CANDIDATE INSTRUCTIONS

Station title: Gina Snow

Time allowed: 10 minutes

You are a junior doctor working at a GP clinic. Gina Snow, an anxious-looking 29

year old lady, walks in slowly. Gina is a housewife and the mother of a 3 year old girl.
She comes to you complaining of a backache. She initially refuses to be examined,
but reluctantly allows examination subsequently, where a bruise is seen on her lower
back.

Tasks:
1. Obtain a detailed history from Gina. (5 minutes)
2. Counsel the patient on management. (5 minutes)

IMPORTANT NOTE:
Candidates will NOT be prompted to move on to the next task, please manage the
suggested time allocation independently.

Created by: Ranithi Sugathadasa

 SIMULATED PATIENT INSTRUCTION

Name: Gina Snow

Age: 29 years old
Occupation: housewife
Aboriginal or Torres Strait Islander status: No

You will be portraying a patient who has experienced domestic violence and is
visiting the GP to obtain painkillers to alleviate body pain from the abuse. You are
very anxious and eager to complete the interview quickly so you can leave with the
medication.

Requirements:

We kindly request you to bring a plaster and a face mask on the OSCE day. The
PALS committee will help you position the plaster on your left cheek so that it is
slightly visible above the mask. This serves as a cue for the student to support the
diagnosis.

During the interview, speak softly and use short sentences, maintaining minimal
eye contact.

Wearing a long-sleeved, fully covered outfit is strongly encouraged to suggest

that the patient may have additional bruises or injuries she is trying to conceal.

Opening “I have a bad back pain and i'm here to get some strong painkillers”
statement

HOPC Back Pain

Where: lower back

When: since yesterday
Quality: aching
Quantity: 7-8/10
Aggravating: painful on movement and touch
Relieving: paracetamol (up to some extent)
Belief: probably from my fall down the stairs

“I need to leave soon. Can you please give me my painkillers?”

Systemic Nil neurological/ other MSK symptoms/ genitourinary/ constitutional

review symptoms
No other symptoms

Created by: Ranithi Sugathadasa

 Past Medical Not significant
History

Medications Paracetamol for pain

Social history Lives with husband and 3 year-old daughter

Married for 4 years
Does not smoke
Drinks only socially

Mention ONLY IF asked about the home situation “How’s your home environment?/ Do you
feel safe at home?/Tell me about things at home/ Does your partner’s behaviour upset you?”.
Only respond after at least 2 attempts AND reassurance (of confidentiality) by student
(you may sound/look hesitant to respond/open up in the 1st attempt)

Physical: ‘Has your Mostly when he’s drunk and I scold him for drinking. I
partner ever hurt shouldn’t have..
you?’ ● Yesterday’s fight was because he came home drunk
too. I didn’t want him to behave that way in front of
my daughter so I scolded him and he hit me.
● If asked only: injury on face and back were by him
throwing a metal bottle and various objects at me
● He’s addicted to drinking now and spends most
money on that. Since he’s the breadwinner of the
family, I’m in a lot of stress now.

History of abuse:
● Duration: 3 months, He was drinking more than
usual these 3 months
● 2-3 times a week, usually at night when he comes
home drunk
● I’m sure he doesn’t mean to hurt us. He’s just
stressed.
● Past injuries: bruising around eyes, cuts
● Back pain from being beaten up, bruised right now
● Usually no use of weapons. Occasionally he picks
up stuff around the house such as metal bottles and
wooden sticks to attack me.
● No admissions
● Biggest fear: “I don't like him getting revenge on my
child”
● Beats child sometimes when drunk
● Does not think husband would kill her or child

Risk assessment Doesn’t feel she’s currently in danger. “He’s usually a very
nice person. He’s just stressed. He apologies afterwards”

Sexual: “Does your partner No

force/ make you do sexual
activities you don't want to?”

Created by: Ranithi Sugathadasa

 Emotional: “How “He says I’m a pile of trash and I’m useless”
does your partner
make you feel? Do
they belittle/
degrade you or try
to control you?”

Financial: “Does No.

your partner control If asked, have some savings enough to leave
your finances?”

History of Patient: No
substance use in Partner: yes, he abuses alcohol
patient and
partner

Screening for ● Low mood

depression/ anxiety ● Guilt: feels responsible for the abuse, feels guilty
that child is suffering because of her
● Low energy
● can’t focus on household chores
● Insomnia/ restless sleep
● Sometimes feels like heart is beating fast and can’t
breathe
● Increased appetite(probably put on a few kg)
● No suicidal ideation

Impact on life ● “I’m not in good terms with my family”

● “I have one close friend but my husband doesn’t like
me associating her so I distanced her”
● “I haven’t discussed this with anyone. I’m
embarrassed”

When candidate is counselling you, say:

“He loves us. He’s just stressed. He’ll get back to his usual self soon”
“I shouldn’t have scolded him. It’s my fault. I’m stressing him even more”

Ongoing Support and therapeutic relationship

● If the candidate offers their support you are willing to take it and keep seeing them as
your doctor
● You are willing to make an emergency plan with the doctor, but redirect them if they
try to make one with you now “e.g im happy to do this a bit later”
● You have not heard of any support services and are willing to consider them but are
afraid that your partner will find out.

Created by: Ranithi Sugathadasa

MARKING RUBRIC

Communication ● Develop a good rapport with the patient and make

them feel comfortable
● Provide assurance on privacy, safety and
confidentiality
○ “this is a safe space”
● Attempt to establish the history of domestic violence
with sensitivity and respect:
○ I am worried that there may be a link between
your relationship with your husband and the
backaches? Or..
○ Do you feel unsafe at home or afraid of your
partner?
○ Sometimes partners use physical force, is this
happening to you?
● Be reassuring, empathetic and non-judgemental
● Listen and allow the patient opportunity for questions
● Acknowledge patient’s emotions
● Provide words of affirmation/validation statement
when patient chooses to disclose, as follows:

History of Abuse ● Establishes history of physical abuse: duration,

frequency, timing, triggers, requirement for
admission, extent/ severity of injuries, asks if
life-threatening, child abuse
● Other types of abuse: sexual/ emotional/ verbal/
psychological/ financial
● Identifies child abuse
● History of substance abuse in both patient and
partner
● Screening for depression/ anxiety/identifies she’s
depressed
● Enquires about her support system and if financially
capable to escape

Management

Diagnosis Intimate partner violence/ domestic violence.

AND Child Abuse

Knowledge ● Types of domestic violence: physical, sexual,

verbal/emotional/ psychological, financial

Created by: Ranithi Sugathadasa

 ● Explain cycle of abuse:
○ tension-incident-reconciliation-honeymoon
○ Emphasise things will not change until the
cycle is broken

● Explain that child is being abused as well and this is

very serious
● Outcome: traumatic harm/ death/ more likely to get
chronic illness and mental health problems

Attitude Establish patient’s attitude of the diagnosis

Education ● State what she’s experiencing is abuse, it is a

criminal offence and she has a right not to be
assaulted
● Explain that child is being abused as well and this is
very serious - mandatory reporting to Child Protection
Service required
● Steps to protect yourself and your child

Management plan ● Police report & Mandatory reporting - apologise

that confidentiality would need to be broken
○ children are involved (in this case, her
daughter) - mandatory reporting to child
protection services

You are not obliged to report violence experienced by

adults (in this case, the patient). You should:
● encourage patient to approach the police directly and
report an incident of family violence or sexual
violence. The police may be able to provide more
information about the patient’s legal options

Created by: Ranithi Sugathadasa

 ● GPs should also offer to report the incident to the
appropriate authorities, including the police, if the
patient wants this. However, it is important to respect
patients’ wishes and not pressure them into making
any decisions.
● If the patient decides to report the family violence to
the police, the police will be able to provide
assistance with and information about protection
orders
● Safety plan: prepare a “Go bag” ready with clothes,
cash, legal documents and identification so you can
leave home anytime

Preventative measures Keep weapons away, involve family and friends, lie if you
need to escape

Information ● Provide information for crisis centres, NGO’s, legal

aid and counselling
● Keep in mind pamphlets may be found by her abuser
● Websites and hotlines for women’s aid organisations
preferred.

Reinforce Information The next steps need to be her decision (about her life)
● Since child is involved (concerns for the child’s
safety), mandatory reporting: (child protection
services)
● DON’T make any decisions for her
● Police reporting if GP believes there is imminent and
serious risk to a patient or child’s life
● It is appropriate to disclose to the police on the basis
of an overriding duty in the public interest.
● It is advisable that GPs seek legal advice from their
indemnity insurer and/or medical defence
organisation

Created by: Ranithi Sugathadasa

 ● Referral to specialist services about legal, financial
and housing needs, or to psychological therapy
● She meets the criteria for MDD: consider counsellor,
psychologist or psychiatrist referral

Evaluate consultation ● Encourage her to seek help/ make decision

● Offer help to discuss the matter with the
spouse/husband
○ (If Gina agrees, you may see her husband in
clinic and offer him a referral to an accredited
behaviour change programme)
● Words of affirmation

Safety Net/ followup ● Schedule a follow-up appointment for ongoing

support
● Always assess the level of danger (immediate and
short term)
● Mandatory reporting to police and Department of
Health and Human Affairs (Child Abuse)

Ref: PALS 2024 Lec 8

Created by: Ranithi Sugathadasa

 https://services.dffh.vic.gov.au/reporting-child-abuse

Created by: Ranithi Sugathadasa