History and Physical Examination

The following findings are clues to battering that can be gleaned from the clinical history and physical examination:

Pregnancy. Pregnant women are high risk for battering; 40 percent of battering begins during the first pregnancy. Among all pregnant women, 17 percent have a history of domestic abuse, and 8 to 9 percent are battered during the index pregnancy; for pregnant teens, the figure is even higher. Any evidence of injury during pregnancy should prompt direct questioning about domestic violence.

Central pattern of injury. Battered patients are more likely to experience injuries to the head, neck, face, thorax, and abdomen than patients injured by other mechanisms.

Injuries suggesting a defensive posture. Forearm bruises or fractures may be sustained when women try to fend off blows to the face or chest. Certain characteristic injuries. Fingernail scratches, bite marks, cigarette burns, and rope burns strongly suggest domestic violence.

An extent or type of injury inconsistent with the patient's explanation. Multiple abrasions and contusions to different anatomic sites, which are inconsistent with the history, should raise the possibility of abuse. An example of such an inconsistency would be a woman with a blowout fracture who says she injured herself falling off a bar stool.

Multiple injuries in various stages of healing. Just as x-rays that reveal old fractures help support a diagnosis of child abuse, evidence of new and old injuries help diagnose partner abuse.

Substantial delay between the time of injury and the presentation for treatment. Battered women may wait several days before seeking medical care. They may see their physician at inappropriate times for seemingly minor or resolving injuries. This may occur because they were prevented from leaving the house, or it might reflect their ambivalence about revealing the nature of their home life.

Frequent visits for vague complaints without evidence of physiologic abnormality. A woman who presents frequently with a variety of psychosomatic complaints previously ascribed to depression might actually be a victim of domestic violence.

Suicide attempts. Up to 25 percent of suicide attempts by women may be related to spousal abuse; 20 percent of pregnant battered women will attempt suicide. When asked what precipitated a suicide attempt, a battered woman may respond "I had a fight with my husband." The emergency physician can make the diagnosis by asking specifically if the fight was a physical fight and exploring whether there is a history of physical and psychological abuse suggestive of domestic violence.

Multiple prior visits. Review of the medical record may reveal frequent emergency department visits for a variety of complaints, including both trauma and nontrauma presentations. Extensive workups for chronic pelvic pain or other chronic pain syndromes may also suggest a history of domestic violence.

Partner's behavior. Partners accompanying victims of domestic violence may provide clues to the diagnosis by exhibiting controlling or abusive behavior. Furthermore, the victim may appear frightened of her partner or refuse to answer questions, instead deferring all responses to him.

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