Ms. R presented with injuries after a “fall.” The history of this fall is provided almost exclusively by Ms. R’s daughter, who interrupts Ms. R’s attempts to contribute to the story. When interviewed alone, Ms. R initially says she fell but then admits to frequent verbal and infrequent physical abuse by her daughter. Her new story is that her daughter was insisting that she sign papers to allow her to control all of her banking and finances.  They argued, as they do frequently, and her daughter struck her twice in the face with Ms. R’s cane.

On physical exam, Ms. R is mildly cachectic-appearing. She has ecchymoses/ bruising in the peri-orbital areas bilaterally, with the left eye nearly swollen shut. She has tenderness in both maxillary sinuses. She also has bruising on her left cheek and on the external aspects of both upper arms. From the imaging results, Ms. R is noted to have an acute left zygoma fracture, an acute displaced nasal bone fracture, and an age-indeterminate right zygoma fracture. On laboratory tests, she’s found to be anemic and to have low albumin, suggesting
poor nutrition.