Formulating The Diagnosis And Management

Question 1

What are the components of a comprehensive medical evaluation?

Answer 1

1. Expanded medical history
2. Documentation of historical details
3. Extragenital and anogenital examination
4. Collection of forensic evidence – if there is a need
5. Collection of specimen for laboratory examinations
6. Differential diagnosis of physical and behavioral complaints and physical injuries
7. Reassurance of the parent/child that the child is “OK”
8. Assessment of mental and emotional state; appropriate referrals
9. Assessment of safety

Question 2

○ Happens when there are long nails and pressure is applied to the skin
○ Usually a linear bruise, about 1 to 2 cm

Answer 2

Fringertip bruise

Question 3

○ Like an imprint bruise, but it’s caused by a linear object
○ It has a clear/pale center, but the sides are well-demarcated (picture)
○ Usually caused by a stick, baton or a stick of a broom

Answer 3

Tramline bruise

Question 4

○ Adult bite mark: intermaxillary canine is 2-3 cm
○ Child bite mark: <2 cm
○ Animal bite mark: more on puncture wounds

Answer 4

Bite mark

Question 5

○ Pinpoint
○ arrest of hemorrhage
○ Seen in patients who are being strangled/suffocated
○ Also seen in patients who are crying too much or
vomiting – need to rule out

Answer 5

Petechial bruise

Question 6

Can see the lining of the belt

Answer 6

Imprint bruise

Question 7

○ Purplish discoloration
○ Usually found in the neck or chest
○ Chikinini – Bisaya term

Answer 7

Suction mark

Question 8

Either hand or lower extremity is submerged in water.

Answer 8

Scald pattern

Question 9

Both hands and feet are submerged in water

Answer 9

Scald “Glove and Stocking” Pattern

Question 10

Tub immersion:

When a child is being submerged in a tub, his/her body will be flexed. The parts of the body that were flexed will get the

Answer 10

Zebra pattern

Question 11

Tub immersion:

The skin that had direct contact with the tub will be spared (e.g. Gluteal regions)

Answer 11

Doughnut pattern

Question 12

What defines different levels of sexual maturity, based on the development of primary (genitalia) and secondary sex (pubic hair and breasts) characteristics?

Answer 12

Tanner staging

Question 13

Represents the prepubertal breast in which there is elevation only of the papilla

Answer 13

Stage 1

Question 14

“Breast bud” forms below the areola

Answer 14

Stage 2

Question 15

Further enlargement and elevation of both breast and areola

Answer 15

3

Question 16

Areola forms a secondary mound above the breast contour

Answer 16

4

Question 17

Fully mature breast, with recession of the secondary mound and a smooth breast contour

Answer 17

Stage 5

Question 18

Prepubertal genitalia male

Answer 18

Stage 1

Question 19

Testes and scrotum enlargement, w reddening and thinning of scrotum, but no penis enlargement

Answer 19

2

Question 20

Penis enlargement in length then diameter, testes and scrotum continue to enlarge

Answer 20

3

Question 21

T and S cont to enlarge, w continue lengthening of penis and enlargement of the glans

Answer 21

4

Question 22

Adult size and proportion of genitalia

Answer 22

5

Question 23

Pubic hair staging

Answer 23

1. Fine vellus hair, no difference found over abdominal wall
2. Sparse growth straight hair at base of penis and along the labia
3. Increase in hair and darker and curlier
4. Resembles adult pubic hair, but escutcheon covers a smaller aren than in adults
5. Increase volume, spread to medial thighs, male or female configuration

Question 24

ANOGENITAL FINDINGS ARE INDICATIVE OF BLUNT FORCE OR PENETRATING TRAUMA

Answer 24

● Acute laceration or extensive bruising of the external genitalia, perineum and anus
● Hymenal laceration
● Contusion (bruising) on the hymen
● Hymenal transection (healed)
● Missing segment of the hymen
● Other possible hymenal injuries includes: Abrasion,
petechia, hematoma

Question 25

FINDINGS DIAGNOSTIC OF SEXUAL CONTACT

Answer 25

● Pregnancy

● Finding sperm on the child’s body
○ Only if the incident happened for less than 72 hours
■ Because motility of sperms last for 72 hours

● If the patient has a disclosure pointing to sexual abuse but there’s no evidence of injury at the time of examination indicate: “No evidence of injury at the time of examination but medical evaluation cannot exclude sexual abuse.”

● If there’s no disclosure: “No evidence of injury at the time of examination.”

Question 26

How many stages are involved in Hymen?

Answer 26

4

Question 27

● A vital document
● Forms the basis of your evidence in chief in court
● May form the basis of your cross-examination
● May be the basis for a criminal prosecution, civil action, or no action at all

Answer 27

THE MEDICO-LEGAL REPORT

Question 28

OCP

Answer 28

PH: <72 hrs
WHO: 3-5 days

Question 29

What has the mechanism of action is to prevent or delay ovulation, it blocks fertilization or interferes with implantation. It does not cause abortion, and it does not affect an existing pregnancy?

Answer 29

Emergency contraception or “morning after pill”

Question 30

What is the criteria for giving ECPs?

Answer 30

If there is a risk for pregnancy, if the patient presents 3-5 days, sometimes for those patients who are irregular or have an irregular menses or cannot recall, we usually do a pregnancy test first before giving the ECP. But again, ECPs do not affect existing pregnancy.

Question 31

What is the preferred regiment?

Single dose, up to 5 days after unprotected intercourse

Answer 31

Progestin-only pill (levonorgestrel only)

Question 32

• less effective
• more likely to cause side effects (nausea & vomiting)
• given 2 or 4 doses 12 hrs apart & within 72 hrs after assault

Answer 32

Combined estrogen-progesterone pill

Question 33

Most frequently contracted infections

Answer 33

• chlamydia
• gonorrhea
• syphilis
• trichomoniasis

Question 34

Test for N. gonorrhea & C. trachomatis

Answer 34

Cultures

Question 35

T vaginalis tests

Answer 35

Wet mount
Culture

Question 36

Syphilis, HIV, Hep B testing

Answer 36

Blood sample

Question 37

Gonorrhea and Chlamydia treatment

Answer 37

Ceftriaxone 500mg IM once (1g IM once if >150kg)

Doxycycline 100mg PO BID x7 days

Question 38

Syphilis tx

Answer 38

Penicillin G 2.4M unit IM once

Question 39

Trichomoniasis tx

Answer 39

Metronidazole

Question 40

Herpes

Answer 40

Acyclovir
Famiciclovir
Valacyclovir

Question 41

Lymphogranulum venerum

Answer 41

Doxycycline

Question 42

HIV tx

Answer 42

ART therapy

Question 43

ART lasts for how many days?

Answer 43

28 days