Case #1: Corey

Corey is an 8 year old boy who was brought into the emergency department where you work, by 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.

• Corey has bilateral bruises on his shoulders and arms. Accidental injuries tend to occur on one side or another, not usually on both shoulders or both arms.
• Corey's explanation that he was "beaten up" by classmates is not consistent with what EMS personnel describe about the injury during physical education class.
• Corey is fearful when his father appears.
• Corey stops crying when his father appears.
• Corey's father is angry and not concerned about his son's injury.
• Corey's father belittles Corey about his ability to play softball; Corey feels that he is never good enough.
• Corey's father uses humiliation (ie. "acting like a baby") because Corey had been crying.

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 Today you note that Juanita is withdrawn and has bruises on her face and arms.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?

• She has bruises on her face and arms.
• Juanita has had a change in behavior, from outgoing and engaging to withdrawn and tearful.
• Ms. Flores says Juanita has been "bad".

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.

• Sam wears a short-sleeved t-shirt even during cold weather; this is inappropriate attire for the season.
• Sam's family did not seek the medical attention that you, as the teacher, suggested because of Sam's limping and apparent injury to his left ankle.
• Sam seems nervous and is easily started.
• Sam is preoccupied during class and doesn't pay much attention to the class work.
• Sam doesn't make eye contact and is isolated at school; he has no friends and is often teased and bullied at school.

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.

• Alicia has lost significant weight since birth. Although some weight loss is not uncommon, by 10 weeks, she should have gained more weight.
• Alicia is fretful.
• The home is lacking formula for Alicia.
• Martin has circular burn marks on his arms and legs; the nurse notes that they look like cigarette burns.
• Martin has a patterned bruise on his back which looks like a wooden spoon.
• Martin is lethargic, cries frequently and seems fearful of adults.

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 has 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.

• Tisha has frequent complaints about abdominal pain; these complaints often happen on Mondays, after spending the weekend with her father.
• Five year old Tisha has tested positive for a sexually transmitted disease.

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?

• The children appear to be hungry when they come to school.
• The children often don't have any lunch, or if they bring lunch it is not enough.
• The Shaw children, normally quiet and private, when they speak with the nurse provide information about their father's underemployment/unemployment.

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. 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 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.

• Some of the boys at the residential treatment center have reported that they have been sexually abused by staff members.
• Tim showed his bloody underwear to the nurse, Jean.
• Jean felt uncomfortable with the way some male staff interacted with the boys, either to rough or too familiar.
• Tim told Jean that an aide, Joe, was forcing him to have sex and that Joe was recording the sexual activity and then selling the DVDs.