Case 24: Evaluation after a fall

Opening scenario

Marisa Hernandez, a 30-year-old female; , comes to the urgent care clinic after a fall.

Vital signs

• Temperature: 98°F (36.7°C)
• Blood pressure: 121/69 mm Hg
• Heart rate: 95/min
• Respirations: 13/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• You have been physically abused by your husband, and this is not the first time it has happened. Act nervous, and do not make very much eye contact with the examinee.
• Paint one bruise on your left upper arm and multiple bruises on your right lower arm. Paint a bruise on your right cheek right below your eye. (Alternatively, show the examinee these pictures during the physical examination: .)
• If the examinee touches or lightly presses on the bruises while examining your arms and face for injuries, tell him/her that it hurts.
• You are not aware of the meanings of medical terms (e.g., ultrasound) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Be defensive when asked open-ended questions about the situation (e.g., “Is there anything else you have noticed/you would like to tell me?”) and the exact mechanism of the fall. Only reveal the information about domestic violence when directly asked. Do not give the examinee any hints!

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History of present illness

• Chief complaint
• I fell down the stairs at home yesterday; , and now my left arm and the right side of my face have these big bruises that really hurt.
• Onset/time of the event
• I fell yesterday night, and the bruises were there when I woke up this morning.
• Precipitating events/mechanism of the fall
• I just slipped on the stairs, and I fell onto my arm and head. I should have been more careful.
  • Loss of consciousness
  • No.
• Progression
• It seems like the bruises might still be getting bigger today.
• Previous episodes
• I get bruises a lot; actually. I think I just bruise easily.
• Frequency
• It is hard to say. I almost always have a bruise somewhere on me.
• Alleviating factors
• I put an ice pack on the bruise on my face earlier and it helped a little.
• Aggravating factors
• It hurts more when I touch it.
• Associated symptoms
• No, what do you mean? I just fell and now I have bruises, what else do you want to hear?

Review of systems specific to easy bruising/evaluation after a fall

• Headache
• My face hurts where the bruise is, but that is it.
• Nausea/vomiting
• No.
• Fever/chills
• No.
• Night sweats
• No.
• Fatigue
• No.
• Rash/skin changes
• No.
• Pain in joints
• No, my arms just hurt where I have the bruises.
• Urinary problems
• No.
• Bowel problems
• No.
• Sleep problems
• I do not always sleep as much as I would like to, but that's just the way it goes with kids, right?
• Appetite
• I have always had a good appetite.
• Weight changes
• No.
• Dizziness
• No.
• Increased bleeding after minor injuries (e.g., cut)
• I have not had a cut in a while, but I remember cutting my finger pretty deep years ago with a kitchen knife and having to change the band-aid like 3 times because it kept bleeding.
• Increased bleeding during childbirth
• I think I lost a little too much blood the second time around. I was really tired for weeks.
• Increased bleeding during menstrual period (number of tampons/day)
• Yes, I used to have to change my tampon nearly every hour, so my doctor started me on birth control after the birth of my second child. It has gotten better since, though.
• Nosebleeds
• No.
• Bleeding of gums after brushing teeth
• I do not think so.
• Bleeding into muscles, joints, or deep tissue
• No.

Past medical history, family history, and social history

• Past medical history
• None.
• Allergies
• None.
• Medications
• I take a birth control pill.
• Hospitalizations
• Only for the birth of my children – 2 and 4 years ago.
• Past surgical history
• None.
• Family history
• My mom has bipolar disorder.
• Work
• I stay at home with the kids. I used to work, but my husband's job is very stressful, so now I stay home and try to support him as much as I can.
• Home
• I live with my husband and my kids.
• Alcohol
• No.
• Recreational drugs
• No.
• Tobacco
• No.

History specific to domestic violence

• Relationship with spouse
• He is really stressed right now, so he sometimes gets angry. I do not think it is his fault, I should just try to be more attentive and find ways to reduce his stress.
• Afraid for own safety/safety of children
• Well, sometimes he moves me around a little too rough or his hand slips. I did not really fall down the stairs yesterday.; I just don't like to tell anyone because he really does not mean it and he always apologizes. I don't think he would ever hurt the kids.
• Gun at home
• No.
• Emergency plan (safe place to go in case of emergency)
• I think I could stay with my sister.
• Support system (friends and family aware of abuse)
• My sister knows about it, but she is the only one. I do not want people to think that there are any problems in our family. I think most marriages go through stressful times.
• Alcohol/drug use of the spouse
• He sometimes drinks a little too much when he comes home from work. That is usually when he gets angry.
• Depression
• No.
• Regularity of abuse
• Maybe once or twice a week when work gets really stressful or when I do not have time to clean up the mess the kids make before he comes home.

RAGE SADR: Relationship with partner, Afraid of partner, Gun at home, Emergency plan, Support system, Alcohol/drug use of spouse, Depression, Regular abuse.

• Washed hands
• Used respectful draping
• Body check
• Head, eyes, ears, nose, and throat examination
  • Inspection of the head
    • 4 x 3-cm hematoma on R cheek and infraorbital area
  • Palpation of the head
    • Tenderness to palpation over the right cheek in the area of the bruise
  • Inspection of the conjunctivae
  • Inspection of the sclera
  • Examination of the pupils
  • Examination of extraocular muscles
• Extremities
  • Inspection of the upper extremities
    • 5 x 5-cm hematoma on L upper arm
    • Tenderness to palpation over the L upper arm in the area of the bruise
    • Multiple tender hematomas in different stages on R lower arm
  • Inspection of the hands
  • Inspection of the lower extremities
• Skin examination

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee did not repeat painful maneuvers during physical examination.
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on support options for domestic violence.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: ”Mrs. Hernandez, I understand that some of my questions may seem unnecessary or intrusive to you. It is really important, though, that I understand exactly what happened to you so that I can help you today. Any information that you share with me is strictly confidential and will not be shared with anyone else. Based on my experience with some of my other patients, I wonder if someone at home has been hurting you – is that the case?”

Patient note

Differential diagnoses

1. Domestic violence: This patient presents with bruises of varying stages on both arms, as well as bruises on her face, which raise concern for abuse. When tactfully questioned, she admits that her husband is physically violent with her 1–2 times weekly, confirming the diagnosis of domestic violence. The physician's role in this case should be to provide support and assistance with whatever course of action the patient desires, while making sure not to report the domestic violence without patient consent (unless the patient is incompetent, e.g., mentally disabled, elderly, or a minor). Although the patient history confirms domestic violence in this case, a different cause of this patient's easy bruising must also be ruled out.
2. Immune thrombocytopenic purpura (ITP): ITP is commonly asymptomatic but can present with symptoms of thrombocytopenia, including those seen here (easy bruising, petechiae, menorrhagia, and prolonged bleeding after injuries), and is a diagnosis of exclusion in isolated thrombocytopenia. It is particularly common in women of childbearing age and children, and often takes a chronic course in adults. Although it can be primary, ITP can also be secondary to an array of serious conditions (e.g., lymphoma, leukemia, SLE, HIV, HCV) and should therefore be carefully considered if thrombocytopenia is found on CBC.
3. Von Willebrand disease (vWD): vWD, like ITP, is commonly asymptomatic but can present with symptoms of thrombocytopenia, as described above. Although less common than ITP, especially in women of childbearing age, it is the most common congenital hemostatic disorder and should be considered in this case as well.

Diagnostic studies

• CBC: Thrombocytopenia (platelets < 150,000/mm³) would be apparent on CBC. Leukocytosis (leukocytes > 10,000/mm³) could indicate leukemia, and SLE could also cause various hematologic disorders on CBC and coagulation studies.
• Peripheral blood smear: Abnormal platelets (e.g., some congenital platelet disorders) and pseudothrombocytopenia (i.e., platelet adherence to neutrophils) could be seen on peripheral smear; The blood smear would be normal in ITP and vWD (other than perhaps a paucity of platelets).
• Bleeding time, PT, PTT: Bleeding time may be prolonged vWD and ITP, depending on the severity of the condition. PT tests the extrinsic and common coagulation pathways and is most commonly prolonged in vitamin K deficiency (e.g., due to warfarin therapy or liver cirrhosis). PTT tests the intrinsic and common coagulation pathways and may be prolonged in vWD (due to factor VIII deficiency) as well as disorders of the intrinsic pathway (e.g., hemophilia).
• Factor VIII activity assay: Factor VIII is normally protected from proteolysis by vWF and can therefore be decreased in vWD.
• Von Willebrand factor antigen assay: screening test for vWF that measures vWF quantity
• Ristocetin cofactor assay: screening test for vWF that measures vWF activity

Other differential diagnoses to consider

• Other hemostasis and bleeding disorders
• Other forms of thrombocytopenia
• Differential diagnosis of platelet disorders