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If you have completed case I, this is a review. Completion of this case will not be counted toward your assignment.
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Abigail Miller is a 34
year-old Caucasian woman who presents to your family practice office complaining of
headaches.
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She describes her current
headaches as happening every day in mid-afternoon for the past month. The pain is steady,
non-pulsatile, and starts in the occipital region with bilateral radiation to the frontal
area. There is no associated aura or photophobia. She is not awoken from sleep with the
headaches and she does not wake up in the morning with a headache. Tylenol lessens the
discomfort "sometimes." Her physical exam is unremarkable with normal vital
signs and neurological exam. When asked if there were any other complaints Mrs. Miller wishes to discuss, she mentions significant stress at home regarding her 9 year-old son. Her concern centers on continued problems with discipline. "He just won't listen to me anymore -- he's always beating up on his little brother and getting into fights at school. His grades have really dropped and he might even be held back this year. I just don't know what to do." In reviewing Mrs. Miller's chart you note she has been in to your office 7 times over the past year: October 14 - CC concern re: discipline of her 9 year-old son July 30 - CC consistent abdominal pain during menses July3 - CC B/L knee pain June 21 - CC MVA May 8 - CC difficulty falling asleep March 12 - CC sore throat January 10 - CC headaches, abdominal pain You also note that Mrs. Miller is due for her annual physical in one month. As you further discuss her son's behavior problems, you notice the patient checking her watch. Due to time you had to spend with a previous patient, you are running 45 minutes behind schedule. Mrs. Miller says she would like to further discuss ways to handle her child, but insists she must be home in 15 minutes. She appears anxious to leave promptly. |
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Mrs. Miller returns for her
annual physical exam. Reviewing the chart prior to entering the room, you note she is a
college graduate and works part-time as a nursery school teacher. She and her husband, an
accountant, have two sons, ages nine and six. PMH includes hypothyroidism (she takes
Synthroid l25mcg each day) and headaches (she takes Tylenol 650mg two or three times a
day). Labs: TSH from 6 months ago = 0.l5mcg/mL and cholesterol two years ago = 172mg/dL.
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Keeping the above information in mind, you continue the conversation with
Mrs. Miller. You asked: "Is there something you would like to discuss." Mrs. Miller: "I…well I never really told anyone." You replied: "Anything we discuss here is confidential. It seems as if you may be concerned about your safety at home." Further discussion reveals that Mrs. Miller's husband has become increasingly controlling over the past few years. In fact, he often calls home up to ten times per day, making sure Mrs. Miller comes home right after work or appointments and stays at home until he returns from work. Mrs. Miller then discloses that he grabbed her around the neck one time. "But it was only once... and that was a few weeks ago. It was probably my fault, because dinner wasn't ready when he got home, and he becomes kind of hypoglycemic." The patient also states her husband shoved her a few months ago in the kitchen during a dispute over how she has been handling their son. The following day she went to the ED after work. X-rays of her lower extremities showed no fractures, but significant swelling persisted in her knees for a few weeks.
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You don't hear from Mrs. Miller for 4 months. Then she presents
to your office with a request for a pregnancy test, in order to
verify a positive home test completed two days ago.
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Over the next few months, you see Mrs. Miller in your office for
prenatal visits as well as for continued difficulty sleeping and
back aches. Mrs. Miller delivers a healthy daughter with no
complications. At each visit, you discuss the situation at home
and provide information regarding the local shelter. Eighteen
months after Mrs. Miller's initial disclosure, she decides she
is ready to leave the abusive environment. She and her children
go to the local shelter, obtain a PFA against her husband, and
begin searching for permanent housing. Primary care physicians have a unique opportunity to identify and interrupt domestic violence. Through increased awareness among health care providers, patients suffering from abuse in the home are being identified and treated. |