Formulating The Diagnosis And Management Flashcards
What are the components of a comprehensive medical evaluation?
- Expanded medical history
- Documentation of historical details
- Extragenital and anogenital examination
- Collection of forensic evidence – if there is a need
- Collection of specimen for laboratory examinations
- Differential diagnosis of physical and behavioral complaints and physical injuries
- Reassurance of the parent/child that the child is “OK”
- Assessment of mental and emotional state; appropriate referrals
- Assessment of safety
○ Happens when there are long nails and pressure is applied to the skin
○ Usually a linear bruise, about 1 to 2 cm
Fringertip bruise
○ 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
Tramline bruise
○ Adult bite mark: intermaxillary canine is 2-3 cm
○ Child bite mark: <2 cm
○ Animal bite mark: more on puncture wounds
Bite mark
○ 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
Petechial bruise
Can see the lining of the belt
Imprint bruise
○ Purplish discoloration
○ Usually found in the neck or chest
○ Chikinini – Bisaya term
Suction mark
Either hand or lower extremity is submerged in water.
Scald pattern
Both hands and feet are submerged in water
Scald “Glove and Stocking” Pattern
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
Zebra pattern
Tub immersion:
The skin that had direct contact with the tub will be spared (e.g. Gluteal regions)
Doughnut pattern
What defines different levels of sexual maturity, based on the development of primary (genitalia) and secondary sex (pubic hair and breasts) characteristics?
Tanner staging
Represents the prepubertal breast in which there is elevation only of the papilla
Stage 1
“Breast bud” forms below the areola
Stage 2
Further enlargement and elevation of both breast and areola
3
Areola forms a secondary mound above the breast contour
4
Fully mature breast, with recession of the secondary mound and a smooth breast contour
Stage 5
Prepubertal genitalia male
Stage 1
Testes and scrotum enlargement, w reddening and thinning of scrotum, but no penis enlargement
2
Penis enlargement in length then diameter, testes and scrotum continue to enlarge
3
T and S cont to enlarge, w continue lengthening of penis and enlargement of the glans
4
Adult size and proportion of genitalia
5
Pubic hair staging
- Fine vellus hair, no difference found over abdominal wall
- Sparse growth straight hair at base of penis and along the labia
- Increase in hair and darker and curlier
- Resembles adult pubic hair, but escutcheon covers a smaller aren than in adults
- Increase volume, spread to medial thighs, male or female configuration
ANOGENITAL FINDINGS ARE INDICATIVE OF BLUNT FORCE OR PENETRATING TRAUMA
● 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
FINDINGS DIAGNOSTIC OF SEXUAL CONTACT
● 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.”
How many stages are involved in Hymen?
4
● 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
THE MEDICO-LEGAL REPORT
OCP
PH: <72 hrs
WHO: 3-5 days
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?
Emergency contraception or “morning after pill”
What is the criteria for giving ECPs?
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.
What is the preferred regiment?
Single dose, up to 5 days after unprotected intercourse
Progestin-only pill (levonorgestrel only)
- less effective
- more likely to cause side effects (nausea & vomiting)
- given 2 or 4 doses 12 hrs apart & within 72 hrs after assault
Combined estrogen-progesterone pill
Most frequently contracted infections
- chlamydia
- gonorrhea
- syphilis
- trichomoniasis
Test for N. gonorrhea & C. trachomatis
Cultures
T vaginalis tests
Wet mount
Culture
Syphilis, HIV, Hep B testing
Blood sample
Gonorrhea and Chlamydia treatment
Ceftriaxone 500mg IM once (1g IM once if >150kg)
Doxycycline 100mg PO BID x7 days
Syphilis tx
Penicillin G 2.4M unit IM once
Trichomoniasis tx
Metronidazole
Herpes
Acyclovir
Famiciclovir
Valacyclovir
Lymphogranulum venerum
Doxycycline
HIV tx
ART therapy
ART lasts for how many days?
28 days
