You are seeing Mrs. McNeil, a 31 year old female in your general practice clinic. She states that she recently injured her arm while cleaning her home. Take a focused history of her complaint.
History
- Inquires about circumstances in which injury occurred
- Timing of injury
- Mechanism (patient eventually discloses that she had been physically abused by her husband)
- Other recent injuries
- Visits to hospital for other reasons
- Asks about any medication use
- Alcohol/drug history
- Determining social context at home (lives with husband, two young children)
- Inquires if husband was verbally abusive
- Inquires if husband was sexually abusive
- Whether husband has used weapons to harm patient, or has access to weapons
- Extent of injury in the past
- Asks if the children have been abused
- Asks if the children have witnessed spousal abuse
- Asks if the husband has a substance abuse problem
- Asks if patient feels safe at home
- Asks if friends/family are aware of the abuse
- Inquires about emergency plans to escape in the event of further abuse
- Asks if she has access to financial resources
- Asks if she would like help from a counselor
- Asks if she would like support from community resources
- Asks if she would like legal counseling
Case 3 – Arm Pain Spousal Abuse