AKT – Abuse and violence

Angela Richards, aged 34, presents to your general practice with vague complaints of insomnia, poor concentration, and fatigue over the past three months. She is reluctant to elaborate on personal issues, but breaks down in tears when asked about her home life. She has two school-aged children and works part-time as a teacher’s aide. Her partner does not accompany her to appointments. She mentions he checks her phone regularly and she has limited access to money.

Relevant Medications, allergies: Nil

Relevant Social history: Lives with partner and children. No other social supports mentioned.

Relevant examination findings: No physical injuries noted today.

What is the MOST appropriate next step in her management?

Robert Lee, aged 82, is brought in by his daughter who is concerned about his increasing confusion and bruises on his arms. He is living with her and her husband. Robert has mild cognitive impairment. When asked about the bruises, Robert becomes agitated and says he ‘bumps into things’. His daughter says he fell recently but cannot specify how. You notice he avoids eye contact when his daughter speaks.

Relevant Past history: Hypertension, osteoarthritis, mild cognitive impairment

Relevant examination findings: Bruises on upper arms bilaterally in various stages of healing

What is the MOST appropriate next step?

Imran Siddiqi, aged 17, presents alone complaining of abdominal pain and poor appetite. During the consultation, he mentions he sometimes sleeps in the park and hasn’t been home in a week. When asked, he becomes vague about why he left. He finally discloses that his stepfather is violent, and he left to protect himself. He does not want you to tell anyone.

Relevant Past history: None documented

Relevant Social history: Lives with mother and stepfather, currently staying with friends

What is the MOST appropriate next step?

Leanne Morris, aged 28, presents requesting emergency contraception after unprotected sex. During history taking, she quietly states that her partner refuses to use condoms and has hurt her during sex. She looks visibly distressed and asks you not to tell anyone. She has no visible injuries.

Relevant Obstetric/sexual history: G1P1, recent normal Pap smear

What is the MOST appropriate response?

Michael Johnson, aged 7, is brought in by his mother with concerns of frequent stomach aches. During the visit, you notice he flinches when you examine him and is unusually quiet. He has bruises on his shins, which his mother says are from playing soccer. When asked alone, Michael says he gets hit ‘when he’s naughty’ but begs you not to tell anyone.

Relevant Past history: Previously well, normal developmental milestones

What is the MOST appropriate next step?

David McGregor, aged 42, presents with chronic lower back pain. He requests stronger opioids, saying he has been getting ‘Panadeine Forte from another GP but they won’t prescribe it anymore’. He appears tense and you notice multiple old scars on his forearms. When asked about his mental health, he becomes defensive and says he’s ‘not crazy’. He reveals he spent time in prison and has PTSD. You suspect a trauma history may be influencing his current presentation.

Relevant Medications: Occasional ibuprofen, no current prescriptions

Relevant Psychiatric history: PTSD, previous self-harm

What is the MOST appropriate next step?

Hannah Elwood, aged 36, attends for a routine cervical screening test. During the procedure, she becomes visibly distressed and asks to stop. She apologises and says this ‘always happens’. On gentle questioning, she discloses a history of sexual assault in her teens but says she’s never spoken about it before.

Relevant Past history: Nil documented

What is the MOST appropriate next step in her care?

Jason Pham, aged 9, presents with poor school performance, sleep issues, and behavioural problems. His teacher reports he often falls asleep in class. He is being raised by his grandmother, who says she struggles to manage him. On further history, she discloses his parents are incarcerated and Jason witnessed significant violence in early childhood.

Relevant Social history: Lives with grandmother. Parents in prison.

What is the MOST appropriate next step in his care?

Emily Wright, aged 22, presents for a mental health care plan. She reveals a history of intimate partner violence and says her ex-partner recently started contacting her again despite an AVO being in place. She appears anxious and fearful, frequently checking her phone. She lives alone and has limited social support.

Relevant Psychiatric history: Generalised anxiety disorder

What is the MOST appropriate action today?

Thomas Riley, aged 52, presents with alcohol misuse and liver function derangement. On further history, he reveals he drinks to cope with the stress of his adult son, who is financially dependent and sometimes physically aggressive. Thomas has visible bruises on his upper chest and says his son ‘just loses it sometimes but he doesn’t mean to’.

Relevant Social history: Widower, lives with adult son

What is the MOST appropriate next step in management?

Fatima Suleiman, aged 31, presents with her 3-year-old son who has developed a speech delay. During the consultation, she appears withdrawn, avoids eye contact and has a healing laceration on her forearm. When asked about the injury, she says she ‘fell on a dish’ but seems anxious. Her partner is waiting in the car.

Relevant Social history: Recent arrival from overseas, limited English, no family support

What is the MOST appropriate immediate action?

Kevin White, aged 62, presents with a laceration to the scalp requiring sutures. On questioning, he states he slipped in the bathroom, but this is his third visit for injury in the past year. He becomes defensive when asked further. He lives with his wife, who has dementia and for whom he is the sole carer.

Relevant Past history: Hypertension, mild depression

What is the MOST appropriate next step in this consultation?

Talia James, aged 14, is brought in by her stepmother for ‘mood swings and defiance’. During a HEADSS assessment, Talia reveals that her older stepbrother has been touching her inappropriately but she was told not to tell anyone. She starts crying and asks you not to say anything.

Relevant Psychiatric history: Nil

What is the MOST appropriate response?

Marko Petrovic, aged 45, presents with a hand injury he says he got from ‘punching a wall after a fight with his partner’. On further questioning, he admits to yelling, throwing things, and once pushing his partner during arguments. He says he regrets it and wants help but is ‘not a violent person’.

Relevant Psychiatric history: Nil

What is the MOST appropriate next step?

Jacqueline O’Neill, aged 68, presents to your clinic with complaints of sleep disturbance and worsening chronic pain. She lives in a residential aged care facility and says she feels scared of a particular staff member who ‘sometimes yells and pulls me roughly’. There are no visible injuries but she is visibly distressed.

Relevant Past history: Osteoporosis, chronic pain syndrome

What is the MOST appropriate action today?

Sally Nguyen, aged 27, attends for follow-up after a recent miscarriage. During the consultation, she appears tearful and discloses that her partner did not allow her to seek medical attention initially. She says he blamed her for the miscarriage and has previously slapped her during arguments.

Relevant Obstetric history: G2P0, miscarriage at 9 weeks gestation

What is the MOST appropriate next step?

Peter Tomlinson, aged 19, presents to your practice with a broken wrist after ‘falling off his skateboard’. You note the story is inconsistent with the pattern of injury. He is quiet and avoids eye contact. Later in the consultation, he mentions his father ‘gets angry’ when Peter is ‘too loud’ and sometimes hits him with objects.

Relevant Past history: Nil

What is the MOST appropriate next step?

Leila Haddad, aged 48, presents with symptoms of depression. On further exploration, she describes an ongoing pattern of verbal humiliation, controlling behaviour, and social isolation from her husband. She denies any physical violence. She believes it is ‘just how marriage works’ in her culture.

Relevant Past history: Nil

What is the MOST appropriate response?

Joshua Ellis, aged 11, presents with poor hygiene, frequent hunger, and aggressive behaviour at school. His mother is a single parent and reports being overwhelmed. On questioning, you learn they have recently become homeless and are living in a car. Joshua reports that he sometimes goes without food for a day.

Relevant Social history: Homelessness, single parent household

What is the MOST appropriate initial response?

Mina Kaur, aged 30, presents for a pap smear but declines after saying she ‘doesn’t want to be touched’. She becomes tearful when asked if anything is wrong. With time, she discloses a recent sexual assault by an acquaintance, which she has not reported. She says she feels ashamed and is scared others will find out.

Relevant Past history: Nil significant

What is the MOST appropriate immediate step?

Olivia Barnes, aged 25, presents for a mental health care plan. She discloses a childhood history of sexual abuse by an uncle, which was never reported. She says she has never told anyone before and feels ashamed. She is not currently at risk and has no children of her own.

Relevant Psychiatric history: Anxiety, disordered eating

What is the MOST appropriate response?

Rohan Singh, aged 4, is brought in by his father for a rash. During examination, you note bruising on Rohan’s back and upper arms. The father states he ‘plays rough’ with his cousins. When gently separated from his father, Rohan appears fearful and says, ‘Daddy gets really mad sometimes’.

Relevant Past history: Fully immunised, previously well

What is the MOST appropriate next step?

Katie O’Brien, aged 31, presents to establish care as a new patient. She recently relocated due to ‘some trouble back home’. She is visibly nervous and checks the door frequently. She mentions her ex-partner has found her new address and she feels unsafe but doesn’t want to involve the police.

Relevant Social history: Lives alone, recently changed phone number

What is the MOST appropriate next step?

Trevor Adams, aged 46, presents with alcohol dependence. During the consultation, he discloses that his father used to beat him during childhood and his mother denied it. He feels worthless and says, ‘maybe he was right’. He has not told anyone before and expresses ongoing shame.

Relevant Psychiatric history: Depression, alcohol use disorder

What is the MOST appropriate initial management?

Amy Chan, aged 34, attends for a cervical screening test. She hesitates and seems anxious. On gentle enquiry, she reveals she was sexually assaulted by her stepfather as a teenager and has not had a pelvic exam since. She asks if the test is really necessary.

Relevant Preventative Health: Overdue cervical screening

What is the MOST appropriate next step?

Marcus Long, aged 38, presents with insomnia and a recent panic attack. On assessment, he reveals he was physically abused as a child by his mother’s partner and has been experiencing flashbacks since his own child turned 8 — the age he was when the abuse began. He has never disclosed this before.

Relevant Psychiatric history: Nil previously recorded

What is the MOST appropriate next step in management?

Chloe Watego, aged 29, presents for contraceptive advice. During the consultation, she discloses she is worried her partner may find out she’s using contraception. She says he has previously thrown her phone and controls her finances. She has no visible injuries but appears fearful when discussing him.

Relevant Social history: Lives with partner, no children

What is the MOST appropriate next step?

Isaac Daniels, aged 13, is brought in for abdominal pain. He is quiet during the consultation and looks at the floor. On examination, he flinches and tenses when palpated. His mother is present and says he is a ‘difficult kid’ and sometimes ‘needs a firm hand’. You suspect physical abuse but there are no visible injuries today.

Relevant Past history: Nil significant

What is the MOST appropriate next step?

Susan Black, aged 57, presents with worsening anxiety and insomnia. She is the primary carer for her adult daughter with schizophrenia. On questioning, Susan describes episodes where her daughter becomes physically aggressive and recently pushed her against a wall. Susan appears ashamed and tries to minimise the event.

Relevant Past history: Generalised anxiety disorder

What is the MOST appropriate next step?

Daniela Costa, aged 21, presents with symptoms of PTSD. She discloses that she was sexually assaulted by a friend after a party two months ago. She has not reported the assault and has withdrawn socially. She asks if she has to tell the police to get help.

Relevant Psychiatric history: PTSD symptoms, not previously diagnosed

What is the MOST appropriate response?

Belinda Ng, aged 40, presents for a review of her asthma. During the consultation, she becomes tearful and discloses that her teenage son has become physically aggressive towards her when she sets boundaries. She feels scared in her own home but doesn’t want him to get into trouble.

Relevant Social history: Single parent, full-time worker

What is the MOST appropriate immediate step?

Nathan Foster, aged 47, presents with chronic pain and poor sleep. During the consultation, he becomes tearful and states he was sexually assaulted by another patient during a hospital stay 6 months ago. He hasn’t told anyone until now and is unsure what he wants to do.

Relevant Past history: Chronic back pain, anxiety

What is the MOST appropriate next step?

Emma Leigh, aged 35, presents with fatigue and requests an iron infusion. During history taking, she discloses her partner controls her meals and criticises her weight constantly. She appears hesitant to speak and avoids eye contact when you ask about emotional wellbeing.

Relevant Past history: Iron deficiency anaemia

What is the MOST appropriate next step?

Sophie Rahman, aged 8, is brought in by her aunt who recently took over her care. Sophie appears underweight and avoids eye contact. Her aunt reports that Sophie’s mother left suddenly and that Sophie had been living with her mother’s boyfriend. Sophie later whispers that ‘he used to come into her room at night’.

Relevant Past history: Unknown

What is the MOST appropriate action?

Gavin Mitchell, aged 60, presents for management of hypertension. During conversation, he discloses that he is caring for his brother with severe intellectual disability and feels overwhelmed. He confides that he sometimes yells and has slapped him out of frustration. Gavin is distressed and ashamed of this behaviour.

Relevant Social history: Full-time carer, limited support

What is the MOST appropriate response?

Rachel Simons, aged 43, presents for a repeat prescription of sertraline. On review, she mentions that her partner frequently insults her, calls her ‘useless’ and restricts how she spends money. She becomes tearful and says she thinks she’s going crazy. There is no physical violence disclosed.

Relevant Psychiatric history: Depression, on stable medication

What is the MOST appropriate next step?

Thomas Byrne, aged 6, presents with enuresis and social withdrawal. His teacher reports he has become fearful and flinches when approached suddenly. His stepfather accompanies him and answers most of the questions. On examination, you note faded bruises on both thighs.

Relevant Past history: Toilet trained since age 3

What is the MOST appropriate next step?

Jin Tao, aged 73, is brought in by a neighbour who is concerned about his weight loss and confusion. Jin lives with his son who is his primary carer. On exam, you note dehydration and poor hygiene. Jin repeatedly says, ‘I’m fine, I don’t want to cause trouble.’

Relevant Past history: Hypertension, early dementia

What is the MOST appropriate immediate action?

Amelia Price, aged 32, presents requesting a termination of pregnancy. She appears anxious and tearful. When asked about her support, she reveals that her partner is strongly opposed to the termination and has previously threatened to harm himself if she left him.

Relevant Obstetric history: G2P1, previous uncomplicated pregnancy

What is the MOST appropriate next step?

Luke Henderson, aged 17, presents for a school medical form. During the HEADSS assessment, he discloses that his girlfriend often threatens to break up with him if he doesn’t send explicit photos and gets angry if he talks to other girls. He seems confused and says he doesn’t think it’s abuse.

Relevant Past history: Nil

What is the MOST appropriate response?

Julia Townsend, aged 58, presents with palpitations and insomnia. On further questioning, she reveals her husband frequently yells at her, controls her access to money and accuses her of infidelity. She says he has never hit her and therefore ‘it’s probably not abuse’.

Relevant Past history: Newly diagnosed hypertension

What is the MOST appropriate next step?

Arjun Mehta, aged 15, is brought in by his older brother who says Arjun is getting into fights at school and not eating at home. On private discussion, Arjun reveals their father frequently yells, breaks things and hits their mother. He says he has never been hit himself.

Relevant Past history: Nil

What is the MOST appropriate next step?

Shelley Grant, aged 61, presents with poorly controlled diabetes. During the consultation, she discloses that her adult daughter, who lives with her, often takes her money and sometimes yells and throws things when frustrated. Shelley looks embarrassed and tries to change the subject.

Relevant Past history: Type 2 diabetes, osteoarthritis

What is the MOST appropriate response?

Nicole Fraser, aged 24, presents requesting emergency contraception. On history, she reveals her partner removed the condom during intercourse without her consent. She appears distressed but is unsure if this ‘counts’ as assault.

Relevant Social history: Lives with partner, works casually

What is the MOST appropriate next step?

Larry Hsu, aged 85, presents for a routine check-up. He is accompanied by a paid carer who answers all questions on his behalf. Larry appears passive and avoids eye contact. On brief separation, he whispers that he hasn’t had dinner for two days and is ‘always cold’ in the house.

Relevant Past history: Hypertension, early dementia

What is the MOST appropriate response?

Alana De Souza, aged 19, presents with a request for STI screening. On further discussion, she reveals she has recently started a relationship with an older man who gets angry when she refuses sex and checks her phone frequently. She says he has never hit her.

Relevant Social history: Lives with parents, full-time student

What is the MOST appropriate next step?

Michael Dwyer, aged 68, presents with unintentional weight loss and anxiety. He reluctantly reveals that his grandson, who moved in recently, has been using his pension card and sometimes becomes aggressive when asked about it. Michael asks you not to say anything because he ‘has nowhere else to go.’

Relevant Past history: COPD, hypertension

What is the MOST appropriate next step?

Kayla Nguyen, aged 26, presents for prenatal care at 12 weeks gestation. She discloses that her partner has been threatening to leave her if she doesn’t have a boy, and has started limiting her contact with family. She becomes teary and says she feels trapped.

Relevant Obstetric history: G1P0

What is the MOST appropriate next step?

Leon Wright, aged 51, is being seen for alcohol misuse. He casually mentions that he was physically disciplined as a child and often locked outside overnight for misbehaving. He says this made him ‘tougher’. He denies current trauma but has frequent nightmares and avoids family gatherings.

Relevant Past history: Alcohol use disorder

What is the MOST appropriate next step?

Ana Matua, aged 30, presents with abdominal pain. On review of her records, you note frequent presentations to different GPs over the past year with vague complaints. When asked gently, she discloses her partner watches her location and gets angry if she is late home from appointments.

Relevant Past history: Multiple non-specific complaints, no clear diagnosis

What is the MOST appropriate response?