Ethics, Communication & Professionalism

Mandatory reporting: abuse, infectious disease, impaired drivers

Clinical Overview and When to Suspect Mandatory Reporting Situations

— Abuse/neglect: child abuse (all 50 states, all professions), elder abuse (most states), dependent adult abuse, intimate partner violence (varies by state — most do NOT mandate IPV reporting for competent adults)

— Infectious diseases: reportable to local/state health department, then CDC (NNDSS); includes STIs, TB, measles, meningococcus, foodborne outbreaks, novel pathogens

— Impaired drivers: patients with conditions affecting safe driving (seizures, syncope, dementia, severe visual loss); reporting requirements vary by state — some mandatory (CA, PA, OR, NV, NJ, DE), most permissive

— Injury inconsistent with stated mechanism or developmental stage

— Delays in seeking care, changing histories, multiple ED visits

— Pattern injuries (loop marks, immersion burns, bilateral symmetric bruises)

— Caregiver answers for patient, isolates them, controls finances

— Positive STI in prepubertal child (especially gonorrhea, syphilis)

— New seizure or syncope in active driver

Board pearl: On Step 3, if you "suspect" abuse, the correct next step is almost always report to CPS/APS first, then medical workup, then social work — NOT "confront the caregiver" and NOT "wait for more evidence."

Mandatory reporting = legally required disclosure by physicians of specified conditions or suspected harms to designated agencies, overriding usual confidentiality (HIPAA permits disclosures required by law)

Three high-yield Step 3 buckets:

Additional reportable situations: gunshot/stab wounds, suspected human trafficking, animal bites (rabies risk), certain occupational injuries, blood lead levels in children, cancer registry

Threshold for reporting abuse is "reasonable suspicion" — not proof, not certainty. Physicians do not investigate; they report and let agencies investigate

Good faith reporters are immune from civil and criminal liability in every state; failure to report carries fines, license action, and potential criminal charges

When to suspect:

Presentation Patterns and Key History

— Injury inconsistent with developmental stage (femur fracture in non-ambulatory infant, "rolled off the couch" with skull fracture in 2-month-old)

— TEN-4-FACES-p bruising rule: bruising to Torso, Ear, Neck in child ≤4 yr, or any bruise in infant <4 months → high specificity for abuse

— Multiple fractures in varying stages of healing, posterior rib fractures, metaphyseal corner ("bucket-handle") fractures

— Sentinel injuries: small bruise or intraoral injury in pre-cruising infant

— Pressure ulcers in well-resourced setting, dehydration/malnutrition, poor hygiene, medication non-adherence with caregiver control of meds

— Financial: missing belongings, new "friend" on accounts, unpaid bills despite resources

— Patient defers to caregiver, fearful eye contact, caregiver refuses to leave room

— Injuries to head/neck/face, defensive forearm injuries, injuries during pregnancy

— Chronic pain, depression, PTSD, frequent ED use, somatic complaints

— USPSTF recommends screening women of reproductive age for IPV (Grade B)

— Travel, sick contacts, food exposures, occupation, sexual history, IVDU, immunization status, animal exposures

— Recent seizure, syncopal episode, new dementia diagnosis, uncontrolled DM with hypoglycemia, substance use, severe OSA with daytime somnolence, progressive visual loss (macular degeneration, glaucoma)

— Ask explicitly: "Are you still driving?" — patients underreport

Key distinction: Screening for IPV is a USPSTF recommendation; reporting IPV in competent adults is not mandatory in most states — respect patient autonomy, offer resources, document safety planning. Contrast with child/elder abuse, where reporting is mandatory regardless of patient/family wishes.

Child abuse red flags:

Elder abuse patterns:

Intimate partner violence:

Infectious disease history:

Impaired driver history:

Physical Exam Findings and Interview Approach

— Full skin survey including scalp, frenulum, genitals, soles; document with body diagrams and photographs

— Funduscopy for retinal hemorrhages (abusive head trauma)

— Oral: torn lingual/labial frenulum suggests forced feeding

— Growth chart review for failure to thrive

— In suspected abuse <2 yr: skeletal survey is mandatory; repeat in 2 weeks to catch healing fractures

— Pressure ulcers (stage and location), poor dentition/hygiene, weight loss

— Bruising in unusual locations (inner arm, back), restraint marks at wrists

— Cognitive assessment (MoCA/MMSE) — capacity affects reporting pathway and intervention

— Central pattern injuries, multiple stages of healing, strangulation findings (petechiae, subconjunctival hemorrhage, hoarseness, neck bruising — requires CT angiography of neck)

— Visual acuity and fields, cognitive screen, gait, reaction time

— Consider on-road driving evaluation by OT for borderline cases

— Open-ended, nonjudgmental: "Tell me what happened"

— Avoid leading questions in pediatric cases (forensic interviewers should obtain detailed history)

— Document quotes verbatim in chart

Step 3 management: When you suspect strangulation in IPV, order CTA neck — carotid/vertebral dissection is the lethal missed diagnosis. Admit for observation even when exam appears benign; symptoms can be delayed 24–48 hours.

Examine the patient alone whenever abuse is suspected — separate caregiver, partner, or adult child under a neutral pretext ("we need to do a private exam")

Child abuse exam:

Elder abuse exam:

IPV exam:

Impaired driver assessment:

Interview technique:

Documentation, Reporting Mechanics, and Initial Workup

— Verbatim quotes in quotation marks

— Objective description of injuries: location, size (measure in cm), color, shape, stage

— Body diagrams and photographs (with consent where required)

— Avoid conclusory language ("definitely abuse"); use "injuries inconsistent with reported mechanism"

— Time-stamped, contemporaneous notes

— Child abuse → Child Protective Services (CPS) by phone immediately, followed by written report within 24–72 hours (state-dependent)

— Elder/dependent adult abuse → Adult Protective Services (APS) or long-term care ombudsman if in facility

— Infectious disease → local/county health department — many jurisdictions have online portals; urgent pathogens (meningococcus, measles, novel respiratory) require phone notification within hours

— Impaired driver → state DMV/department of motor vehicles medical review board

— Suspected child abuse <2 yr: skeletal survey, head CT (or MRI), ophthalmology consult for retinal exam, LFTs/lipase (occult abdominal trauma), CBC/coags (rule out bleeding disorder mimic), urine tox in select cases

— Suspected sexual assault: SANE exam, forensic kit, STI testing (NAAT GC/CT, HIV, syphilis, hepatitis), pregnancy test, emergency contraception, HIV PEP within 72 hr

— Reportable infections: confirmatory testing per pathogen (e.g., TB: AFB smear/culture, NAAT, CXR; meningococcus: blood/CSF culture, PCR)

Board pearl: Reporting is based on suspicion, not confirmation. Do not wait for skeletal survey results before calling CPS. Workup proceeds in parallel with the report.

Documentation principles (legally critical):

Reporting mechanics:

Initial labs/imaging by category:

Confirmatory Workup and Forensic Considerations

— Repeat skeletal survey at 10–14 days catches healing periosteal reactions invisible on initial films

— MRI brain superior to CT for shear injury, subdural hematomas of varying ages

— Bone health workup to rule out mimics: calcium, phosphate, alk phos, vitamin D, PTH; genetic testing for osteogenesis imperfecta if multiple fractures without bruising

— Coag workup if bruising-predominant: PT/PTT, vWF, factor levels

— Collect within 120 hours ideally (some jurisdictions extend to 7 days)

— Chain of custody documentation

— Toxicology if drug-facilitated assault suspected (collect urine ASAP, blood within 24 hr)

— Public health lab confirmation for select pathogens (measles IgM + PCR, novel influenza subtyping)

— Contact tracing initiated by health department, not physician

— TB: sputum × 3, IGRA, drug susceptibility; airborne isolation pending

— Neuropsychological testing for cognitive concerns

— EEG, MRI for seizure workup

— Sleep study for OSA

— Formal driving evaluation through rehabilitation/OT — gold standard

Key distinction: Differentiating accidental from inflicted trauma:

— Accidental: single mechanism, consistent history across tellers, developmentally plausible, anterior shins/forehead/elbows ("leading edges")

— Inflicted: multiple injuries varying ages, changing history, posterior/protected surfaces (buttocks, inner thighs, ears), patterned (loop, bite, immersion line)

CCS pearl: In a suspected non-accidental trauma case on CCS, order CPS notification, skeletal survey, head imaging, ophthalmology consult, and social work in the same action block — don't sequence them serially.

Child abuse — confirmatory layer:

Sexual assault forensic evidence:

Infectious disease confirmation:

Impaired driver confirmation:

Decision Framework: To Report or Not, and to Whom

— Step 1: Identify the category (abuse, infection, driving impairment, other)

— Step 2: Determine if state law mandates reporting

— Step 3: If mandatory → report regardless of patient/family consent

— Step 4: If permissive → weigh confidentiality vs. third-party harm using Tarasoff-style duty-to-protect logic

— Suspected child abuse/neglect (all professionals)

— Specified reportable infectious diseases

— Gunshot/stab wounds (most states)

— Suspected human trafficking (growing list of states)

— Elder abuse (most mandate; few permissive)

— IPV in competent adults (most do NOT mandate)

— Impaired drivers (few mandate, most permissive)

— Patient threatens identifiable victim (Tarasoff)

— HIV-positive patient refusing to disclose to known partner — partner notification programs through health department; physician disclosure permissible

— Competent adult IPV victim: respect autonomy, offer hotline (1-800-799-SAFE), safety planning, documentation; do NOT report against their wishes unless state requires

— Adult with impaired capacity: APS report often appropriate

— Minor with abuse: report regardless of minor's wishes

Step 3 management: When the stem says "patient asks you not to tell anyone" but the situation is mandatory reporting → answer is to explain the limits of confidentiality and report. The therapeutic alliance is preserved by transparency, not silence.

Decision algorithm:

Mandatory across all states:

Variable by state:

Permissive but ethically supported (duty to warn/protect):

Capacity considerations:

Pharmacotherapy and Prophylaxis in Reportable Situations

— HIV PEP: tenofovir-emtricitabine + raltegravir or dolutegravir × 28 days; start within 72 hours, ideally <2 hr

— STI prophylaxis: ceftriaxone 500 mg IM (gonorrhea) + doxycycline 100 mg BID × 7 d (chlamydia) + metronidazole 2 g PO (trichomonas)

— Hepatitis B: vaccine ± HBIG if unvaccinated and source high-risk

— HPV vaccine if age-eligible

— Emergency contraception: levonorgestrel 1.5 mg or ulipristal acetate within 5 days; copper or LNG IUD most effective

— Tetanus update if wounds

— Active TB: RIPE (rifampin, isoniazid, pyrazinamide, ethambutol) × 2 mo, then RI × 4 mo

— Latent TB after contact tracing: rifampin × 4 mo or INH/rifapentine weekly × 12 wk (3HP)

— Pyridoxine with INH to prevent neuropathy

— Ceftriaxone for patient; chemoprophylaxis for close contacts: rifampin, ciprofloxacin, or ceftriaxone

— Health department coordinates contact tracing

— Wash wound, rabies immunoglobulin infiltrated locally + rabies vaccine days 0, 3, 7, 14 (28 if immunocompromised)

Board pearl: HIV PEP after sexual assault must start within 72 hours — beyond that window, efficacy drops sharply. On exam, "patient presents 96 hours after assault" → PEP generally not offered; baseline HIV testing and 4th-gen follow-up at 6 wk and 3 mo.

Post-sexual assault prophylaxis (initiated in ED, reporting in parallel):

TB (reportable):

Meningococcal disease (reportable):

Pertussis: azithromycin for patient and household/close contacts

Rabies exposure (animal bite reportable):

IPV/abuse: treat injuries, screen for depression/PTSD, refer for trauma-focused CBT; SSRIs first-line for PTSD

Procedural and System Actions — How Reporting Actually Happens

— Call state CPS hotline (each state publishes a number); document call time, recipient name, case number

— Written report within 24–72 hours per state

— Medical hold if discharge poses imminent danger — hospital can legally retain the child pending CPS investigation without parental consent

— Notify hospital social work and child protection team; pediatric forensic specialist if available

— APS hotline; if in nursing facility, also notify long-term care ombudsman and state survey agency

— Law enforcement if violent crime or imminent danger

— Local health department; CDC NNDSS aggregates data

— Some pathogens require immediate phone notification (measles, novel respiratory, viral hemorrhagic fever, plague, anthrax, smallpox, botulism)

— Hospital infection prevention engaged for nosocomial implications and contact tracing

— In mandatory states: submit medical report to DMV (e.g., CA Form DS 326)

— In permissive states: physician may report in good faith; many states grant immunity

— Counsel patient directly: document "I advised the patient not to drive until [condition resolved/cleared]"

— Seizure: most states require seizure-free interval of 3–12 months before resumed driving

— Syncope: evaluate cause; cardiac syncope generally requires treatment plus observation period

— Notify law enforcement; preserve clothing as evidence; chain of custody

CCS pearl: On a CCS case with suspected child abuse, key orders include: CPS notification, social work consult, skeletal survey, ophthalmology consult, admit for protective custody, hospital child protection team consult. Do NOT discharge home pending investigation.

Child abuse pathway:

Elder/dependent adult abuse:

Infectious disease:

Impaired driver:

Gunshot/stab wounds:

Special Populations — Elderly and Cognitive/Capacity Considerations

— ~10% of community-dwelling elders; most perpetrators are family members

— Types: physical, sexual, emotional, neglect (most common), financial, abandonment

— Risk factors: cognitive impairment, social isolation, caregiver burnout, substance use in caregiver, shared living arrangement

— Competent elder who declines APS report: in mandatory states, physician still reports; APS will respect the competent elder's right to refuse services after investigation

— Capacity is decision-specific — an elder may lack capacity to manage finances but retain capacity to refuse a medical intervention

— Document a structured capacity assessment: understanding, appreciation, reasoning, expression of choice

— Dementia: mild dementia may retain driving ability initially; moderate dementia (CDR ≥2) → cease driving

— Counsel family, document recommendation, refer to OT driving evaluation

— AAN guidelines support physician reporting in concerning cases

— Adjust tenofovir-emtricitabine if CrCl <60 (consider TAF formulation)

— Reduce ciprofloxacin/rifampin doses with severe renal/hepatic impairment

— Ceftriaxone safe in renal impairment but avoid in severe hepatic + renal dual failure

Key distinction: Self-neglect (elder unable to provide for own basic needs) is reportable even though there's no abuser — this often surprises learners. APS provides services; courts handle guardianship if capacity is lost.

Elder abuse epidemiology:

Capacity-based decision-making:

Self-neglect is reportable to APS in most states even without a perpetrator

Driving in the elderly:

Renal/hepatic dosing for prophylactic regimens above:

Polypharmacy as a clue: missing controlled substances may indicate diversion by caregiver (elder financial/material abuse)

Special Populations — Pediatrics, Pregnancy, Adolescents

— All 50 states mandate reporting suspected child abuse by physicians

— Reporting threshold is reasonable suspicion, not proof

— Sentinel injuries in infants <6 mo (any bruise, intraoral injury) → workup + report

— Suspected sexual abuse → forensic pediatric exam; NAAT for GC/CT preferred over culture in prepubertal children

— Minors can typically consent to STI testing/treatment, contraception, mental health, substance use treatment without parental notification (state-specific)

— Statutory rape reporting requirements vary — pregnant 13-year-old with adult partner generally triggers report; consensual peer sexual activity often does not (varies)

— IPV often escalates during pregnancy; leading cause of trauma in pregnancy

— Screen at first prenatal visit, each trimester, postpartum (ACOG)

— Reporting still depends on state law for competent adult; offer safety planning, shelter resources

— Some states mandate reporting maternal substance use; others treat it as a public health issue

— CAPTA requires notification to CPS for infants affected by prenatal substance exposure (Plan of Safe Care), but this is not necessarily a finding of abuse

— Neonatal abstinence syndrome management with morphine/methadone weans

— Congenital syphilis, neonatal HSV, congenital CMV (some states), HIV exposure

Board pearl: A pregnant patient with positive urine toxicology for opioids on prenatal visit → engage MAT (buprenorphine/methadone), social work, neonatology; CAPTA Plan of Safe Care notification at delivery, not punitive CPS removal absent additional safety concerns.

Pediatric specifics:

Adolescent confidentiality:

Pregnancy and IPV:

Substance use in pregnancy:

Reportable infections in neonates:

Complications and Adverse Outcomes of Reporting (or Failure to Report)

— Misdemeanor or felony charges depending on state

— Medical license disciplinary action

— Civil liability if the patient is subsequently harmed

— Sentinel injury missed in infant → 25–30% mortality risk on subsequent abusive event

— Family disruption, foster placement (sometimes worse outcomes than home in marginal cases — but this is a CPS decision, not the physician's)

— Loss of therapeutic alliance — mitigate with transparency: "I am required by law to make this report; my role is to keep you safe"

— Retaliation against IPV victim if perpetrator learns of disclosure — never report IPV without victim awareness when legally optional

— Stigma (HIV, STI) — protected health information rules apply within public health framework

— Quarantine/isolation orders may invoke civil liberties concerns

— Travel/work restrictions

— License loss → loss of employment, social isolation, depression in elderly

— Counsel about alternatives: rideshare, paratransit, family

— Patient may seek care elsewhere — document recommendations meticulously

— Good faith immunity statutes protect reporters even if the report is later unsubstantiated

— Document objective findings, not conclusions

— Reports are confidential — patient does not have right to know reporter's identity in most states

Step 3 management: If a patient confronts you angrily after a CPS report ("Did you call them?"), the appropriate response is honest acknowledgment plus reaffirmation: "Yes, I made the report because I am required by law when I have concerns. My role remains to provide care for your child."

Failure to report consequences:

Risks of reporting:

Infectious disease reporting complications:

Impaired driver reporting complications:

Litigation protection:

Escalation — Hospitalization, Consults, and Multidisciplinary Coordination

— Child with suspected abuse and unsafe discharge environment — admit pending CPS investigation (medical hold)

— Strangulation in IPV → admit for observation, CTA neck

— Severe neglect, malnutrition, dehydration requiring inpatient stabilization

— Acute reportable infection requiring isolation (TB, meningococcus, measles, novel respiratory) — airborne or droplet precautions

— Suicidality in IPV/abuse victim

— Hospital child protection team / child abuse pediatrics — formal expert documentation

— Forensic nurse examiner (SANE) for sexual assault

— Social work — resources, safety planning, placement coordination

— Psychiatry for trauma response, PTSD, suicidality

— Infectious disease for complex reportable infections

— Ophthalmology for retinal exam in suspected abusive head trauma (within 24–48 hr — hemorrhages may resolve)

— Neurology for seizure-related driving cases

— Ethics committee if conflict between confidentiality and disclosure unclear

— Severe abusive head trauma, hemodynamic instability from inflicted trauma

— Septic shock from reportable pathogen (meningococcemia)

— Status epilepticus in undiagnosed seizure disorder

— Law enforcement: violent crime, weapons, imminent threat

— DMV medical review board: impaired drivers

— Public health: contact tracing, outbreak investigation

— Long-term care ombudsman: nursing facility complaints

CCS pearl: For suspected abusive head trauma, sequence: stabilize airway/circulation → head CT → ophthalmology consult → skeletal survey → CPS notification → admit to PICU. Don't forget coagulation studies to rule out bleeding diathesis mimicking abusive injury.

Admit when:

Consultations:

ICU triage:

Coordination with non-medical agencies:

Key Differentials — Mimics Within the Reportable Category

— Osteogenesis imperfecta — multiple fractures, blue sclerae, family history; genetic testing

— Bleeding disorders (hemophilia, vWD, ITP) — coag studies before attributing bruising to abuse

— Mongolian spots — flat blue-gray patches over sacrum, common in pigmented skin, not bruising

— Coining/cupping/moxibustion — cultural healing practices producing patterned skin changes; not abuse but warrants conversation

— Vitamin K deficiency bleeding in breastfed infants

— Glutaric aciduria type I — bilateral subdural hematomas mimicking abusive head trauma

— Birth-related injuries — clavicle fracture, cephalohematoma in first weeks

— Senile purpura, anticoagulant-related bruising

— Pressure ulcers from immobility despite adequate care

— Weight loss from cancer/dementia rather than neglect

— Falls from orthostasis, polypharmacy

— Athletic injuries, occupational injuries, accidental trauma

— Bleeding disorders

— TB vs. fungal/NTM pulmonary disease

— Meningococcal vs. pneumococcal meningitis (both serious, only meningococcal triggers contact prophylaxis)

— Measles vs. roseola, fifth disease, drug rash

Key distinction: Cultural healing practices (coining, cupping) leave symmetric, patterned, non-tender marks and the child appears well and bonded to family. Education, not reporting, is appropriate — unless practice causes significant injury or accompanies other red flags.

Mimics of child abuse:

Mimics of elder abuse:

Mimics of IPV injuries:

Reportable infections mimicked by non-reportable:

Differentials — Other-Category Considerations and Ethical Branch Points

— Pediatric femur fracture: abuse vs. accident vs. metabolic bone disease vs. malignancy

— Subdural hematoma in infant: abusive head trauma vs. birth trauma vs. glutaric aciduria vs. coagulopathy vs. arachnoid cyst rupture

— Recurrent admissions: medical child abuse (Munchausen by proxy) vs. genuine chronic disease — medical child abuse is reportable

— Caregiver fabricates/induces illness in dependent

— Clues: discordance between history and exam, symptoms only in caregiver's presence, multiple specialists, unusual lab patterns

— Reportable as child abuse; covert video monitoring may be employed by child protection teams

— HIV-positive patient with sexual partner unaware: encourage disclosure, offer partner notification through public health; if patient refuses and partner is identifiable and at ongoing risk → duty to warn may apply (state-specific)

— Patient with active psychosis and homicidal ideation toward identifiable target → Tarasoff duty to protect: warn victim, notify police, consider hospitalization

— Mild cognitive impairment: counsel + driving evaluation, not immediate report

— Recent seizure + active driving: state-specific seizure-free interval before resuming; report in mandatory states

Board pearl: Tarasoff = duty to protect identifiable third parties from a patient's credible threat. Originated in California; varies by state. The Step 3 answer typically involves a combination of: warn the victim, notify law enforcement, and arrange psychiatric evaluation/hospitalization — not just one of these.

When the clinical picture overlaps:

Munchausen syndrome by proxy / factitious disorder imposed on another:

Voluntary disclosure decisions (non-mandatory situations):

Driving vs. autonomy:

Discharge Planning, Safety Resources, and Long-Term Coordination

— Never discharge a child to a potentially unsafe home pending CPS evaluation

— Adult IPV victim: safety planning with the patient, written but kept secure

— National DV Hotline 1-800-799-SAFE (7233)

— Local shelter contact, lethality assessment, emergency bag plan, code word

— Elder abuse: APS-coordinated placement, home health, respite care for caregivers

— Treatment adherence plan (TB DOT — directly observed therapy is standard)

— Isolation duration: measles (4 days after rash), pertussis (5 days of antibiotics), TB (until sputum negative ×3 and clinical improvement)

— Contact tracing handoff to public health

— Return precautions for treatment failure or transmission concerns

— Written instruction not to drive until cleared

— DMV report submitted

— Alternative transportation plan

— Specialty follow-up (neurology for seizure, cardiology for syncope, sleep medicine for OSA)

— Trauma-focused CBT for child/adult abuse survivors

— SSRIs for PTSD, depression

— Substance use treatment if comorbid

— Universal IPV screening at subsequent visits

— Vaccination updates after infectious exposures (HBV, HPV, MMR catch-up)

Step 3 management: When discharging an IPV victim who is returning home, the most protective intervention besides safety planning is a scheduled follow-up appointment within 1–2 weeks with documented continuity — isolation breaks safety, continuity preserves it.

Abuse victim discharge:

Infectious disease discharge:

Impaired driver discharge:

Secondary prevention:

Follow-Up, Monitoring, and Ongoing Counseling

— STI repeat NAAT at 2 weeks

— HIV testing at 6 weeks, 3 months, (6 months if PEP used)

— Hepatitis B/C at 3 and 6 months

— Pregnancy test in 2–3 weeks

— Mental health follow-up at 1–2 weeks, then ongoing

— Repeat skeletal survey at 10–14 days

— Pediatric primary care follow-up post-CPS placement

— Developmental surveillance, mental health services

— Coordinate with APS-assigned case manager

— Home safety evaluation

— Reassess at next primary care visit and document interim events

— TB: monthly sputum until conversion, LFTs monthly on RIPE, eye exam baseline for ethambutol

— STI: test of cure for pharyngeal GC, rectal infections; rescreen at 3 months

— Hepatitis: viral load monitoring

— Seizure: 6–12 month seizure-free interval (state-specific) before DMV reapplication

— Dementia: re-evaluate every 6 months

— Syncope: cleared after definitive treatment (pacemaker, antiarrhythmic) and event-free interval

— Trauma-informed care principles: safety, trustworthiness, choice, collaboration, empowerment

— Validate, don't interrogate

— Document patient's stated goals

Board pearl: USPSTF recommends screening for IPV in women of reproductive age with referral to support services (Grade B). Screening tools: HITS (Hurt, Insult, Threaten, Scream), HARK, WAST. Memorize at least one — it appears in Step 3 vignettes.

Post-sexual assault follow-up:

Child abuse case follow-up:

Elder abuse follow-up:

Infectious disease follow-up:

Impaired driver re-evaluation:

Counseling content:

Ethical, Legal, and Patient Safety Considerations

— HIPAA explicitly permits disclosures required by law, for public health activities, and to report abuse/neglect

— Inform patient of the limits of confidentiality at the start of the visit when feasible

— Transparency preserves therapeutic alliance better than concealment

— Sexual assault forensic kit: separate consent for examination, evidence collection, and law enforcement release — patient may consent to exam but decline reporting to police (in jurisdictions where they have that choice)

— Adolescent confidentiality vs. parental notification: many states allow minors to consent to STI/contraception care confidentially; if reportable abuse is identified, that supersedes confidentiality

— Competent elder may refuse APS services after report; physician still required to report in mandatory states

— Capacity is decision-specific; document the assessment

— Credible threat to identifiable victim → warn, notify, hospitalize

— Failure → potential liability (varies by state)

— Document "advised not to drive" with date and patient's stated understanding

— Even in permissive states, document recommendations and rationale

— Hand-off communication must include open CPS/APS reports, pending public health reports, driving restrictions

— I-PASS structured handoff reduces communication errors

— Studies show disproportionate CPS reporting of minority and low-income families — apply consistent thresholds based on injury characteristics, not socioeconomic assumptions

— Use structured screening tools to reduce implicit bias

Step 3 management: When a patient says "promise me you won't tell anyone" before disclosing something, the correct response is to clarify limits of confidentiality first: "I'll keep what you say private except in situations the law requires me to report, like harm to a child or yourself." Never promise unconditional secrecy.

Confidentiality vs. mandatory reporting:

Informed consent edge cases:

Capacity and reporting:

Tarasoff duty to protect:

Driver counseling documentation:

Transition of care safety:

Bias and equity:

High-Yield Associations and Rapid-Fire Facts

— Bacterial: TB, syphilis, gonorrhea, chlamydia, meningococcal, pertussis, Legionella, Salmonella, Shigella, E. coli O157, cholera, plague, anthrax, brucellosis, tularemia, Lyme

— Viral: measles, mumps, rubella, polio, hepatitis A/B/C, HIV, rabies, arboviruses (WNV, Zika, dengue), novel influenza, SARS-CoV-2

— Parasitic: malaria, Cyclospora, trichinellosis

— Measles, meningococcal, viral hemorrhagic fever, plague, anthrax, smallpox, botulism, polio, SARS, novel respiratory pathogens

— Expedited Partner Therapy (EPT) legal in most states for chlamydia and gonorrhea — physician prescribes for partner without exam

— Seizure: typically 3–12 months seizure-free (state-specific); commercial drivers stricter (often 5–10 years off meds)

— Syncope: cardiogenic — varies; vasovagal — usually no restriction

— MI: 1–4 weeks for non-commercial; longer for commercial

— TIA/stroke: typically 1 month if no recurrence, residual deficit, or seizure

— Child abuse: ChildHelp 1-800-422-4453

— IPV: 1-800-799-SAFE

— Elder abuse: Eldercare Locator 1-800-677-1116

— Human trafficking: 1-888-373-7888

Board pearl: Reportable disease lists are state-specific but CSTE/CDC NNDSS maintains the national standard. When in doubt on Step 3 — if the disease is in the differential and on the national list, the answer is "notify public health."

Reportable infections (representative US list):

Immediate (phone) notification typically required:

STI partner notification:

Driving milestones:

TEN-4-FACES-p bruising rule for child abuse screening

PLAN of Safe Care (CAPTA): notification, not punishment, for substance-exposed newborns

National hotlines:

Board Question Stem Patterns

Key distinction: Step 3 favors act first per legal duty, document thoroughly, communicate transparently with patient/family. "Confront caregiver" or "wait for more evidence" are nearly always wrong when reporting threshold is met.

Pattern 1 — Sentinel injury: "2-month-old with a 1-cm bruise on the cheek brought for well-child visit, otherwise well-appearing." → Report to CPS + skeletal survey + head imaging + ophthalmology + admit. Wrong answer: "reassure, return if other concerns."

Pattern 2 — IPV competent adult: "32-year-old woman with facial bruises says husband hit her, asks you not to tell anyone." → Validate, offer hotline/shelter, safety plan, document; do NOT report in most states. Wrong answer: "call police over patient's objection."

Pattern 3 — Elder neglect: "82-year-old with stage 4 sacral ulcer brought from home, lives with adult son who controls finances." → Report to APS, treat ulcer, social work. Wrong answer: "discuss with son first."

Pattern 4 — Reportable infection: "20-year-old college student with fever, neck stiffness, petechiae; LP confirms gram-negative diplococci." → Ceftriaxone, droplet isolation, notify public health, chemoprophylaxis for close contacts (rifampin/cipro/ceftriaxone).

Pattern 5 — Impaired driver: "65-year-old with first unprovoked seizure, drives daily for work." → Counsel not to drive, document, report to DMV per state law, neurology and EEG/MRI workup.

Pattern 6 — Tarasoff: "Patient tells psychiatrist he plans to kill his ex-girlfriend, names her and address." → Warn the victim, notify law enforcement, consider involuntary hold.

Pattern 7 — Adolescent confidentiality: "15-year-old requests STI testing, asks you not to tell parents." → Test confidentially; report only if abuse identified.

Pattern 8 — Munchausen by proxy: Recurrent unexplained symptoms only in caregiver's presence → Report to CPS, separate caregiver, consult child protection team.

One-Line Recap

One-liner: Mandatory reporting obliges physicians to disclose suspected child/elder abuse, specified infectious diseases, and (in many states) impaired drivers to designated agencies on the basis of reasonable suspicion — overriding usual confidentiality, protected by good-faith immunity, and complemented by transparent communication with the patient.

Board pearl: When the stem pits patient autonomy against mandatory reporting, the law wins, but the alliance is preserved by honesty — tell the patient what you must do, why, and how you will continue to care for them.

Threshold: reasonable suspicion, not proof; workup and report happen in parallel — never wait for confirmation before calling CPS/APS/public health

Confidentiality vs. duty: HIPAA permits legally required disclosures; inform patients of confidentiality limits up front; IPV in competent adults is not mandatory in most states — respect autonomy, offer resources, document

Agency map: child abuse → CPS; elder abuse / dependent adult / self-neglect → APS; reportable infections → local/state health department → CDC; impaired drivers → state DMV medical review board; identifiable threat → Tarasoff warn + notify + hospitalize

Documentation = legal protection: verbatim quotes, objective injury descriptions, body diagrams, time-stamped notes; good-faith reporters are immune from liability even if reports are unsubstantiated

High-yield reflexes: sentinel bruise in infant <4 mo → full abuse workup + report; strangulation in IPV → CTA neck + admit; sexual assault <72 hr → HIV PEP + STI prophylaxis + emergency contraception + SANE exam; first unprovoked seizure in active driver → counsel + DMV report; meningococcal disease → ceftriaxone + chemoprophylaxis for contacts + public health notification