Eduovisual
Behavioral Health
Intimate partner violence: screening, safety, and reporting
— ~1 in 4 women and ~1 in 10 men experience contact sexual violence, physical violence, or stalking by an intimate partner with IPV-related impact in their lifetime (CDC NISVS).
— Lifetime prevalence among pregnant patients ~3–9%; IPV often starts or escalates during pregnancy.
— Highest acute risk: age 18–24, pregnancy, separation/divorce period, presence of firearms in home.
— Injury pattern inconsistent with stated mechanism, delay in seeking care, repeated ED visits.
— Injuries to face, neck (strangulation marks), breasts, abdomen, or genitals; central/defensive bilateral forearm bruises.
— Partner answers questions for patient, refuses to leave the room, monitors phone.
— Chronic somatic complaints: pelvic pain, headaches, IBS, insomnia, fibromyalgia-like presentations.
— Depression, anxiety, PTSD, substance use, suicide attempts, missed appointments, poor chronic disease control (HbA1c, BP).
— Unintended pregnancy, repeat STIs, requests for emergency contraception, reproductive coercion (partner sabotaging contraception).
Board pearl: IPV is best conceptualized as a chronic disease of coercive control with acute exacerbations, not a series of isolated injury events — this framing drives screening, safety planning, and longitudinal follow-up.
— Vague somatic complaints: chronic pelvic pain, headaches, GI distress, chronic pain syndromes, atypical chest pain.
— Mental health: depression, anxiety, panic, PTSD, insomnia, suicidality, new or worsening substance use.
— Reproductive: unintended pregnancy, late prenatal care, recurrent STIs, requests for repeat EC, miscarriage with abdominal trauma.
— Poorly controlled chronic disease despite apparent adherence (partner withholding meds is a form of economic/coercive abuse).
— Frequent missed appointments or, conversely, frequent ED utilization for minor issues (a "cry for help" pattern).
— HITS (Hurt, Insult, Threaten, Scream) — 4 items, score ≥10 positive.
— HARK (Humiliation, Afraid, Rape, Kick).
— WAST (Woman Abuse Screening Tool).
— PVS (Partner Violence Screen) — 3 questions.
— All are validated; choose one and apply consistently.
— Interview patient alone, in a private space, with a professional interpreter if needed — never use the partner or family member as interpreter.
— Normalize: "Because violence is so common, I ask all my patients about it."
— Open-ended, non-judgmental: "Do you feel safe at home?" "Has anyone hurt you, threatened you, or made you feel afraid?"
— Ask specifically about strangulation ("choking"), forced sex, and access to firearms — each is an independent lethality marker.
— Frequency, severity, escalation, last episode.
— Children in the home (witnessing IPV = child maltreatment in many states).
— Firearm access in the home — single strongest predictor of intimate partner homicide.
— Pregnancy status and reproductive coercion.
Key distinction: A positive screen is not a diagnosis requiring intervention against the patient's wishes — it is an invitation to validate, assess safety, and offer resources. Patient autonomy is paramount unless mandatory reporting applies.
— Central distribution: face, neck, chest, breasts, abdomen, genitals — accidental injuries cluster on extremities and bony prominences.
— Bilateral, symmetric defensive injuries on forearms (ulnar surface), inner thighs.
— Injuries in multiple stages of healing — bruises of varied color, old + new fractures on imaging.
— Pattern marks: belt buckles, cord loops, hand/finger imprints, bite marks, ligature marks.
— Strangulation findings: petechiae on face/conjunctiva/oral mucosa, neck abrasions or linear bruising, subconjunctival hemorrhage, hoarseness, dysphagia, voice change, dyspnea. Strangulation may have minimal external findings despite serious internal injury.
— Even without external marks, consider CT angiography of neck for carotid/vertebral artery dissection; admit for observation if symptomatic. Delayed airway edema and anoxic injury can occur hours later.
Board pearl: Strangulation ("non-fatal strangulation") is the single strongest predictor of subsequent intimate partner homicide — increases risk ~7-fold. Always ask, always document, always assess airway and neurovascular status.
— Firearm in the home (single strongest factor).
— Prior strangulation or threat to kill.
— Recent separation or attempted separation.
— Escalating frequency or severity of violence.
— Partner's unemployment, substance use, jealousy/stalking.
— Threats to children or pets; forced sex.
— Pregnancy.
— Depression (PHQ-9), anxiety (GAD-7), PTSD (PC-PTSD-5), suicidality (Columbia or direct ask).
— Substance use (AUDIT-C, DAST).
— STI/HIV testing if recent sexual assault or reproductive coercion: GC/CT NAAT, HIV, syphilis, hepatitis B/C, trichomonas.
— Pregnancy test (urine hCG) — drives EC eligibility and pregnancy-specific safety planning.
— Plain films for suspected fractures; skeletal survey is for children, not adults — in adults, image only symptomatic regions.
— CT head for any loss of consciousness, persistent headache, focal deficits, or anticoagulation.
— CTA neck for any strangulation with neuro symptoms, persistent neck pain, hoarseness, or carotid bruit.
— Obstetric ultrasound + continuous fetal monitoring ≥4 hours for abdominal trauma after 20 weeks gestation; longer if contractions, bleeding, or non-reassuring tracing.
Step 3 management: Order labs/imaging based on injury pattern and exposure, not reflexively. The "test" that matters most is the Danger Assessment — it changes disposition.
— Patient's statements in direct quotation ("My boyfriend punched me in the face") — avoid "patient alleges" (legally weaker than direct quote).
— Identify perpetrator by relationship and name when patient discloses.
— Objective injury description: location, size, color, shape, pattern; use body diagrams.
— Photographs with written informed consent; include ruler and patient identifier; store securely.
— Time of injury, time of presentation, mechanism as stated.
— Mental status, affect, presence of partner during interview.
— Chain of custody preserved by SANE nurse or trained clinician; do not let patient shower or change before exam if within evidence-collection window (typically ≤120 hours, jurisdiction-dependent).
— Patient may have evidence collected and stored anonymously without filing a police report ("Jane Doe kit") — preserves future option.
— Child abuse / child witnessing IPV: mandatory in all states.
— Elder abuse and vulnerable adult abuse: mandatory in most states.
— Injuries from weapons (gunshot, stab): mandatory in most states.
— IPV against competent adults: NOT mandatory in most states — only a few (e.g., California requires reporting of injuries from assaultive conduct). Know your state, but for Step 3, default is report when weapon involved, child involved, or vulnerable adult; otherwise respect patient autonomy.
Board pearl: When the stem describes a competent adult woman disclosing IPV with no children present and no weapon injury, the correct answer is safety planning + referral, NOT calling police — reporting against her wishes can escalate danger and violates autonomy.
— 1. Validate and assess immediate safety.
— 2. Treat acute injuries and medical sequelae.
— 3. Connect to resources and plan follow-up.
— High acute risk (recent strangulation, weapon threat, escalating violence, plans by perpetrator to harm, patient feels unsafe to go home): offer emergency shelter placement now, involve social work, consider admission for medical or safety reasons, call National DV Hotline 1-800-799-7233 with patient.
— Moderate risk: safety plan, warm handoff to DV advocate, close follow-up (≤1–2 weeks), provide hotline and shelter info in a discreet format (card that fits in shoe, phone number disguised).
— Lower acute risk / not ready to act: validate, document, offer resources, schedule follow-up — continued engagement is itself an intervention. Patients leave abusers an average of 7 times before final separation.
— Identify a safe place to go (friend, family, shelter).
— Pack a "go bag": IDs, money, medications, copies of documents, keys, children's items.
— Code word with trusted contacts.
— Plan exit route from home.
— Memorize key phone numbers.
— If firearms present, discuss removal (extreme risk protection orders/red-flag laws where available).
Step 3 management: Disposition decision is driven by the Danger Assessment + patient readiness, not by clinician opinion that the patient "should" leave.
There is no medication for IPV itself, but the index visit often requires time-sensitive pharmacotherapy for exposures and sequelae. Know these by heart.
— Copper IUD — most effective (>99%), can be placed up to 5 days post-coitus; also provides ongoing contraception. First line if available and acceptable.
— Ulipristal acetate 30 mg PO once — effective up to 120 h; superior to levonorgestrel beyond 72 h and in BMI >26.
— Levonorgestrel 1.5 mg PO once — OTC, less effective if BMI >26 or beyond 72 h.
— TDF/FTC (Truvada) + raltegravir or dolutegravir × 28 days.
— Baseline HIV, HBV, HCV, renal function, pregnancy test; repeat HIV at 6 weeks and 3 months.
— Ceftriaxone 500 mg IM × 1 (gonorrhea; 1 g if ≥150 kg).
— Doxycycline 100 mg BID × 7 days (chlamydia).
— Metronidazole 500 mg BID × 7 days (trichomonas/BV).
— Hepatitis B vaccine (± HBIG if perpetrator HBsAg-positive or unknown high risk) for unvaccinated patients.
— HPV vaccine series if age-eligible and unvaccinated.
— SSRI for PTSD/depression (sertraline, paroxetine FDA-approved for PTSD).
— Avoid benzodiazepines as first-line in PTSD — worsen long-term outcomes and risky in patients with concurrent substance use or suicidality.
— Prazosin for trauma-related nightmares.
Board pearl: A patient presenting after sexual assault needs EC + HIV PEP + STI prophylaxis + HBV vaccine + safety plan + SANE exam offer — missing any of these is a classic Step 3 trap.
— Ongoing support services (counseling, home visits, advocacy programs, parenting support, mentoring) reduce IPV recurrence and improve mental health and birth outcomes.
— Brief office-based counseling alone has modest effect; the key is warm handoff to an advocacy organization.
— National Domestic Violence Hotline: 1-800-799-SAFE (7233) — 24/7, multilingual, can connect to local shelters.
— Local DV shelter — many offer emergency housing, legal advocacy, children's services.
— DV legal advocate for protective/restraining orders, custody, immigration relief.
— Social work consult (in ED or clinic) for case management.
— Mental health referral for trauma-focused therapy (TF-CBT, CPT, EMDR have strongest evidence for PTSD from IPV).
— Substance use treatment if comorbid.
— Protective order / restraining order — civil; patient initiates.
— Address Confidentiality Programs in many states.
— VAWA self-petition / U-visa / T-visa — undocumented IPV survivors may obtain immigration relief without depending on abusive spouse; immigration status alone should never deter screening or services.
— Extreme Risk Protection Orders (red-flag laws) for firearm removal where available.
— Offer long-acting reversible contraception (LARC) that partner cannot detect — IUD with strings trimmed short, subdermal implant, or injectable DMPA.
— Avoid methods requiring partner cooperation/visibility if reproductive coercion suspected.
Step 3 management: Universal precautions in the office — post DV hotline numbers in bathrooms (where partner cannot intercept), train all staff in private rooming, use professional interpreters only. These system-level interventions are themselves testable patient-safety answers.
— Spouse/partner can be lifelong abuser or new caregiver-perpetrator.
— Older adults face unique barriers: cognitive impairment, financial dependence, isolation, fear of nursing home placement, loyalty.
— Forms: physical, sexual, psychological, financial exploitation (very high yield in elders), neglect.
— Unexplained weight loss, dehydration, pressure ulcers, poor hygiene.
— Medication mismanagement (overdose or withholding).
— Bruising in unusual locations; bilateral upper-arm grip marks.
— Caregiver answers all questions, refuses to leave; patient is fearful in caregiver's presence.
— Unexplained financial changes, missing belongings, new authorized users on accounts.
— If the older adult has decision-making capacity, respect autonomy regarding interventions but still report per state law.
— If lacking capacity, involve APS, ethics, and possibly guardianship.
— 2–4× higher IPV prevalence than non-disabled peers.
— Abuser often is caregiver — withholding mobility aids, medications, communication devices, or assistance is abuse.
— Screen with patient separated from caregiver, with accessible communication (sign language interpreter, AAC).
— Reportable as vulnerable adult abuse in most jurisdictions.
Board pearl: In an elder IPV/abuse stem, the single best next step is almost always "report to Adult Protective Services" — unlike competent adult IPV, autonomy does not override mandatory reporting in this group.
— IPV affects ~3–9% of pregnancies; homicide is a leading cause of maternal mortality in the US.
— Abuse often begins or escalates in pregnancy; abdominal trauma raises risks of placental abruption, preterm labor, PROM, fetal death, low birth weight.
— Screen at initial prenatal visit, at least once per trimester, and postpartum (ACOG).
— After any abdominal trauma >20 weeks: continuous fetal monitoring ≥4 h, Kleihauer–Betke if Rh-negative, Rh immune globulin if indicated.
— Reproductive coercion in pregnancy includes forcing/refusing abortion, sabotaging prenatal care.
— ~1 in 11 high school students reports physical dating violence in past year.
— Screen confidentially without parent present; explain confidentiality limits up front (suicidality, homicidality, abuse reporting).
— Most states allow minors to consent to STI testing, contraception, mental health, and sexual assault care without parental notification — know your state.
— Child abuse mandatory reporting applies if perpetrator is parent/caregiver or if age difference triggers statutory rape laws.
— IPV prevalence is equal or higher than in heterosexual relationships; bisexual women have the highest rates.
— Unique dynamics: outing as a tool of control, withholding hormones/HIV meds, exploiting lack of legal protections.
— Use gender-neutral language ("partner"); do not assume perpetrator gender.
— Threats of deportation are a coercive tool; immigration status does not bar access to emergency care, shelter, or VAWA/U-visa relief.
— Use professional interpreters only — never family, partner, or children.
— Confidentiality concerns are heightened; hotline has multilingual access.
Step 3 management: In an ACOG-flavored stem, the answer to "when do you screen for IPV in pregnancy?" is at the first prenatal visit, each trimester, and postpartum — not "if she looks bruised."
— Traumatic injuries: fractures, lacerations, internal bleeding, traumatic brain injury (TBI).
— Strangulation sequelae: carotid/vertebral dissection, stroke (may present days later), laryngeal injury, miscarriage, delayed airway edema, anoxic brain injury, death.
— Repetitive head trauma → chronic TBI symptoms (cognitive impairment, headaches, mood lability) — increasingly recognized analog to sports CTE.
— Sexual assault sequelae: STIs, HIV, unintended pregnancy, anogenital trauma.
— Chronic pelvic pain, dyspareunia, IBS, fibromyalgia, chronic headaches.
— Cardiovascular: hypertension, ischemic heart disease (mediated by chronic stress, cortisol, behavioral risks).
— Poor chronic disease control (diabetes, asthma) due to medication interference and missed visits.
— Depression (3× risk), PTSD (~30–60% of IPV survivors), anxiety, panic disorder.
— Substance use disorders — often initiated as coping.
— Suicide attempts — IPV survivors have markedly elevated suicide risk; always screen.
— Witnessing IPV is an Adverse Childhood Experience (ACE) → lifelong increased risk of mental illness, substance use, cardiovascular disease, and perpetuating/experiencing IPV.
— Increased rates of pediatric depression, PTSD, behavioral problems, school difficulties.
— Children in homes with IPV have higher rates of direct physical and sexual abuse.
— Intimate partner homicide accounts for ~50% of female homicide victims in the US.
— Firearms used in ~55% of intimate partner homicides — firearm access is the dominant modifiable risk factor.
Board pearl: Unexplained chronic somatic symptoms + multiple ED visits + poorly controlled chronic disease in a reproductive-age woman = screen for IPV — these are the dominant outpatient complications and the most common Step 3 presentation.
— Strangulation with any neurologic, respiratory, or vascular finding (or persistent symptoms) — observation ≥24 h; CTA neck.
— Significant TBI, fractures requiring operative management, intra-abdominal injury.
— Pregnancy >20 weeks with abdominal trauma, contractions, bleeding, or non-reassuring fetal monitoring.
— Acute psychiatric emergency: active suicidal/homicidal ideation with plan, psychosis.
— Acute overdose or severe withdrawal.
— Patient unsafe to return home, no shelter bed available, high Danger Assessment score, recent escalation, strangulation, weapon threats — "social admission" is legitimate and exam-appropriate when shelter cannot be arranged immediately and patient consents.
— Social work / DV advocate — for safety planning, shelter, resources, legal navigation.
— SANE (Sexual Assault Nurse Examiner) for forensic exam if assault within evidence window.
— Psychiatry for suicidality, acute PTSD, complex substance use.
— OB/GYN for pregnant patients with trauma or reproductive coercion.
— Pediatrics / CPS if children involved.
— Trauma surgery for significant injuries.
— Neurology / vascular surgery for strangulation with arterial injury.
— Hospital ethics / risk management for capacity questions or reporting dilemmas.
— Move patient to private room; remove partner.
— Order: vitals, focused trauma exam, urine hCG, CBC, CMP, type and screen if bleeding, imaging per injury, CTA neck if strangulation, fetal monitoring if applicable.
— Treat injuries; offer EC, HIV PEP, STI prophylaxis, HBV vaccine, tetanus.
— Consult social work / DV advocate and SANE if applicable.
— Complete Danger Assessment; arrange shelter or safe disposition.
— Document with quotes, body diagrams, photos (with consent).
— Report only per state law (children, weapons, vulnerable adults) — otherwise respect autonomy.
— Schedule follow-up in 1–2 weeks; provide hotline.
— Mechanism consistent with injury pattern, single episode, no escalation, no fear in patient's affect, partner not controlling interview.
— Injuries cluster on extremities and bony prominences (shins, knees, elbows), not central body.
— No injuries in multiple stages of healing.
— Orthostasis, syncope, gait disorder, polypharmacy, sensory impairment.
— Workup: orthostatic vitals, gait assessment (Get Up and Go), medication review, vision/hearing, vitamin D, B12, TSH, ECG.
— Key distinction: Bilateral grip-pattern bruises on upper arms are never from a fall.
— Easy bruising on extremities, mucosal bleeding, family history.
— Workup: CBC, PT/INR, aPTT, von Willebrand panel, medication review.
— Coexists with IPV — does not exclude it.
— Linear cuts on forearms, thighs, abdomen; patterns suggest patient's dominant hand.
— Often disclosed if asked nonjudgmentally; associated with borderline traits, prior trauma (including IPV).
— Intoxication-related falls, fights, MVCs.
— Again, often comorbid with rather than instead of IPV.
— Mongolian spots (infants), hemosiderin pigmentation, purpura from steroids, senile purpura, vasculitis, EDS.
— Endometriosis, IBS, migraine, fibromyalgia, depression, anxiety, thyroid disease, sleep apnea.
— All of these may coexist with — and be exacerbated by — IPV. Screening costs nothing.
Key distinction: Differential thinking in IPV is inclusive, not exclusive — accidental trauma, medical disease, and IPV frequently coexist. Finding one explanation does not "rule out" abuse. Always screen regardless of alternative diagnosis.
— Always reportable to CPS; clinicians are mandatory reporters in all states.
— Witnessing IPV qualifies as maltreatment in many jurisdictions.
— Patterns: retinal hemorrhages + subdural in abusive head trauma; metaphyseal corner fractures, posterior rib fractures, spiral fractures in non-ambulatory children; immersion burns with sharp lines.
— Step 3 management: child abuse is reported regardless of caregiver wishes or competence.
— Categories: physical, sexual, psychological, financial, neglect (self-neglect counts in many states).
— Mandatory APS reporting in nearly all states.
— Financial exploitation is the most common form and easiest to miss — check for new account access, unexplained property transfers, new "friends."
— Overlaps significantly with IPV; the perpetrator is sometimes the intimate partner ("Romeo pimp").
— Red flags: someone else holds patient's ID/documents, scripted answers, accompanied by controlling person, branding tattoos, multiple STIs, inconsistencies in story, lives at workplace, signs of physical abuse, fear of authorities.
— Screening tool: National Human Trafficking Hotline 1-888-373-7888 (24/7).
— Reporting: adult trafficking reporting laws vary; minors are always reportable as child abuse. Federal services (HHS, ORR) available regardless of immigration status; trafficking survivors qualify for T-visas.
— Different perpetrator profile; same need for forensic documentation, mental health support, safety planning.
— Similar safety-planning principles; different legal remedies (workplace orders).
Board pearl: When a stem features a young woman with multiple STIs, scripted answers, a controlling "boyfriend" who carries her ID, and inconsistent address — think human trafficking, call the 1-888-373-7888 hotline, and engage social work. Treat like IPV plus federal trafficking-specific resources.
— Continuity matters more than any single intervention. Patients often disclose over multiple visits.
— Schedule frequent, brief follow-ups (every 1–4 weeks initially) to maintain trust and reassess safety.
— Use the same clinician when possible; warm handoffs if not.
— Safety plan written/reviewed; resources stored discreetly (hotline number disguised in phone contacts).
— DV advocate contact confirmed; appointment scheduled if accepted.
— Mental health referral made; first appointment scheduled.
— Medications dispensed/prescribed: PEP, STI prophylaxis, EC, vaccines, tetanus, mental health meds.
— Contraception provided (LARC if reproductive coercion).
— Pediatric follow-up if children involved.
— Mandatory reports filed per state law.
— Follow-up appointment scheduled before the patient leaves.
— Photos and documentation completed.
— Complete HIV PEP × 28 days with adherence support; HIV testing at 6 weeks and 3 months.
— Hepatitis B vaccine series completion at 1 and 6 months.
— HPV vaccine series if eligible.
— Repeat STI testing at 2 weeks (NAAT for GC/CT/trichomonas) and 4–6 weeks for HIV/syphilis/HBV/HCV.
— Pregnancy test follow-up at 2–3 weeks if EC given.
— Manage chronic disease that may have been undertreated (HTN, DM, depression).
— Trauma-focused CBT, cognitive processing therapy, EMDR — strongest evidence for IPV-related PTSD.
— SSRI maintenance; reassess at 4–6 weeks then every 3 months.
— Sharing PHI with new clinicians/insurance may inadvertently reach abusive partner — flag chart for confidential communication, alternative address, no voicemails.
Step 3 management: Build the outpatient cadence explicitly: 1–2 weeks → 1 month → 3 months → ongoing. Documentation of this plan is itself a Step 3-style answer for "best next step."
— Week 1–2: Reassess safety; review whether safety plan steps were taken; reassess injuries; STI repeat NAAT; mental health check; PEP tolerance/adherence; pregnancy test if EC used.
— Week 4–6: HIV/syphilis/HBV/HCV repeat; complete HBV vaccine #2; mental health response to SSRI; ongoing safety reassessment; reinforce advocate engagement.
— Month 3: HIV final test; PTSD/depression reassessment (PHQ-9, PCL-5); HBV #3.
— Month 6–12: Continue trauma therapy; address chronic disease; ongoing safety screening at every visit.
— Repeat IPV screening at every visit — situations evolve.
— Danger Assessment at periodic intervals or with any change in circumstances (separation, pregnancy, partner job loss, new firearm).
— Mental health scales: PHQ-9, GAD-7, PCL-5 quarterly.
— Substance use: AUDIT-C, urine drug screen as clinically indicated.
— Children's well-being: pediatric visits, school functioning.
— Validate without pressuring action; respect ambivalence.
— Educate on cycle of violence (tension → acute episode → reconciliation/honeymoon → calm) — patients often recognize themselves.
— Reinforce that escalation is common and that separation is the highest-risk period — plan accordingly.
— Discuss children: how to keep them safe, what to teach them about calling for help, whether to involve school counselor.
— PCP coordinates; DV advocate provides expertise; mental health clinician provides therapy; OB/GYN if pregnancy; legal advocate for orders; social work for benefits, housing, food security.
— Documented IPV screening rates are tracked in HEDIS and ACO measures.
— Embed screening in EMR templates with privacy safeguards.
Board pearl: "Best next step" at follow-up visits is rarely a new test or medication — it's almost always reassess safety, reassess Danger Assessment, reinforce resources, and continue the relationship.
— Competent adult survivors have the right to decide whether to leave, report, or take any specific action. Clinicians inform, validate, and offer, but do not override autonomy in competent adults.
— Forcing action (e.g., contacting police against patient's wishes) can escalate danger and break trust.
— Child abuse / child witnessing IPV: report to CPS in all states.
— Elder abuse and vulnerable adult abuse: report to APS in nearly all states — overrides patient refusal.
— Injuries from weapons (gunshot, stab) and certain assault injuries: mandatorily reported to law enforcement in most states.
— Competent adult IPV (no weapon, no child, no vulnerable adult): not mandatory in most US states (California is a key exception requiring reporting of injuries from assaultive conduct). Default exam answer: respect autonomy + offer resources.
— Do not leave voicemails about IPV-related care; use patient-designated contact methods.
— Flag chart for partner not to access PHI; in shared insurance plans, send EOBs to alternate address (Confidential Communication Requests under HIPAA).
— Adolescents: explain confidentiality and its limits before asking sensitive questions.
— Photographs require written consent; explain they may be used in legal proceedings.
— Forensic kits can be collected without filing a police report.
— Capacity: a patient with TBI or intoxication may not have capacity to refuse safety interventions in the acute moment — document carefully, involve ethics.
— Never use partner/family as interpreter — patient safety event.
— Post hotline information in private spaces (bathrooms).
— Train all staff in trauma-informed care.
— Confidential location/address programs prevent stalking via medical records.
— Federal Lautenberg Amendment prohibits firearm possession by those convicted of misdemeanor DV or under qualifying restraining orders.
— Counsel on Extreme Risk Protection Orders / red-flag laws where available — strongest documented homicide-reduction intervention.
Step 3 management: In a competent adult with IPV, no weapon use, and no minors involved, reporting to police against her wishes is the wrong answer — the right answer is safety plan + advocate referral + close follow-up.
Key distinction: USPSTF endorses screening reproductive-age women (Grade B) — evidence is insufficient (Grade I) for older adults, but professional societies still recommend screening. Don't confuse "insufficient evidence" with "don't screen."
— "32-year-old woman, multiple ED visits, chronic pelvic pain, partner answers all questions in the room — best next step?"
→ Interview patient alone and screen for IPV.
— "Patient discloses IPV, lives with abusive husband, no children, no weapons, declines police involvement — best next step?"
→ Validate, safety plan, refer to DV advocate, schedule close follow-up. Do NOT call police against her wishes.
— "Pregnant patient at 28 weeks struck in abdomen by partner — initial management?"
→ Trauma assessment, continuous fetal monitoring ≥4 h, Kleihauer–Betke if Rh-negative, RhIG if indicated, IPV resources, social work; report children at home per state law.
— "Woman strangled by partner last night, hoarse voice, neck tenderness, no external bruising visible — next step?"
→ CT angiography of the neck to evaluate for carotid/vertebral dissection; admit for observation.
— "Sexual assault 36 hours ago, presents to ED — which of the following should be offered?"
→ All of: forensic exam (SANE), EC, HIV PEP, STI prophylaxis (ceftriaxone + doxycycline + metronidazole), HBV vaccine ± HBIG, tetanus, mental health referral.
— "82-year-old with bilateral upper-arm bruises, daughter is sole caregiver and answers all questions, weight loss, pressure ulcers — next step?"
→ Report to Adult Protective Services (mandatory, overrides patient's preference).
— "Patient discloses IPV, says abuser keeps a gun in the home — most important counseling?"
→ Firearm removal / safe storage / Extreme Risk Protection Order; document; safety plan.
— "Adolescent in confidential visit discloses dating violence — most appropriate action?"
→ Confidential counseling, safety plan, mental health referral; report only if mandatory triggers (perpetrator is parent/caregiver, statutory rape, weapon).
— "Patient with chronic depression and headaches, partner controlling, asks for 'birth control my husband won't know about' — best option?"
→ Subdermal implant or IUD with strings trimmed, or DMPA injection.
Board pearl: When the stem highlights autonomy of a competent adult survivor, the wrong answers include calling police, contacting the abuser, hospitalizing against her will, or pressuring her to leave. The right answers cluster around validate, screen, treat, document, refer, follow up.
Intimate partner violence is a chronic, often lethal disease of coercive control — universally screen reproductive-age women (USPSTF Grade B), assess danger (firearms, strangulation, separation, pregnancy), respect competent-adult autonomy while reporting child/elder/vulnerable-adult abuse and weapon injuries, deliver the acute prophylaxis bundle when indicated, and build a longitudinal, trauma-informed care relationship that survives multiple "not yet" moments.