Intimate Partner Violence
Age: years old
Gender:
HISTORY:
Presents with - history of
Symptoms include:
Assessment of safety:
Immediate danger:
Safe to return home:
Need for immediate police intervention:
Risk factors:
, , ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Skin: on
Musculoskeletal: joints ,
Cervical spine: on , range of motion
Shoulder: : on , range of motion
Elbow: : on , range of motion
Wrist: : on , range of motion
Hand: : on , range of motion
Lumbar spine: on , range of motion
Hip: : on , range of motion
Knee: : on , range of motion
Ankle: : on , range of motion
Foot: : on , range of motion
Pelvic: external genitalia , vagina , cervix , uterus , adnexa ,
Mental status: , , speech , mood , thought , , judgment
ASSESSMENT:
DDx: physical abuse, psychological abuse, sexual abuse, emotional abuse, economic abuse, stalking, cyberbullying, neglect, coercive control, adjustment disorder, post-traumatic stress disorder, anxiety disorders, depressive disorders, substance abuse, eating disorders, sleep disorders, somatic symptom disorders, personality disorders, chronic pain syndrome, sexual dysfunction, injuries from physical violence
PLAN:
Treatments:
- Safety planning
- Psychoeducation about intimate partner violence
-
-
- Cognitive behavioral therapy
- Trauma-focused therapy
Further care:
- Referral to social worker
- Referral to local domestic violence resources
- Referral to psychologist
- Follow-up in
- Return if condition worsen or if new symptoms develop such as suicidal thoughts
- Call 911 if immediate danger is present
HISTORY: EXAM: ASSESSMENT: PLAN: