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Annual exam — psychosocial screening with safety disclosure

Lala Kazuko Casper · 48y · female · 2020-06-17

General examination of patient (procedure)

Chart background

Active conditions

  • Risk activity involvement (finding)
  • Received higher education (finding)
  • Recurrent urinary tract infection (disorder)
  • Past pregnancy history of miscarriage (situation)
  • History of tubal ligation (situation)
  • Body mass index 30+ - obesity (finding)
  • Has a criminal record (finding)
  • Medication review due (situation)
  • Stress (finding)
  • Victim of intimate partner abuse (finding)

Active medications

  • Hydrocortisone 10 MG/ML Topical Cream
  • Loratadine 10 MG Oral Tablet
  • NDA020800 0.3 ML Epinephrine 1 MG/ML Auto-Injector

After-visit summary

Visit summary

What we discussed
• Victim of intimate partner abuse
• Stress with mild anxiety symptoms
• Substance use
• Obesity (BMI 30+)
• Recurrent urinary tract infection
• Health maintenance

Next steps
• Disclosure validated; confidential domestic violence hotline number provided unlabeled at her request.
• Safety planning discussed, including the protective presence of her sister in the home.
• Documented with patient consent; open-access return offered for any change in safety.
• Depression screening ×2 and assessment of anxiety completed; supportive counseling provided.
• Walking recommended as an accessible stress and weight intervention.
• Follow-up visit in approximately one month to reassess.
• Assessment of substance use and screening for drug abuse completed.
• Harm-reduction counseling: no use before driving; secure storage away from children; reassess if reliance grows.

deterministic_extractive_v1 · not_clinically_reviewed

Clinical note

**Subjective:** Ms. Lala Casper is a 48-year-old woman presenting for a general examination and overdue medication review. She describes several months of feeling persistently tense and vigilant — nighttime rumination about finances, delayed sleep onset, and an intermittent fluttery chest sensation accompanying worry that resolves with sleep. She denies exertional chest pain, dyspnea, syncope, and edema, and denies depressed mood or anhedonia. She was laid off from restaurant work during pandemic shutdowns; her partner's hours were cut; the household now includes eight people (patient, partner, two children, her sister, and sister's three children) with reported annual family income of about $10,131, creating significant financial strain. On domestic abuse screening (HARK 2) with follow-up discussion, she disclosed that her partner, when drinking, repeatedly humiliates her in front of the children and her sister, and that she feels afraid during his escalations, moving the children to another room; she denies physical violence toward herself or the children, denies feeling in immediate danger, and reports her sister is aware and supportive. She reports occasional nighttime cannabis use to decompress. Gynecologic history includes a prior miscarriage and tubal ligation after her youngest child; menses roughly regular; no pregnancy risk. Recurrent urinary tract infections historically; currently no dysuria, urgency, frequency, or hematuria. Never smoker. She has not seen a dentist in years because of cost. Allergies: aspirin, animal dander, and a general allergic disposition. Medication review completed: hydrocortisone 10 mg/mL topical cream for intermittent skin flares, loratadine 10 mg tablets seasonally, and an epinephrine 1 mg/mL (0.3 mL) auto-injector carried in her purse, never deployed.

**Objective:** BP 108/77 mmHg, HR 67/min, RR 16/min, weight 91.4 kg, height 172.9 cm, BMI 30.57 kg/m2, pain 1/10. Initially guarded, increasingly engaged; no acute distress. Heart regular rate and rhythm; lungs clear; abdomen soft; no edema; skin without active rash today. Screening: GAD-7 7; PHQ-2 0; HARK 2; DAST-10 2.

**Assessment and Plan:**

### Victim of intimate partner abuse
HARK score 2 with disclosure of recurrent verbal and emotional abuse by her partner when drinking, with fear responses; no physical violence to patient or children reported; no immediate danger identified today.
- Disclosure validated; confidential domestic violence hotline number provided unlabeled at her request
- Safety planning discussed, including the protective presence of her sister in the home
- Documented with patient consent; open-access return offered for any change in safety

### Stress with mild anxiety symptoms
GAD-7 7 (mild), congruent with financial strain, crowded housing, pandemic job loss, and relationship stress; PHQ-2 0 argues against depression.
- Depression screening ×2 and assessment of anxiety completed; supportive counseling provided
- Walking recommended as an accessible stress and weight intervention
- Follow-up visit in approximately one month to reassess

### Substance use
DAST-10 score 2 reflecting occasional nighttime cannabis use as a coping outlet.
- Assessment of substance use and screening for drug abuse completed
- Harm-reduction counseling: no use before driving; secure storage away from children; reassess if reliance grows

### Obesity (BMI 30+)
BMI 30.57 kg/m2 in the setting of stress and limited resources.
- Gradual activity goals set; further nutrition discussion deferred to follow-up per patient preference

### Recurrent urinary tract infection
Historical; asymptomatic today.
- No testing or treatment indicated; return promptly with symptoms

### Health maintenance
Medication review due addressed; aspirin and animal dander allergies re-verified.
- Influenza vaccine (split virus, trivalent, preservative-free) administered
- Patient referral for dental care placed to sliding-scale community clinic
- Assessment of health and social care needs completed; one-month follow-up scheduled

FHIR resources at this visit

Observation 13Procedure 8DiagnosticReport 5Condition 4Immunization 1

Transcript

DRMs. Casper? I am Dr. Lin. Sorry about the wait — the masks and the spacing have everything running slow these days.

PTIt is okay. Honestly this is the quietest hour I have had all week. There are eight of us in the house right now.

DREight — that is a full house. Who all is home?

PTMe, my partner, my two kids, my sister and her three. She lost her apartment in March, so we doubled up. It is tight.

DRThat is a lot of people to look after. I am glad you carved out an hour for yourself. What brought you in today?

PTThe clinic called about a checkup being overdue, and the letter mentioned a medication review too. And honestly... I have been wound so tight lately, I figured I should get looked at while I had the excuse.

DRWound tight — tell me about that.

PTI do not sleep great. My mind runs — money, mostly. I got laid off from the diner when everything shut down, my partner's hours got cut, and unemployment barely covers groceries for eight people. Some nights my chest gets this fluttery feeling.

DRFluttery like your heart racing, or fluttery like worry?

PTWorry, I think. It fades once I finally fall asleep.

DROkay. Any chest pain with activity? Shortness of breath, fainting, swelling?

PTNo, nothing like that. Physically I am healthy as a horse. Always have been.

DRThen let us do the review part. The chart shows three things: hydrocortisone cream, loratadine — the allergy tablet — and an epinephrine auto-injector. Still have all three?

PTYes. The cream for when my skin flares up, the pill most days in spring, and the EpiPen lives in my purse. My allergies are the dramatic part of me. Animal dander sets me off, and I cannot take aspirin — I hope that one is on my chart in red somewhere.

DRIt is, and I have just re-confirmed both, plus the dander. Any reactions lately? Ever had to use the EpiPen?

PTNever used it, knock on wood. Sneezing and hives is as far as it goes, and we keep no pets — hard enough keeping eight humans.

DRHa, understood. The urinary infections you have had on and off over the years — anything brewing now? Burning, urgency, blood?

PTNo, I have been clear for a good while. Believe me, I know the drill when one starts.

DRGood. Periods still fairly regular? Any chance of pregnancy?

PTRegular-ish, and no — I had my tubes tied after my youngest. That door is closed. I lost one before the kids came, so when I was done, I was done.

DRThank you for telling me — I know that history is not easy to say out loud. Now, the nurse had you fill out several questionnaires. May I go through the results with you? A couple touch personal territory.

PTThat is fine. I answered them honest, which is new for me.

DRI noticed, and I want you to know that took courage. The anxiety score was a seven — that is the mild range, and it matches the wound-tight feeling you described. The depression screen was a zero — stressed but not down. Does that fit?

PTRight. I am not sad. I am... braced. All the time.

DRBraced is a good word for it. Now — the safety questionnaire. The one that asks about being humiliated, being afraid, being hurt. You marked yes on two. Are you comfortable telling me about that? What you say stays between us unless you want otherwise.

PT...It is my partner. He does not hit me — I want to say that first. But when he has been drinking, the things he says. In front of the kids, in front of my sister. He cuts me down to nothing. And lately when he gets loud I take the kids to the bedroom, and I notice my heart pounding and I am... scared. Of what, I do not even know. That sounds crazy, right?

DRIt does not sound crazy at all. Fear like that is information. Being humiliated and made afraid in your own home is abuse, even when nobody lays a hand on you. I am really glad you said it out loud. Are you in danger right now — today, this week?

PTNo. Not danger-danger. He has never touched me or the kids. It is words, and a wall got punched, twice maybe.

DRI hear you, and you know your situation best. A few things, and you choose what is useful. There is a confidential domestic violence hotline — I can write the number small, no label, however you want it. They do safety planning even for people who are not leaving, just so a plan exists. Would you take that?

PTSmall and no label. Yes. My sister knows some of it already, so I am not alone in the house with it, at least.

DRThat matters — your sister knowing is genuinely protective. With your permission I will also note this in your chart, which is confidential, so any clinician who sees you can support you without you having to retell it from the start. Is that all right?

PTThat is all right. Saying it once was the hard part.

DROne more from the forms — the substance questions scored a two. Tell me about that.

PTSome nights, after everyone is asleep, I smoke a little weed my sister gets. It is the only half hour my shoulders come down off my ears. It is not a thing. But I answered honest.

DRHonest is all I ask. At that level my cautions are the practical ones — never before driving, and keep it locked away from the kids. If it ever becomes the main way you cope, we will talk about other options together.

PTDeal.

DRLet me examine you now... deep breath... again... lungs are clear, heart is regular and unhurried. Your blood pressure today was one-oh-eight over seventy-seven, pulse sixty-seven — your body is calmer than your week, I would say. Weight came in at ninety-one point four kilos, and the math puts your BMI just over thirty.

PTThe stress-baking economy is thriving at our house.

DREight people, tight money, a pandemic — you get some grace on that. When things settle even slightly, walking is free and it helps the anxiety at least as much as the waistline. And speaking of free — when did you last see a dentist?

PTYears. Dental costs real money, and the kids' teeth come first.

DRI am putting in a referral to the community dental clinic — sliding scale, often nothing with Medicaid. Adults need their teeth looked after too.

PTIf it is sliding scale, I will actually go.

DRAnd one shot today — the flu vaccine. With eight in the house, one case of flu becomes eight fast.

PTLord, do not speak it into existence. Yes, fine, the shot.

NURSELittle pinch coming... there we go. All done. Hold the cotton for a minute for me.

PTThank you, sweetheart.

DRSo here is your plan, and none of it is homework you have to ace. The hotline number, written the way you asked. The dental referral. The flu shot is done. Walking when you can steal the time. And I want to see you back in about a month — partly for the anxiety, mostly because you deserve one appointment a month that is just about you.

PTA month. Okay. I can do a month.

DRAnd Lala — if anything at home changes, if the fear gets bigger, you call or you walk in. No appointment needed, any hour we are open. What you did today was strong.

PTThat is the first time anybody has called it strong. Thank you, doctor. Really.

DRTake good care of yourself. The front desk will set the follow-up on your way out.