Observing during the patient encounter


Certain physical findings, either as a chief complaint or an incidental observation, can be suggestive of an abusive situation.  This is especially the case if:

  • the explanation doesn’t fit the injury
  • there has been a delay in seeking treatment
  • there is a pattern of repeated ED visits. 


Suggestive physical evidence of injury by another person, whether the patient admits it or not, requires mandatory reporting in most circumstances (see State Law).  If you are not sure what to do, contact Risk Management (723-6824) and/or ask Social Services (723-5091) for an evaluation.

Suggestive physical findings include:

  • bruises or other injuries, possibly in various stages of healing, usually on the central trunk area
  • “defensive injuries” on forearms
  • unexplained, multiple or bilateral injuries
  • rectal/genital injuries
  • burns
  • welts
  • bite marks
  • fractures, dislocations
  • injury during pregnancy, especially to abdomen or breasts
  • contusions or injury to head, neck or chest
  • face, eye, mouth/dental trauma
  • choking sequelae – hoarseness, difficulty swallowing or breathing (due to edema – note can be delayed and fatal), scleral hemorrhage, new seizure, unexplained stroke (see description of choking injury at Polaroid site)
  • neurologic changes – tingling, numbness, hearing or visual loss


Suggestive pelvic exam findings include:

  • reluctant to remove clothing; partially undresses
  • avoids eye contact, fearful eye contact
  • flat affect, appears “zoned out”
  • unexplained crying
  • excessive distress or discomfort out of proportion to the clinical situation
  • exaggerated startle response to touch
  • avoidance behavior i.e. keeping knees together, withdrawal from examiner
  • increased muscle tension during exam


Tips for doing an exam:

  • maintain eye contact (if culturally appropriate)
  • reduce power differential (sit on low stool)
  • give patient control/options – that you will stop at any time
  • ask permission and let patient know what you are doing next
  • ask if there are any parts of the exam, such as breast or pelvic, which are particularly difficult - what could be done to make exam more comfortable?
  • keep explaining, encourage questions
  • ask periodically about anxiety levels
  • remind patient why you are performing exam – the benefits to her
  • allow extra time
  • prepare to reschedule prn


Other Clues

These symptoms may be red flags to have you ask more closely about possible abuse:


sleep problems
eating disorders
substance abuse
distrustful, angry, defensive


exacerbation of chronic pain, especially abdominal or pelvic
recurrent STDs
new HIV
sexuality issues
exacerbation of medical conditions such as asthma, diabetes, IBS, autoimmune, hypertension, musculoskeletal
vague somatic symptoms
cognitive problems (traumatic brain injury from choking)
seeming non-compliance with medical advice
frequent/unexplained appt. changes or no shows “hides” with heavy make-up, sun glasses, clothing which covers arms and neck


unplanned pregnancy
no or late prenatal care
bleeding during pregnancy
miscarriage, stillbirth
preterm labor
low birth weight
decreased breastfeeding

These symptoms may be red flags to have you ask more closely about possible abuse: