interactive Violence Manual

Mandy was a 23-year-old patient currently 28 weeks pregnant. I attended her birth and have been her doctor since then. I knew her quite well as she had asthma and spent more than the usual time in my office. I also looked after her mother and sister and grandmother.

She did not do well in school and hung with the rough crowd. Although we had talked about contraception on previous visits, she was unreliable taking her birth control pills. Therefore, it was not a surprise to find her presenting to my office for pregnancy care. Her relationship was unstable but at present she was living with the baby’s father, an El Salvadorian immigrant involved in the drug trade. The pregnancy was progressing uneventfully until one day Mandy presented with facial bruising and abdominal pain.

Case adapted from The Medical Women’s International Association’s Interactive Violence Manual

“A patient on my list for over 10 years, aged 87 years, lived after her daughter’s death with her son-in-law in a detached family house. The patient was suffering from cardiac insufficiency and repeatedly she came with injuries and excoriations on her legs to my private practice. “She is always running down the stairs too quickly!” said the son-in-law who accompanied her. His behaviour was then rather uncooperative and “strange”. The patient insisted that she was kindly well nursed by him and a niece with a nurse living nearby looked after her.”

Adapted from a case study from RACGP (2014): Abuse and Violence: Working with our patients in general practice

This case is about Daniel, a 4-year-old boy, and his mother Ms. Luscak, aged 27 years who had four different partners. She misuses alcohol and depicts occasional violence towards her partners. She speaks little English. Daniel had 2 siblings, a 7-year-old sister Anna by mum’s first partner and a 1-year-old brother Adam by mum’s fourth partner, Mr. A. On 27 different occasions, the police were called to domestic violence incidents often complicated by both parents being drunk. On 2 occasions Daniel’s mum took sleeping pill overdoses with the intention of committing suicide. The family moved house on numerous occasions due to an inability to pay rent. When pregnant with Adam, Mr. A. urged Ms. Luscak to have a termination. She missed 4 antenatal appointments. At one stage she was hospitalised and Mr. A took the drip out of her arm and she self-discharged.

Daniel had a spiral fracture to the left arm reported as due to jumping off the settee with his sister the previous when being seen at the emergency room. Bruises on his shoulder and lower tummy were explained by his mother to be due to falling off his bike regularly. Meetings of health care professionals took place but the long history of domestic violence was not considered. When Daniel started school, there were frequent absences as for his sister Anna. Teachers became concerned as Daniel was getting markedly thinner and always seemed hungry, taking food from lunchboxes of other children. Daniel had poor English and was a shy and reserved boy and did not talk to the teachers.

Task for reflection
(1) Reflect on the numerous signs and red flags presented in Daniel’s case. What were the early indicators of potential abuse, and how might they have been identified sooner?
(2) What were the missed opportunities for intervention and support of healthcare professionals? How could it have been done better?

Case from The Medical Women’s International Association’s Interactive Violence Manual

A little girl comes to your dental practice with her mother. She is about five years old. You notice that the girl, unlike most other girls her age, is very quiet and anxious. She is also much smaller and thinner. You also notice that the girl is wearing clothes that are clearly dirty. She also does poorly during your examination, and all of her existing milk teeth are severely damaged by decay. The girl tells you that some of her teeth hurt. The mother states that the teeth have actually been darkly discoloured for the whole time, i.e. for several years.

Task for reflection
(1) What could be possible causes or reasons for the child’s poor dental status?