Case #1: Corey

Corey is an 8 year old boy who was brought into the emergency department where you work, by emergency medical services (EMS) personnel after he was hit by a softball during physical education class at school. Corey lost consciousness for several minutes. During the physical exam, you note that he has bilateral bruises to his shoulders, arms and abdomen. Crying, Corey reports that he was "beaten up" by classmates. When his father arrives at the ED, Corey becomes visibly fearful and stops crying. The father is clearly angry; he begins to shout at Corey about having to leave work early during an important business meeting; he was shouting at Corey about not paying attention to the game, about being a lousy ball player and acting like a baby. As the physician in the ED, you note the dad's behavior and how Corey is responding to it.

Case #2: Juanita

You are a family nurse practitioner working in a primary care office. Juanita's mother comes to the office in follow-up to the hypertension noted at the last visit. She brings 9-year old Juanita with her to the appointment, as she usually does. Today you note that Juanita is withdrawn and has bruises on her face and arms. She looks like she's been crying. Juanita is typically a chatty girl who usually engages you in talking about her love of dancing, often showing off her latest moves for the staff. Her mother appears irritable and distracted. You ask her what's wrong and she says she's fine. You mention that Juanita is so quiet and looks upset today, to which she replies that Juanita has been "bad". What would you do if you were the nurse practitioner this situation?

Case #3: Sam

Twelve year old Sam comes to school wearing only a short sleeved t-shirt and jeans on days when the temperature is in the 30s. Sam is a quiet, slender young man. He often seems nervous; he is easily startled. Sam is a C student. He never seems to be paying much attention during class; he looks preoccupied. Sam doesn't make much eye contact. He spends most of his time alone; he doesn't really have any friends at school. Indeed, often Sam is the focus of harassment and teasing from his classmates. About 2 weeks ago Sam came to class limping. He said he sprained his left ankle. The ankle didn't get better after a week, so you sent a note home to have Sam's family get medical attention for Sam. That was last week and there has been no change. As the teacher in this 7th grade classroom you wonder if Sam might be really injured.

Case #4: Alicia and Martin

The visiting nurse comes to the home to follow-up on 10 week old Alicia. The baby was born to a 19 year old mother with a history of cocaine addiction. Alicia weighed 6 lbs. 2 oz. at birth and was not drug addicted. Today, the first day you have been able to get into the home since the referral was made 6 weeks ago, you note that Alicia weighs 4 lbs. 6 oz. The mom tells the nurse that she ran out of formula yesterday and hasn't had a chance to get to the store yet today. Alicia is fretful, but does not cry. Also, during the home visits the nurse notes that 3 year old Martin has circular burn marks on his arms and legs. He is a lethargic child who cries frequently and is very shy and fearful of adults. The nurse examines Martin and finds that he also has a patterned bruise on his back which looks much like a wooden spoon.

Case #5: Tisha

5 year old Tisha has been to see her primary care provider almost weekly for the past month. Each week Tisha has complained to her mother that her stomach hurts, so her mother brings her in to be examined. Tisha's only symptom is abdominal pain. She has no nausea, vomiting or diarrhea. She is well nourished and developmentally appropriate for her age; she clearly has been well cared for. Multiple diagnostic tests have been run over the past month. As the family nurse practitioner in this practice, you must inform Tisha's mother that Tisha has tested positive for syphyllis.

Case #6: Marcus, Amber and Isaiah

Sometimes, the Shaw children come to school appearing to be hungry. You are the school nurse who comes to this school most afternoons, usually getting to the school at lunchtime. You note that the Shaw children often don't have any lunch. When they do bring a lunch, it is often not enough food. Other than this, the children seem well-groomed and well-behaved. The children are generally quiet, rather private. As the nurse, you begin talking to them and learn that their father does seasonal work and is often between jobs. How would you handle this if you were the school nurse?

Case #7: Tim

At a residential treatment center for boys age 13-16, recently some of the boys have alleged that they were sexually abused by staff. The internal investigations at the facility have never supported these claims. One of the registered nurses, Jean, suspects that what she is being told by the boys is correct; she has noted how some of the aides, mostly males, treat the boys so roughly on the one hand and then at other times are often way too familiar. She has often felt uncomfortable with their behavior. 15 year old Tim showed Jean his bloody underwear. He also told Jean that one of the aides, Joe, was forcing him to have sexual relations with some of the other aides and that Joe was recording these sessions and making money by selling the DVDs. Jean complains to the facility administration about these allegations, but was told that an internal investigation has occurred and there is no evidence that these allegations are based in fact.