Target Lesion Bents Fort 1982

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Target Lesion (Bents Fort 1982)
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Child Physical Sexual Abuse

• A Clinically Based Overview

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At Issue

• 14 mo male Caucasian presents to ED with unusual
  bruising.
• Brought in by TPD with parents.
• Daycare made report of suspected abuse this AM
  (Monday) when child was brought in by parents
  with unusual bruises.
• Parents state that child had no bruises when left
  at daycare this AM.

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So Now What?

• HINT The JUSTICE Center medical team all went
  to different meetings at the same time.
• YOYO!

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Sexual Abuse Case Studies

• You are, once again, night float, the JUSTICE
  Center medical team is unavailableagain.
• You guessed it YOYO!
• And the ED is full of this stuff!

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• The following cases are real Only the pictures
  have been changed in order to protect the
  innocent.. because I couldnt find the
  originals!
• Your mission (whether you like it or not!), is to
  evaluate these cases in order to interpret their
  clinical significance, determine what evidence
  collection is required, what their disposition
  should be.

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A Holy Pain in the.

• This 4 year-old male attends a local church
  affiliated day care which is well respected in
  your area.
• He has been fine according to his parents until
  this afternoon. After being picked up from
  daycare, parents noted blood in his whitey
  tighties the child was complaining of pain.

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A Holy Pain in the..

• Child has a very benign health history daycare
  denies any accidents that day.
• Child has not made any disclosures.
• There are no male workers in the daycare, but
  father had sole access to the child for about two
  hours after he picked the child up.
• Child presents to ED, then to you, as the ED
  physician feels strongly that this is likely
  sexual abuse.

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Diagnosis

• Group A Streptococcal Anal Celluitis!

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Doctor Mom

• This six year-old female just returned from a
  weekend (court ordered) visit with her father.
• As is her custom, the mother checked her over
  real good when she returned from her visit, as
  she has always suspected the father of being a
  perpetrator.
• Child now complains of dysuria has some
  vaginal bleeding.
• Childs private physician is very concerned about
  possible abuse over the weekend.

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Doctor Mom

• Mother states I just freaked out. I told her
  Youve got to tell me who did that to your
  coochie! It was your daddy wasnt it? she
  shook her head yes.
• Child has a benign medical history has no other
  signs of illness at this time.

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Diagnosis

• Lichen Sclerosis et Atrophicus!

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The Great Divide

• This 14 month-old female has recently changed
  doctors, has been seen by her new physician for
  otitis media.
• The new physician insists on a complete physical
  exam notes a laceration of his new patients
  posterior forchette.
• Child has no GU symptoms mother denies any
  accidental injuries. Mother is sole care
  provider.

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The Great Divide

• Since the new PCP doesnt deal with sexual
  abuse, child is sent to the ED.

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Diagnosis

• Congenital failure of midline fusion!

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Clueless

• This 3 year-old female came to the attention of
  DHS when her daycare provider made a report of
  suspected abuse.
• Child arrived at daycare today complaining of
  pain on urination. Daycare provider saw apparent
  injury after she accompanied youngster to the
  bathroom child screamed when provider attempted
  to wipe her.

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Clueless

• Child was reportedly in the sole care of the
  biomother over the weekend, with no reported
  unsupervised contact with others.
• According to the mother, child has been
  completely asymptomatic through the weekend
  today.
• After some reflection, mom thinks child might
  have fallen (clothed) on a toy late Saturday
  evening.

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Diagnosis

• Healing penetrating genital injury.
• Now what?

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Alien

• It is the day before Thanksgiving, late in the
  evening (at bath time) mother notes blood in this
  4 year-olds underwear. When she looks at her
  little girls genitals she says Oh my God, who
  has been messing with my baby?!
• She immediately takes her 4 year-old to the ED.
  At the ED, the physician says Oh my God, who has
  been messing with your baby? Your pager goes
  off.

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Alien

• The youngster has not made any disclosures, but
  mother is very concerned.
• Earlier that day, a male 12 year-old cousin had
  been visiting, who the mother is just not too
  sure about. He did have unsupervised access to
  the patient on several short occasions during
  his visit.

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Diagnosis

• Urethral prolapse.

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Holes The Case, Not the Movie

• This 3 year-old female just returned from a court
  ordered visit with her mother her mothers new
  live-in paramour (not the childs father).
• The paternal grandmother (who has custody of the
  child.its a long story) noticed on the night of
  the return that Pumpkins hole was too bigjust
  gaping open AND She smells like sex.
• Child is completely asymptomatic.

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Holes The Case, Not the Movie

• Childs primary care physician definitely feels
  that the introitus appears nearly marital.
• Since the last possible contact with a possible
  perpetrator was only hour before, the physician
  feels that a rape kit is in order, thus sending
  the child to the ED.

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The Abyss

• This 7 year-old female presents to you after
  giving a clear history of mothers paramour
  forcing her to orally sodomize him. This
  disclosure was made after the mother walked in
  as the act was taking place in the bathroom.
• No other disclosures have been made.
• She has a normal genital examination a normal
  medical history.

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Pooh?

• This 7 year old (mentally handicapped) male
  presents to you through the emergency room where
  he was brought by his mother.
• Earlier today, mother had to go out for a while
  left him in the care of her upstairs neighbor.
  She does not remember the neighbors name, his
  apartment number, his telephone number, or the
  exact time when she left the child.

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Pooh?

• The child is very verbally limited. He says
  mommy, Johnnie, owie. When you begin to
  examine his anus, he exclaimsJohnnie owie. He
  later says mommy owie for no apparent reason.
• The police have spoken with the upstairs neighbor
  (Johnnie), who confirms that he took care of the
  child for 4 hours that day.
• He further states that the little retard soiled
  his underwear that the injuries probably
  resulted from his vigorous cleaning of the anus.

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Pooh?

• Mom states that the child had underwear on when
  left with the neighbor, though the underwear can
  no longer be found.
• Mom gives benign medical history except for
  extreme prematurity special education classes.

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Diagnosis?

• Acute penetrating anal injury.
• Now what?

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