Question 3

Clara is a 27-year-old married woman with asthma and hypertension. She has been seen twice previously in your practice for routine medical care. She presents without an appointment asking for free samples of the medications you have prescribed for her. She appears anxious and looks exhausted.  You open the interview by saying, "Help me understand what is going on."  Clara breaks down in tears. Since you just finished reading a guidebook about intimate partner violence, you follow up by asking, "Is someone hurting you? Are you safe at home, in your relationship?" 

After reassuring the patient that whatever she tells you will be kept confidential except if you believe her children might be in danger, Clara relates that she and her three young children have been living secretly in a spare room in a friend's apartment since she fled an abusive marriage two months ago. She, herself, is undocumented but her children were all born in the US so they are citizens. She entered the US illegally with the help of a "coyote" when she was a teenager.   She met her husband shortly after arriving in the US and got married after a brief courtship. When she was living with her husband, she was a full-time homemaker not working outside the house. Once she fled her marriage, though, she needed to find a source of income. Because she cannot work legally, Clara has recently started working "under the table" as a house cleaner to make ends meet, but has discovered that she can only earn enough money for bare essentials for herself and her children. Her friend has asked if she could start helping out with rent, which Clara cannot afford at this time. Although her husband does not know where she and the children are living, he still texts her several times a day-sometimes apologizing for having a "temper" and telling her he loves her and wants her to return to the marriage. At other times, though, he send texts saying he knows where she is staying and that unless she returns the children immediately, he will call the immigration authorities to seize the children and have her deported.  His most recent texts warn that if she doesn't come back immediately, whenever he finds her, he will "finish her off once and for all" as she is not worth the space she takes on the planet.  Clara has run out of blood pressure medication and is on her last asthma inhaler. Even though her husband is employed and she and the children are named on his health insurance plan, she is afraid to get her prescriptions refilled out of fear that he will find out where she is staying and report her to "the authorities." Even if she did go to the pharmacy, she would not be able to afford the co-pay on the medications. She does not see a way forward and is starting to think that she has no alternative but to return to her husband. Other than appearing tired and tearful, physical exam is unremarkable except for HR 104, BP of 150/92, and scattered wheezes on deep inspiration.   

Question 3-In this particular case, risk factors for intimate partner violence include:  [Select three that apply]