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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.
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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 Today you note that Juanita is withdrawn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?
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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.
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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.
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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
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Case #6:Leah and Tisha
As a clinical social worker, you are Leah's therapist.
Leah is step-mother to 5 year old Tisha, having been married
to Tisha's father, Michael, for the last 6 months. The
whirlwind relationship has been the frequent topic of
your sessions. Leah has also talked about her role as
a step-mother and her discomfort with it. She thinks that
Michael and Tisha are too close; it makes her uncomfortable.
Leah reports that she thinks Michael is too protective
of Tisha, not really allowing her to play with other children
when she is staying at their house, even limiting her
contact and relationship with Tisha. In the last session
with Leah, she told you that she fears that Michael is
sexually abusing Tisha: she saw him leave Tisha's room
early in the morning, when he thought she was sleeping;
she saw him toss a condom in the trash. As the therapist,
what should you do?
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Case #7: 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?
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Case #8: 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 making money on it. 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.
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Ken Hammond, USDA
These situations are real, or at least they
could be real; several are based on real situations. If you
were faced with these situations, what would you do? Do you
know what child abuse looks like? Would you recognize child
abuse if signs and symptoms were presented to you? Would you
know what to do ethically if you suspect child abuse? Do you
know what you must do legally if you suspect child abuse?
What if you are not sure? Do you know what you might face
legally if you did not report your suspicions? Would you face
repercussions if you did report? How should you proceed?
Continue on to
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