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Case Studies from Web Based Peer Review

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Case Studies from Web Based Peer Review Case Studies from Web Based Peer Review David W. Bernard, MD Professor of Pediatrics Medical Director Sexual Assault Nurse Examiner Program The CHIPS Center Children’s of Alabama I have no actual or potential conflict of interest in relation to this program/presentation. This program is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $499,669.00. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government Disclosure Statement Health Education Learning Program for Sexual Assault in Rural Appalachia (HELP_SARA) Disclosures: David Bernard MD • Does not intend to discuss commercial products or services and does not have relevant financial arrangements • Pediatric emergency physician by choice Goals of web based peer review • Support for providers conducting pediatric forensic medical examinations • Standardize the care and interpretation of pediatric examinations • Educate regarding rare and unusual cases • Network providers across the region and advocate for improving care Details of the quarterly series • Email announcement and request for cases in the month prior • Presentation prepared with submitted cases • Zoom software utilized for voice conferencing and viewing of my desktop • 1 hour CME credit provided by COA • [email protected] Take home…… • Normal to be normal • Yes, even in adolescent and adults • Everything that goes wrong “Down There” is not abuse • The much desired corroborative evidence is NOT usually found on medical examination • Injuries cannot determine consent Pediatric Adolescent • Medical conditions • Exam because of often prompt the reported sexual suspicions for abuse assault • 95% or more with • Acute injuries in normal exams around 50% • No PEP in most • PEP in almost all cases cases • Developmental level • Consensual / presents exam statutory issues challenges • Nongenital injuries common Case • Almost 6 yo presented to PCP because of vaginal itching • Concerns of PCP prompted urgent referral for forensic examination • Enlarged body habitus with urinary leakage • Urinalysis negative The most likely diagnosis is: A) Enlarged hymenal diameter suggesting sexual abuse B) Congenital absence of hymen C) Normal examination D) Pinworms E) Disrupted hymen SANE called stat to the OR…. • 8 yo M with scrotal abscess being drained surgically • Possible spider bite several days before • Femur fracture several months prior • Abnormal anal appearance The most likely diagnosis is: A) Rectal prolapse B) Hemorrhoids C) Normal examination D) Repetitive penetrating anal trauma E) Proctitis Differential of anal findings • Irregular pectinate line • Diastasis ani • Venous congestion • Anal dilatation secondary to anesthesia, decreased muscle tone, stool or gas in the vault • Erythema secondary to specific or nonspecific infections / irritants • Anal tags Findings commonly caused by medical conditions other than trauma or sexual abuse • Anal dilatation in children with predisposing conditions, such as current symptoms or history of constipation and/or encopresis, or children who are sedated, under anesthesia, or with impaired neuromuscular tone for other reasons, such as postmortem No expert consensus regarding degree of significance. These physical findings have been associated with a history of sexual abuse in some studies, but at present, there is no expert consensus • Complete anal dilatation with relaxation of the internal as well as external anal sphincters, in the absence of other predisposing factors such as constipation, encopresis, sedation, anesthesia, and neuromuscular conditions Case • 22 yo developmentally delayed F • Disclosed vaginal and anal sexual assault by maternal boyfriend occurring 5 days before examination The most likely diagnosis is: A) Normal examination B) Injuries from a single acute sexual assault C) Sequelae of repetitive blunt force penetrating vaginal trauma D) Repetitive penetrating anal trauma E) Sequelae of prior childbirth Case • 15 yo reportedly first sexual experience • 18 yo “friend” • Occurred approximately 12 hours prior to examination • No period of memory loss or drug usage The most likely diagnosis is: A) Normal examination B) Injuries from acute sexual assault C) Injuries from consensual sexual contact D) Trichomonas vaginitis E) Drug facilitated sexual assault 45 40 35 30 25 Consensual 20 Nonconsensual 15 10 5 0 Laceration Abrasions Bruises Edema Jones et al, 2003 Case • 14 yo with forced vaginal penetration • Friend of brother who was spending the night in the house • Suicide note was found • Seen for acute examination several hours later • Seen in followup 3 weeks later The most likely diagnosis is: A) Examiner induced injury B) Tampon induced injury C) Injuries from consensual sexual contact D) Acute hymenal transection E) Acute hymenal transection plus laceration of posterior fourchette Injury patterns Fossa Hymen Labia Normal Adams et al, 2001 Case • 13 yo F referred b/c 1 week painful genital ulceration not improved on Amox • Recurrent oral ulcerations, recent 5 lb weight loss, intermittent diarrhea • Report of low grade fever • No history of sexual contact The most likely diagnosis is: A) Herpes simplex type I B) Herpes simplex type II C) Acute genital ulceration D) Blister beetle bite E) Syphilis Acute genital ulceration • Lipschutz ulcer • Average 12-15 years • Sexually inactive • Prodromal viral symptoms common • Intensely painful • Red border / necrotic gray-black eschar • kissing pattern • 2-6 week duration Diagnostic criteria • First episode of acute genital ulceration • Age <20 years without immunodeficiency • Presence of one or multiple deep ulcers which are well demarcated and painful • Bilateral, "kissing" pattern • Absence of any sexual history • Acute course, with abrupt onset and healing within six weeks Differential diagnosis • EBV (other viruses) • Complex apthosis • Bechet’s syndrome • Crohn’s disease • Fixed drug eruption • HSV • Syphilis • HIV Case • 2 yo male left with 14 yo cousin • Picked up by mom and noted to have some bleeding from the penis • Seen acutely and again 19 days later • Cousin reportedly with some emotional problems • No disclosure reported The most likely diagnosis is: A) Normal exam B) Masturbation induced injuries C) Dehisced coronal adhesion plus penile shaft bruising D) Suction injury to penis E) Indeterminate Case • 6 yo F with vaginal bleeding seen acutely • Disclosed that caretaker “stuck her with a brush” • Moderate pain and some ongoing oozing of blood • Would allow gentle labial separation but no exploration or prolonged traction The most likely diagnosis is: A) Accidental straddle injury B) Blowout injury to vagina C) Hymenal injury D) Fossa navicularis and posterior fourchette injury E) Chronic sexual abuse When is exam / repair under anesthesia indicated? • Prepubertal intravaginal bleeding • Significant bleeding and pain with inability to perform exam • Gaping laceration to fossa navicularis, posterior fourchette, or perineum • Ongoing intravaginal bleeding postpubertally and inability to perform speculum exam to localize Case • 7 yo F seen in COA ED by SANE • Penile-genital & penile-anal contact from 15 yo male a few hours earlier • Had genital pain & bleeding that lasted a few days • Striking examination findings with followup two weeks later The most likely diagnosis is: A) Blunt force penetrating anal trauma B) Multiple anal fissures secondary to constipation C) Perianal strep with mucosal breakdown D) Perianal venous congestion E) A + D HIV PEP • CDC guidelines 2005 • Provide prophylaxis with known HIV exposure in the setting of sexual assault < 72 hours previously • Unknown status---risk assessment – Perpetrator at high risk of HIV-infection (hx incarceration, IV drug use, man who has sex with other men, promiscuity, other STIs) – Victim has genital mucosal trauma, anal assault, multiple assailants, unknown risk factors • Medically complex and expensive! Case • 27 yo with severe developmental delay (3) • Abnormal gait with language delay • Returned from school with pad in underwear though does not use bathroom at school • No history of trauma reported by school • Seizure disorder The most likely diagnosis is: A) Sexual abuse B) Straddle injury C) Physical abuse D) Self-injurious behavior E) Unknown Case • Almost 13 yo F with consensual sexual contact with 20 yo male • Met on social media • Last episode of vaginal penetration at least one month prior to clinic visit. • No history of bleeding or traumatic injury The most likely diagnosis is: A) Findings of prior blunt force vaginal trauma B) Normal examination C) Hymen not intact D) Need additional examination techniques .
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