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Cat's Questions > Child maltreatment/Ethics > Flashcards

Child maltreatment/Ethics Flashcards

1
Q

Four-year-old female brought in by CAS worker due to concerns about sexual abuse. Exam shows vulvar irritation and discharge. What to do?

A. STI swabs and culture
B. Avoid bubble bath
C. Reassure
D. Something else

Or

CAS worker brings in a four-year-old girl with concerns regarding sexual abuse. The child has mild vulvovaginitis (erythema) with vaginal discharge. What is your next step:

A. Screen for STI and culture vaginal
B. Topical therapy with mupirocin cream
C. Tell them to avoid bubble bath and ensure wiping front to back
D. Reassure that discharge is physiologic

A

Answer: B (bubble bath) vs A (STI )depends how legitimate the concerns for sexual abuse are.

Or

C ( avoid bubble bath) vs A (STI)

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2
Q

What is the best way to prevent people with disabilities from suffering sexual abuse.

A. Less autonomy
B. Putting them in day facilities with more supervision
C. Better sexual education

A

C. Better sex education

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3
Q

7 y.o girl discloses that her 14 y.o stepbrother has been sexually abusing her. On exam you find a complete cleft in the posterior hymen. This is:

A. Diagnostic of sexual abuse
B. Diagnostic of previous hymenal injury
C. Normal variant
D. Congenital abnormality

A

B. Diagnostic of previous hymenal injury

Other variant of this question satiates - cleft in the inferior hymenal rim this it could be congenital or normal variant vs trauma

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4
Q

Which fracture is most consistent with abuse ?

A. Femur fracture
B. Posterior rib fracture
C. Clavicle fracture
D. Metatarsal fracture

A

B. Posterior rib fracture

CML - classic metaphyseal lesion

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5
Q

A 2 month old baby presents for a routine check up. You notice a bruise behind his ear and on his chest. He previously had a circumcision with no complications. What is the most likely diagnosis ?

A. Accidental trauma
B. Hemophilia
C. Child maltreatment

A

Answer C. Child maltreatment

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6
Q

A 16-year-old girl discloses sexual abuse. You do a physical examination and note a gap in the hymen at 12 o’clock this is most likely:

A. A normal variant
B. Diagnostic of sexual abuse
C. From repetitive trauma

A

A. Normal variant

Crescentic shape

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7
Q 
What is the most common Brain injury resulting from abusive trauma?
A. Epidural hemorrhage
B. Skull fracture
C. Subgaleal hematoma
D. Subdues hemorrhage
A

D. Subcutaneous hemorrhage

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8
Q

Kid ravenous, growing well, hugging you, but not receptive to caregiver

A. Diencephalic syndrome
B. Neglect

A

B. Neglect

Diencephalic syndrome is a rare consequence of hypothalamic tumors and is characterized by FTT with severe emaciation but normal linear growth, increased appetite and hyperactivity.

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9
Q

13 y.o girl with history of sexual abuse 3 weeks ago, which treatment ?

A. Tell authorities (police) so they can investigate
B. You investigate
C. Should do vaginal exam now and get sperm kit
D. Call CAS

A

D. Call CAS

A). Wouldn’t tell police (reporting to police is a choice of the child/family; physician duty is to report to CAS if child <16years + individual who is a figure of authority over the child or of unsupportive parents. - per TO review lecture

B). Not the physicians duty to investigate
C). New guidelines - DNA kits can be done 7 days of contact in postpubertal (per TO review lecture)

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10
Q

Most common finding in sexual abuse kid?

A. Normal genital exam
B. Midline year
C. Bruising

A

A. Norma genital exam

95% of children who undergo a medical evaluation following sexual abuse hav e a normal physical exam

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11
Q

In a two-year-old girl, which of the following factors is most concerning for child abuse?

A. Clavicle
B. Femur
C. Scapula
D. Linear skull fracture

A

C. Scapula

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12
Q

What would be most suspicious of abuse ?

A. Anal non midline lesions
B .patchy redness in vulva

A

A. Anal non midline lesions

Up to date: midline anal tags are not indicative of abuse, whereas deformities outside of the midline may indicate chronic trauma

Irritant vaginitis is a non-specific finding that neither confirms or discounts a disclosure of sexual abuse

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13
Q

Most common PE finding in a child who has been sexually abused ?

A. Normal exam
B. Dilated rectum with stool
C. Scar at midline
D. Bruising in posterior fourchette

A

A. Normal exam

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14
Q

Metaphyseal chip fracture, history of falling off change table. Most likely dx?

A. Osteogenesis Imperfecta
B. Child abuse
C. Rickets

A

B. Child abuse

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15
Q

Which of the following fracture is not suggestive of abuse ?

A. Spiral fracture of tibia
B. Supracondylar fracture
C. Posterior rib

A

C. Posterior rib

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16
Q

Sign of sexual abuse ?

A. Midline anal tag
B. Scar outside of midline anus
C. Atrophic shiny vaginal mucosa
D. Big rectum >2cm with lots of stool

A

B. Scar outside of midline anus

A. Midline anal tag - normal variant
C. Strophic shiny vaginal mucosa - lichen sclerosis
D. Big rectum with stool - would be if no stool present

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17
Q

Which of the following is a risk factor for child abuse?

A. Prematurity
B. Larger number of siblings
C. Older parents
D. Attends daycare

A

A. Prematurity but apparently B is also right (siblings)

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18
Q

2019Q 9 month old has a left hymenal midshaft fracture, no provided history. Normal development, previously healthy. Skeletal survey does not show any other fractures. Dilated fundoscopy exam is normal. Bloodwork is normal including CBC, extended lytes (Ca, PO4, Mg), ALP, U/A, liver enzymes (AST, ALT). Most appropriate management:

A. Abdominal ultrasound
B. Genetics referral
C. Repeat skeletal survey in 2 weeks
D. Repeat Ophtho exam in 2 weeks

A

C. Repeat skeletal survey in 2 weeks

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19
Q

2019Q: 4 risk factors for child abuse aside from social and environmental (child factors)

A

Child risk factors for child abuse/neglect

  1. Premature birth, birth anomalies, low birth weight, exposure to toxins in utero
  2. Temperament: difficult or slow to warm up
  3. Physical/cognitive/emotional disability, chronic or serious illness
  4. Childhood trauma
  5. Anti-social peer group
  6. Age
  7. Child aggression, behaviour problems, attention deficits
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20
Q

2019Q: 8 y.o developmentally normal child sent to you because teacher is worried about sexual abuse. The child is found putting her hands down other children’s pants. Name 3 other sexual behaviours you will ask for that may suggest abuse ?

A
  1. Any sexual behaviours That involve children who are four years apart
  2. A variety of sexual behaviours displayed on a daily basis
  3. Sexual behaviour that results in emotional distress or physical pain
  4. Sexual behaviours associated with other physically aggressive behavior.
  5. Sexual behaviours that involve coercion.
  6. Behaviors are persistent and child becomes angry if distracted.
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21
Q

2019Q: 17 y.o with Duchenne’s and sequelae of that. Apart from informed consent, what 3 criteria do you need to fulfill to apply for MAID in Canada?

A

Substantive criteria needed to qualify to receive MAID

  1. Being 18 years of age and capable of making health decisions
  2. Having a grievous and irremediable medical condition more specifically:
    - having a serious and incurable illness, disease or disability
    - Being in an advanced state of irreversible decline in capability
    - Experiencing enduring, intolerable physical or psychological suffering
    - with natural death being reasonably foreseeable
  3. Making a voluntary request for MAID and
  4. being capable of giving informed consent (after having been informed of means available to relieve suffering, including palliative care
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22
Q

Picture of CXR (we’re not sure what it was: rib fractures? RUL consolidation ? Narrow mediastinum, cardiomegaly), but 4 month old presenting afebrile, tachypneic and irritable; what investigation would you do next ?

A. Broad spectrum antibiotics
B. Bone scan
C. Echocardiogram
D. Calcium, ALK phos

A

B. Bone scan?

Not enough information

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23
Q

1 year old child presents with metaphyseal femur fracture. What is the next step?

A. Calcium, phosphate and alkaline phosphates seems levels
B. Full skeletal survey
C. Bone scan
D. No further investigations

A

B. Full skeletal survey

< 2y.o with fractures suspicious for child abuse should have radiographic skeletal survey.

In children with fractures suspicious for abuse, serum calcium, phosphorus and alkaline phosphates should be reviewed.

24
Q

7 month old infant with severe head injury. Social worker suspects the father abused the child and mentions it to you.

A. Decision to withdraw should still involve complete communication with family
B. Decision to withdraw made by judge/court
C. Decision made by health care team
D. Police need to be informed before care is withdrawn
E. Decision still must involve both parents, including father

A

Answer: A complete communication with family or E Decision still must involve both parents including father

25
Q

15 y.o girl sexually assaulted 5 days ago by a 32 year old man for whom she babysits. All of the following are true except.

A. Forensics are not indicated
B. CAS must be Informed 
C. Give post coital contraceptive now
D. Low risk for STD
E. She is competent to refuse further treatment and investigations
A

Answer given is D - low risk for STD

  • risk after sexual assault in adults is 6-12% NG and 4-17% for CT and 0.5-3.0 % for syphillis
  • generally recommend treating for STIs prophylactically (ceftriaxone and azithromycin)

In CPS says STI is rare in prepubescent but says nothing about post pubescent. One study says All pubertal girls evaluated for sexual abuse should be tested for STDs because of high prevalence of asymptomatic infections.

Why not A. Forensics are not indicated ? - as per AAP acute sexual assault = 72h but is different in different areas

Nelson’s says 5days (120h) and Maddie’s notes says up to 12days in postpubertal children, it’s only 72h in prepubertal kids….

26
Q

18 month old girl anal warts, how’d she get them ?

A. Perinatal from mom
B. Sexual abuse
C. Toilet seat
D. Dad had warts on finger, transmitted changing diaper
E. Sister warts on finger, in bath
A

Answer:

A. Perinatal from mom (most likely) vs D. Dad had warts on finger, transmitted changing diaper - sick kids.

27
Q

Mother who has been abused as a child asks you about advice for preventing child abuse. What is the evidence ?

A. Nurse home visitor program reduces risk of child abuse
B. Parenting classes reduce risk
C. Frequent visits to paediatrician can reduce risk

A

Answer: A (but also B)

Toronto consensus group said C….sigh

28
Q

All are true of shaken baby syndrome except:

A. Homicide is the most common cause of death due to injury in kids <4y.o
B. External physical findings of shaken baby syndrome are not always present
C. Shaken baby syndrome does not occur after 3y.o
D. Retinal hemorrhages are not always present

A

Answer A - leading cause is unintentional injury by MVA

29
Q

4 month child with ALTE. He was resuscitated by mom, brought to ER. Baby is breastfed. Mom is a cocaine addict. Dad finds out his is documented in the chart and threatens to sue if it is not removed. You:

A. Remove information as requested
B. Talk to the ethics committee
C. Report the threat to your superior
D. Talk to dad, reassure him that the information is confidential

A

D. Talk to dad and reassure him that the information is confidential

30
Q

Baby with bruising on cheek and helix of ear; different ages. What’s the best thing to do ?

A. PT, PTT
B. Factor V Leiden
C. Hospitalization
D. CBC

A

Answer C - needs a full work up so need to admit.

31
Q

A 14 y.o female comes to the ER after having been sexually assaulted 3 weeks ago.

A. Contact the CPS to undertake an investigation
B. The attending pediatrician is responsible for the investigation
C. Perform a vaginal examination, with tests to look for sperm and acid phosphates
D. Do not assess the patient until parental consent is obtained
E. If a parent is not available, then admit the child to hospital overnight

A

A. Contact the child protection agency

32
Q

A child is sent to the hospital for pneumonia. There is an obvious consolidation on the chest X-ray, but the radiologist calls you to inform you that he also sees several rib fractures, and he is worried about child abuse. What do you do ?

A. Inform parents that you think they abused their child, call social services to arrange foster care
B. Call social services and send the child back to the referring doctor
C. Tell the parents that you are admitting the child for pneumonia, and investigate for other injuries
D. Do further investigations before informing the parents
E. Discuss the fractures with the parents, explain the need to inform social services, and admit the child for further investigations

A

Answer E: always good to be honest and to generalize the situation ie; we do this with every rib fracture case

33
Q

An 18 month old girl is referred to you because of concern of venereal warts around her vagina and anus. The physical exam is otherwise normal.

A. Venereal warts are always a sign of inappropriate sexual contact
B. The incubation time is short, suggesting sexual abuse within the past 3 weeks
C. Venereal warts in childhood are never a sign of sexual abuse

A

C. Manifestation of congenital exposure

A- can be due to non-sexual contact ie; diaper change
B. Incubation time can be very long
C. They can be a sign of sexual abuse but rarely

34
Q

5 year old child is sexually abused. Definitive evidence is not likely to come from:

A. The child
B. The parents
C. The physical exam
D. Culture positive for STDs

A

D. Culture positive for STDs

35
Q

Signs suggestive of sexual abuse in a baby:

A. Anal skin tags in midline
B. Anus dilated to 20mm with stool in the ampulla
C. Anal scars not on the midline
D. Hymen opening 2mm

A

C. Anal scars not in the midline

36
Q

Which is true regarding retinal hemorrhages:

A. Needed to diagnose shaken baby syndrome
B. Can occur on a vaginal delivery
C. Do not occur in a c-section
D. Always a/w trauma 
E. Can occur with CPR
A

B. Can occur in vaginal delivery

A- - not always present in shaken baby syndrome
C- can occur in C - section
D- not always a/w trauma
E- can occur with CPR but very rare so go with B as more common

37
Q

An 8 month old comes on with bruising. List 4 things on history and physical exam that would make you concerned for physical abuse ?

A

Red flags for inflicted injury in a child with bruising

  1. Bruises in babies who are not yet cruising
  2. Bruises on the ears, neck, feet buttocks or torso (torso includes chest, back, abdomen, genitalia)
  3. Bruises not on the front of the body and/or overlying bone
  4. Bruises that are unusually large or murmurous
  5. Bruises that are clustered or patterned (patterns may include handprints, loop or belt marks, bite marks)
  6. Bruises that do not fit with the causal mechanism described.
38
Q

You see a 7y.o girl who disclosed that she was sexually assaulted by her father. On physical exam you see the following:

A. Please identify the following structures: label urethra, introitus (vaginal opening) and hymen

B. Based on your examination, what can you tell the police ?

A

B- nothing; must be reported to CAS but not police unless sanctioned but the court to release medical information.

Really can’t tell them it’s normal exam ?

39
Q

4 month old baby brought in for irritability. On PE you note 1x1cm purple bruise to forearm. Name 3 laboratory or diagnostic imaging tests you would do (3) ?

A

Recommended 1st line lab testing

  1. CBC and peripheral smear
  2. PT/aPTT
  3. Fibrinogen
  4. VWD studies + blood group
  5. Factor 8, 9 levels
  6. LFT
  7. Renal function tests

Imaging

  • skeletal survey
  • head imaging ie; CT
  • ophthalmology
40
Q

16 month old boy brought to ER by his mother because of inconsolable crying. You take off the sleeper and find this: picture shown of baby’s legs with confluent 2nd degree burns on feet up to mid calf, sharply demarcated. You suspect non- accidental injury.

A. What are 2 things about this child’s presentation that make you suspicious of non- accidental injury ?

B. What are 3 important steps in management with regards to this child’s non- accidental injury ?

A

A. What are 2 things that make you suspicious ?

  1. Pattern of injury concerning for immersion injury ( b/l symmetric nature and sharp demarcation, uniform depth
  2. Injury was not declared at presentation - presenting complaint was unconsolable crying

B. 3 important steps in management with regards to this child’s non- accidental injury ?

  1. Admit to hospital
  2. Notify CAS, determine if other children live at home
  3. Thorough history and full physical exam looking for other injuries (bruises, fractures)
  4. Work up for other injuries, including - skeletal survey, ophthalmology +/- head imaging, screen for abdominal trauma AST, ALT, amylase
  5. Appropriate burn and pain management (IV fluids, dressings, surgical consultation)
41
Q

4 month old child being assessed for b/l metaphyseal fractures. There was no hx of trauma reported for the fractures. What are 3 aspects that are consistent with a non-accidental cause for this injury ?

A
  1. Age - non ambulatory
  2. Type of fracture - metaphyseal, bilateral
  3. No mechanism provided
  4. Multiple fractures
42
Q

8 year old developmentally normal girl is touching boys under their pants and the teachers are wondering about sexual abuse. What are 5 other specialized behaviours that would make you worried about sexual abuse ?

A
  1. Sexual experimentation with age inappropriate partners
  2. Acts out sexual acts with toys
  3. Asks other people to perform sexual behaviours on them
  4. Compulsive masturbation
  5. Undressing other children
  6. Attempting to perform sexual acts on other children (in the question stem)
  7. Not a behaviour but also knowledge of sexualized language
43
Q

Baby came in with bruising on the chest, vomiting, lethargy, vitals stable, CBC and coags were normal. Name 5 management steps.

A
  1. Admit to hospital
  2. Consult expert in child maltreatment and child protective services
  3. Complete physical exam to rule out other injuries (like bruises, bites, burns) and neurological exam
  4. CT head for intracranial bleed +/- cerebral edema
  5. Ophtho exam for retinal findings
  6. Skeletal survey
  7. Blood work- CBC, coags, and as necessary: glucose, lytes, metabolic screen, toxicology and micro. If abdominal trauma includes liver and pancreatic enzymes, and send urine and stool for blood.
  8. Taking photographs and proper documentation
44
Q

An 8 month old boy presents to the ED with a URTI. On exam, you find one bruise on the posterior chest, and another somewhere else on the body. The remainder of the exam is normal. The mother does not know where these bruises came from. What 3 questions would you ask on further questioning ?

A
  1. Medical history should include any previous bleeding or bruising, other injuries (ie; post circumcision bleed, birth cephalohematoma, post venipuncture bleed, petechiae at clothing line pressure sites)
  2. Developmental history (gross motor abilities)
  3. Family history with similar questions as asked to the patient, as well as, hx of bleeding disorder or inheritable conditions that could predispose to bruising (like Ehlers- Danlos). Can ask about mother’s menstrual and postpartum bleeding history
  4. Psychosocial history to identify risk and protective factors within the family. Who are the caregivers involved in the child’s care ? (Parents, babysitter)
  5. Medication history (ie; NSAIDS)
  6. History of trauma
45
Q

Image of female infant genitalia. Disclosure from child to daycare worker of abuse.

A. Describe
B. How would you report findings to child protective services ?

A

A. Describe

  1. Tanner stage - Brest and pubic hair
  2. External genitalia - normal, red, neck, discharge, abrasions/bruising
  3. Hymen
    - configuration - annular or crescentic
    - hymenal rim - normal or narrow
    - hymenal edges - smooth, bumps or notches
    - injuries - hematoma, lacerations, transaction
  4. Anus

B. How to report?
- objectively and promptly.

46
Q

5 month old girl brought into custody because her twin sister has been diagnosed with shaken baby syndrome. Her foster parents state that she is feeding well, interacting appropriately, with no concerns. What investigations would you perform in this baby ? List 3

A
  1. Eye exam
  2. Neuroimaging
  3. Skeletal survey

Perform even if the initial physical exam is normal

47
Q

What 4 fractures are very specific for child abuse

A
  1. Classic metaphyseal lesions or bucket handle fractures
  2. Rib fractures, especially posteromedial
  3. Scapular fractures
  4. Spinous process
  5. Sternal fractures
48
Q

Sequence of colour changes in bruising

A

Trick question - there is no reliable colour change sequence

49
Q

What are 4 characteristics of a child that puts them at increased risk of abuse ?

A
  1. Prematurity
  2. Disability
  3. Difficult temperament
  4. Sleeping difficulty

Specifically for abusive head trauma

  • male gender
  • colicky baby
  • perinatal illness such as prematurity, prolonged hospitalization
50
Q

Father brings 3y.o child for suspected abuse. Multiple bruises acquired while staying with mom over weekend.

A. Three things required for immediate management in the ER

B. Identify four radiological signs consistent with abuse

A

A. Three things immediate management in ED

  1. Call CAS
  2. Full dermatological exam and look for MSK/ other injuries
  3. Bloodwork for coagulopathy

B. 4 radiological signs

  1. Rib fractures
  2. Scapular
  3. Metaphyseal
  4. Sternum
51
Q

9 month old boy who has come in with a story of an accident. Nurse mentions he has been in here 5 times previously with other injuries. He is a well child otherwise. Picture of X-ray of bones with bony chip off the distal humerus.

A. What does the X-ray show?
B. What could have caused this ?

A

A. What does the X-ray show?
Likely a metaphyseal fracture
B. What could caused this ?
- non-accidental injury

52
Q

Child with burns on hands and chest with blisters. Says it happened at day care when child spilled hot drink. What are 3 indications for admission ?

A
  1. Burns affecting > 10% BSA (or > 10-20% in adolescent/adult)
  2. Third degree burns
  3. Suspected child abuse or neglect (many suspicious factors in this case- unlikely to be given access to hot drink at daycare, unlikely to burn b/l hands)
  4. Associates injuries (fractures)
  5. Inadequate home or social environment
  6. Burns to face, hands, feet, perineum, genitals, or major joints
  7. Other indications (not relevant here)
    - electrical burns caused by high tension wires or lightning
    - chemical burns
    - inhalation injury, regardless of the amount of BSA burned
    - burns in patients with preexisting medical conditions that may complicate the acute recovery phase
    - pregnancy
    - children who have been in enclosed -space fires and those who have face and neck burns - should be hospitalized for at least 24h to observe for CNS effects of anoxia from CO poisoning and pulmonary effects from smoke inhalation
53
Q

8 y.o girl being picked up from dad’s, and tells mom “dad’s private’s touches my privates “. Mom brings the girl to the hospital and you’re seeing them in the ED.

A. List the 3 questions you would ask on history In order to guide your physical exam.
B. What is the next most important step ?

A

A. 3 Questions to ask on history

  1. What happened
  2. When did it happen
  3. Symptoms - vaginal/anal pain, bleeding discharge

Other

  1. What parts of the patients body were touched
  2. Was there any exposure to blood or body fluids
  3. Symptoms - vaginal pain, anal pain, bleeding, discharge
  4. Who was the person who did this ?
  5. With what parts of his/her body
  6. How many times was the child touched
  7. When was the last time that it happened
  8. At what location did the abuse occur
  9. For male assailants was there any ejaculation
  10. Did the child tell anyone about the incident

B. What is the next most important step ?

  • contact child protective services
  • Inquire about any other children in dad’s care
54
Q

A child presents with suspected NAI.

A. Below what age should you do a skeletal survey for al children with suspected NAI
- < 2y.o

B. What are 3 radiologic findings specific to NAI that would not present with any symptoms or signs ?

  • posterior rib
  • Scapula
  • sternum, spinous processes
  • multiple fractures at different stages of healing
A

See question

55
Q

Boy with CP was in a motor vehicle accident and has had a GCS of 4 for the last week. Parents want to withdraw. What do you do ?
A. Consult ethics
B. Call CAS
C. Withdraw if the parents are reasonable and understand the situation

A

C. Withdraw if parents are reasonable and understand the situation

Cat's Questions (13 decks)

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