A 21-year-old woman complains of fatigue and difficulty swallowing. She describes the difficulty swallowing as a choking sensation that occurs randomly and not with eating. She denies fever, chills, nausea, or vomiting. She notes some difficulty sleeping at night. She is 28 weeks pregnant with her first child. You note that she is wearing long sleeves in warm weather to cover up bruising on her forearms; she also has a bruise on her left lateral thoracic area. How would you most appropriately introduce your concern about domestic violence?
A. “Those bruises look uncomfortable. Do you want to talk about how you got them?”Since a woman rarely spontaneously reports domestic abuse to her doctor, recognizing signs and symptoms of domestic abuse may be the only opportunity the physician has to intervene. It is also important to recognize the increased risk of domestic abuse during pregnancy. An abused woman can have vague physical symptoms, including headache, fatigue, insomnia, choking sensations, gastrointestinal complaints, and pelvic pain. Inviting the patient to discuss the situation in a caring and sensitive fashion will create a trusting environment and may encourage the patient to accept help. However, opening the conversation with a joke, or jumping to the conclusion that the patient’s spouse caused her apparent injuries, is not appropriate or effective. A compassionate and yet professional approach may open the door to help, even if the abused patient is unwilling to accept intervention at her first visit.