A case study of a woman in a hispanic community who sought healthcare for a Urinary Tract Infection, but it was discovered that she was being seriously sexually abused. How it was handled and difficulties encountered.

1. A case study
by Ann Sparks, RN, BSN
ILLINOIS STATE UNIVERSITY

2. CC:Here for “possible UTI” on 6/20/11
 Client is a 44 year-old, female, Hispanic, Spanish-only speaking
patient
 Her 22 y/o daughter who speaks English accompanies her
HPI: Bilateral groin pain X 7 days but became worse in
midline pelvic region. Currently pain is 4/10 severity
 Burning on urination
 (+) frequency
 (+) hesitancy
 (+) urgency
 Nothing seems to make the pain better or worse
 Has not tried any treatment
Elvira, office assistant, was present for translation

3.  General: No weight
loss, (+) chills, (+) night
sweats
 Head: No trauma, no
headache or visual changes
 Ears: No hearing loss or
tinnitus
 CV: No chest pain. (+) DOE
since birth of second child 20
years ago
 Resp: No cough, SOB at
rest, no sputum production.
Denies chronic lung disease
 GI: (-) N/V or indigestion;
(+) constipation X 1 month
 GU: (+) Burning on
urination, (+) frequency,
(+) hesitancy, (+) urgency.
Pain in the bilateral groin
and suprapubic area for one
week is 4/10 SEVERITY
 Genital:
 STD hx& treatment: none
 sexual interest: heterosexual
function/problems: does not
want to have sexual
relations with husband
(separated X 4
months), marital problems

4.  FEMALE: Mild-moderate
dysmenorrhea with cramping, and
“normal cycle” with
menstruation; LMP 6/10/11, No
itching, but states she feels
blisters inside of her vagina. She
states discharge has increased and
is clear-yellow and odorless
 MSK: Denies weakness
 Neuro: Denies dizziness, tremors
or blackouts
 Hematologic: No abnormal
bleeding or bruising
 Endocrine: No diabetes or thyroid
problems
 Psych/sleep: Reports, “Lots of
stress,” and sleep is without
difficulty

5.  The patient became extremely tearful
 Even though she and her husband were separated 4
months, he keeps coming to her residence and forcing her
to have sex
 The daughter added that he is stalking the patient and
threatening other relationships

6.  Gravida: 4, Para: 4,
AB: 0
 Last PAP, 4 years ago
 Last mammogram,
none
 History of HTN – not
currently on medication
 1st visit - March 31, 2011:
 Somatic neck muscle
pain / Cervicalgia –
 Flexoril 5mg PRN
 Ibuprofen 800mg TID
 Depression with first
recorded incidence on
3/31/11
 Recommended by PCP
to attend counseling for
depression
 She attended counseling
4/5/11 and Citalopram
20mg was ordered
 i PO daily #30
 -0- refill

7.  Patient was a no call, no show for a F. U.
appointment with the Nurse Practitioner on
4/29/11
 Had only come for first office visit and one session of
counseling. Not seen since 4/5/11

8. FAMILY HISTORY
 Mother is living
 HTN
 Father is living
 Diabetes
 Four living children – no
significant illness
 22 y/o F – lives next
door
 19 y/o M – lives with pt
 18 y/o M – lives with pt
 11 y/o F – lives with pt
SOCIAL/ENVIRONMENTAL
HISTORY
 Employment: Factory
worker w/ annual income:
~ $20,000
 Highest grade completed:
8th grade
 Religion: Catholic
 Denies
drug/alcohol/tobacco use
 No exercise program

9. CULTURAL
 Pt is of Hispanic descent –
Native of Mexico
 Spanish-speaking only
 Living in Chicago area
 PAST SURGICAL
HISTORY: None
 MEDICATION
PROFILE:
 Pt reports she is not
currently taking
medication
 NKDA
SCREENING TESTS:
Per LCSW 4/5/11, patient is sad most
days, lack of interest in pleasurable
activities, Hypersomnia/insomnia, anxiety
and difficulty controlling worry
 Axis I Major Depressive Disorder
 Axis II 0
 Axis III 0
 Axis IV Financial, Matrimonial
 GAF 60
(Global Assessment of Functioning)
60 = Moderate symptoms (e.g., flat affect
and circumstantial speech, occasional
panic attacks) OR moderate difficulty
in social, occupational, or school
functioning (e.g., few
friends, conflicts with peers or co-
workers).

10.  There is a lot of data missing
 More detailed family history would be helpful – Mental
illness? Dysfunctional family of origin?
 What is her relationship like with her adult sons who live
with her?
 Possibly volatile with the “machisimo” cultural beliefs of the
Hispanic population
 Catholic faith can be paternalistic and/or shaming in
nature
 These are the types of things that would come out
in counseling

11.  With depression, IPV, financial restraints and
language/cultural barriers, likely the only reason
this patient sought assistance this day was for acute
pain of the UTI
 Patient needs to learn to be empowered
 Only SHE can choose to make changes in her life
 Only SHE can choose support systems to help her
 Will she return for follow-up?

12.  On original intake, pt denied Domestic
Violence
 She states, “He doesn’t hit me,” and, “He yells at me
a lot.”
 Pt needs definition of domestic violence
 During ROS, pt denied sleep problems
 Visit to LCSW on 4/5 showed
hypersomnia/insomnia as a symptom –
 pt needs definition of normal sleep patterns

13.  looks or acts in ways that are
frightening
 tries to control what the other
person does, who the other person
sees or talks to, or where the other
person goes or tries to stop the
other person from seeing friends or
family members
 tries to take the other person’s $$$
 makes the other person ask for
money or refuses to give the other
person money that is supposed to
be shared
 makes all of the decisions
 threatens to take away or hurt the
children
 prevents the other person from
working or attending school
 acts like the abuse is no big
deal, denies doing it, or blames
something or someone else, even
the person being abused
 destroys the other person’s
property or threatens to kill pets
 intimidates the other person with
guns, knives or other weapons
 Shoves, slaps, chokes or hits the
other person
 forces the other person to try and
drop charges
 threatens to commit suicide
 threatens to kill the other person
________________________________
If you answered ‘yes’ to even one of these
questions, you may be in an abusive
relationship.
For support and more information call
the National Domestic Violence
Hotline at
1-800-799-SAFE (7233) or at
TTY 1-800-787-3224.

14.  GENERAL: Well-
developed, well-nourished;
tearful intermittently. Pt is
well-groomed, but appears
tired with otherwise flat
affect
 VS: Stable
 T - 98.6 F
 P - 80
 R - 20
 BP- 124/88
 Hgt (inches) 60.5
 Wgt (pounds) 169# --> 0.8#
loss: Change
 BMI 33 – No Change
 SKIN: Intact, W/D, without
ecchymosis or scars
 Head: NC/AT
 HEART: Regular rate and
rhythm, normal S1, S2, no
murmurs, rubs, gallops, or
clicks
 LUNGS: Chest symmetrical
with resps; Clear to
auscultation, bilaterally; no
respiratory distress
 ABDOMEN: Symmetrical.
Slightly rounded, soft, non-
tender. Some guarding
noted. No dullness to
percussion.
(+) CVA tenderness

15.  GU:(+) guarding in
groin/pelvic area. EGBUS
WNL. Vaginal exam
shows no lesions, tears, or
unusual discharge.
“Normal Female” genitalia
 RECTAL: Sphincter tone
intact with one
hemorrhoid noted, non-
thrombosed
 MSK: Normal symmetric
tone
 NEUROLOGIC: Alert and
appropriate. Normal
strength and tone
Pertinent Lab Values
6/20/11 Urinalysis shows:
Leukocytes Moderate
Nitrite (+)
Urobili Normal
Protein Negative
PH 7.5
Blood Moderate
Spec Grav 1.010
KetonesNeg
BiliNeg
Glucose Neg

16.  Looking back, the symptoms presented on March
31, 2011 (Somatic neck muscle pain / Cervicalgia)
could have well been from an injury sustained
during an episode of rape
 Always beware of patients who simply don’t
understand healthy lifestyles or “what IS healthy”
 Be alert for symptoms of abuse even when not a
word is said about it – missed
appointments, multiple system involvement, flat
affect and lack of eye contact can be symptoms of a
much deeper problem

17.  (+) chills, (+) night
sweats
 (+) DOE since birth of
second child 20 years ago
 (+) constipation X 1
month
 (+) Burning on
urination, (+)
frequency, (+)
hesitancy, (+) urgency.
Pain in the bilateral
groin and suprapubic
area for one week
 WBC count WNL
 (+) Mild-moderate
dysmenorrhea with
cramping, and “normal
cycle” with menstruation;
LMP 6/10/11, No itching
 She feels blisters inside of
her vagina, though Vag
exam normal
 Discharge has increased
and is clear-yellow and
odorless
 “Lots of stress”
 Sexual contact being
forced on her by husband
after separation

18.  UTI
 IPV (Intimate
Partner Violence)
 STD risk
 Depression
 Constipation
 Peri-menopause
 UTIs, constipation and
STDs are symptoms of
Intimate Partner
Violence (IPV)
(Draucker, 2002)
 Depression, shame, la
nguage
barriers, isolation, fina
ncial dependence add
to the symptoms and
risks for IPV
(Montalvo-Liendo, 2009)

20.  UTI – UA w/ leukocytes,
nitrites and blood
 IPV (Intimate
Partner Violence)
 Depression
 STD risk
 Peri- menopause
 Constipation
 Immediate goals:
 address
pain/infection
 safety
 Education and Trust-
building essential
element for her return
for F.U.

21.  The cycle of IPV is
 Abuse
 Promises of change
 Subsequent increasing
abusive behavior
 The most grim
consequence of D.V. is
death
 Majority of women who
are killed in the U.S. are
killed by a current or
former intimate partner
(Draucker, 2002)

22.  Rape / sexual assault
 Three in four women (76%)
who reported they had
been raped and/or
physically assaulted since
age 18 said that an intimate
partner (current or former
husband, cohabiting
partner, or date) committed
the assault.
(U.S. Department of
Justice, Prevalence, Incidence
, and Consequences of
Violence Against Women:
Findings from the National
Violence Against Women
Survey, November 1998)
 One in five (21%) women
reported she had been
raped or physically or
sexually assaulted in her
lifetime.
(The Commonwealth Fund,
Health Concerns Across a
Woman’s Lifespan: 1998
Survey of Women’s Health,
1999)
 Stalking
 Annually in the United

24. Problem List:
 UTI – lower and upper
 IPV - rape
 Constipation
 HTN
 Depression
 Needs Annual female
exam: CBE, Pap, pelvic
*** Chronic stress
decreases immunity
Priorities of Care:
1. UTI
 Bactrim DS
1 tab PO BID X 10 days
#20
-0- Refill
 Educate: Increase water
consumption to 8-12
glasses daily
2. Family Disruption
 Education/counseling
on D.V.

25. FAMILY DISRUPTION – Cont’d
 Previously, PCP ordered counseling
Attended only one session
 Started Citalopram 20mg daily on 4/5/11
 No call, no show on 4/29/11. No follow-up since
4/5/11
 Today presents with same complaints
 Reinforced follow-up
 Follow-up with counseling and health care will help
her help herself

26. FAMILY DISRUPTION -- Cont’d
 EDUCATED:
 REINFORCED - Return for follow-up
 Counseling
 Medications
 Other health needs of HTN, Depression, Annual Female
exam
 REINFORCED - That ACCESS to CARE is the name of
the clinic
 Don’t let inability to pay prevent getting the care needed
 Even if paying $1.00, services are provided

27. FAMILY DISRUPTION – Cont’d
 Plan now to see LCSW in A.M. for counseling.
Pt voices understanding of counseling appt. at 1100 6/21/11 here at clinic
 If stable, restart antidepressant
 Pt encouraged to protect self
 Instructed the patient that not setting and keeping firm limits on
this man’s behavior is giving him permission to continue his
inappropriate behaviors
 Desires local PD involvement. Wishes granted and 9-1-1 called
for domestic violence complaint
 Pt counseled that police are there to help & protect her
 Police at clinic 6/20/11, report unknown

28. FAMILY DISRUPTION
-- Cont’d
Labs ordered:
 HIV
 GC/CT
 RPR
 Herpes I & II
 CBC
 Labs resulted 6/23/11
F.U. CARE:
 RTC:
 6/21/11 to see
Suzanne, LCSW
 RTC:
 In 2 weeks for STD
results and UTI
F.U.
 RTC if symptoms
worsen

29. PLAN FUTURE VISITS FOR:
 If continued constipation problems
 Resume Depression care and referrals for
support group(s)
 HTN evaluation
 Needs Annual female exam: CBE, Pap, pelvic
and mammogram

30.  CBC Result Normal Values
 WBC 5.5 (4.5 - 11.0) TH/mm3
 RBC 4.31 (4.0 - 5.2) mil/mm3
 Hgb 12.9 (12.0 – 16.0) gm/dl
 Hct 38.5 (36.0 – 46.0) %
 MCV 89.2 (80 – 100) FL
 MCH 30.0 (26.0 – 34.0) PG
 MCHC 33.6 (31.0 – 37.0) %
 RDW 14.7 *** (11.5 – 14.5) RDW UNI
 Plt 292 (150 – 450) TH/mm3
 MPV 8.8 (7.0 – 10.4) FL

31.  HIV 1 & 2 Non-reactive
 RPR Non-reactive
 Chlamydia, Ampl Negative
 GC, Amplified Negative
 Herpes I IGG > 5.00 – High ***
 Herpes II IGG < 0.90 (Negative)

32.  This pt has poor
coping skills and
limited support
systems
 Multi-faceted problem
needs a
multidisciplinary
approach
(Youngkin, 2004)
Resources patient needs:
 Health services
 Counseling
 Support groups
 Legal Help
 Children’s Services
 Financial Assistance
 Safe House
information

33.  She’s likely been in
survival mode a long
time
 Much of what this
patient needs is basic
caring and teaching
about her value as a
human being
 Define terms for her
such as “abuse,” and
“normal sleep” patterns
 Give information on
preventative care
 Stress reduction
 Support groups
 Health maintenance
exams and F. U.
 The key is getting her
plugged into resources
 A list of resources
available, in Spanish

34.  This clinic has bold
posters on the wall of
the bathroom
 What to take with
you when you leave a
domestic violence
situation
 Resources for the
abused in multiple
languages

35.  The primary goal after
the infection/pain
and safety, is for the
patient to return for
care
Clearly this patient has
multiple needs
yet to be addressed

36.  Pt did arrive to her
scheduled counseling
appointment on
6/21/11
 She had been
summoned for a
restraining order (Order
of Protection) to be at
court 6/21/11, but she
missed that court date
(she didn’t realize she
had to be present)
 Likely <50% chance that
this patient will follow-
up for lab results or
further routine care
 Cultural values are to
seek assistance for
pain, but preventative
care is not commonly
sought
 Follow-up appointment
for week of 7/5/11 for
STD results and UTI
F. U.

37.  Appointment 7/5/11:

38. Center for Disease Control (CDC). Sexual Violence website. Retrieved June 30, 2011.
http://www.cdc.gov/ViolencePrevention/sexualviolence/index.html
Domestic Violence Awareness Project. Retrieved July 1,
2011http://dvam.vawnet.org/about/aboutdv.php
Domestic Violence Resource Center (DVRC). Retrieved July 1, 2011. http://www.dvrc-
or.org/domestic/violence/resources/C61/
Draucker, Claire Burke (January 31, 2002). "Domestic Violence: The Challenge For Nursing" Online
Journal of Issues in Nursing. Vol. 7 No. 1, Manuscript 1. Available:
www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Tableof
Contents/Volume72002/No1Jan2002/DomesticViolenceChallenge.aspx
Montalvo-Liendo, N. (2009). Review paper: Cross-cultural factors in disclosure of intimate partner
violence: an integrated review. Journal of Advanced Nursing. 65(1), 20–34 doi: 10.1111/j.1365-
2648.2008.04850.x
World Health Organization (WHO). Sexual Violence website. Retrieved June 30, 2011.
http://www.who.int/violence_injury_prevention/violence/global_campaign/en/chap6.pdf
Youngkin, E. Q., & Davis, M. S. (2004). Woman’s Health: A primary care clinical guide. 3rd Edition.
Pearson/Prentice Hall, Upper Saddle River, NJ.