Kaplan USMLE Step 3: What story might these bruises tell?

If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 3 exam, you might want to know which questions are most often missed by test-prep takers. Check out this example from Kaplan Medical, and read an expert explanation of the answer. Also check out all posts in this series.  

A 26-year-old woman and her fiancé just moved to your area from abroad. Today she presents to your clinic with a bruised left arm. This is her fourth visit to the clinic for various bruises and injuries. On this visit she has diffuse ecchymoses and purpura over her entire left arm and forearm, in the shape of a hand. She claims that she fell while walking down the stairs.

The patient is otherwise healthy and denies using tobacco or alcohol. She tearfully reports that her fiancé "drinks too much and got fired from his job." Her physical examination is remarkable for a left arm discoloration, as well as other bruises that are in various stages of healing. Which of the following is the next step in management?

A. Ask the patient in simple, direct language if she has been hit by her fiancé.

B. Contact the police for intervention.

C. Evaluate the patient in the presence of a health care worker in the clinic.

D. No action is indicated, in order to not damage the patient-physician relationship.

E. No action is indicated, as the patient does not consent to intervention.

The correct answer is A.

Ask the patient in simple, direct language if she has been hit by her fiancé. Because of the high prevalence of domestic violence, routine screening must be a part of preventive care.

Choice B: Contacting the police is not appropriate; it has not even been established that this patient suffers from domestic violence, and you should first try to address the issue with the patient. Doctor-patient confidentiality does not allow for reporting of domestic violence without the patient's knowledge and agreement.