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PHYSICAL EXAMINATION: The General Physical Examination

An immediate assessment of the child/adolescent's status must be made to determine the presence of acute, life-threatening trauma and need for emergency intervention. This might include signs of head trauma; shock; abdominal bleeding; or bleeding from any vaginal, rectal, penile, or other trauma site. Once the patient is known to be stable, perform a complete physical examination and document the findings of the physical examination in the medical record. For more information on documentation, see DOCUMENTATION: Documenting the Physical Examination.

The physical evaluation of a child sexual abuse victim should be general and not limited to solely looking for evidence of sexual abuse. It is important to remember that even when the initial reported abuse only involves a complaint of sexual abuse, the exam may reveal signs of physical abuse or neglect. The medical evaluation may also reveal a previously undiagnosed medical problem.


General Examination Outline line line Appearance
Document the general appearance and emotional state of the child/adolescent. In some cases, it is appropriate to describe the child/adolescent's affect and behavior.

Growth parameters
Measure and record on a standardized growth chart height, weight, and in children under two, head circumference.

Skin
If the abuse is thought to have occurred within the previous 96 hours, scan the entire body and clothing with an ultraviolet light to look for semen, which fluoresces blue-green. If 24 hours has elapsed since the assault or if the patient has bathed, semen may no longer be detected.

Record the presence of any bruises, bite marks, abrasions, lacerations, rope marks, gag or tether marks, injection sites, or other dermatologic lesions. Describe them in detail, including size, shape, color, and location. Note degree of healing of an abrasion. Based on current literature, an exact determination of the age of a bruise by color is not possible. A body diagram can be helpful in indicating the exact position of any lesions on the body surface. For an example of a body diagram, see Appendix C.

Document all cigarette, patterned, or scald burns. An assessment of the burn surface area may be indicated, including the percentage of body surface burned and the depth of the burn. For an example of a burn surface area chart, see Burn Assessment - Rule of Nines, Appendix D.

Include in the medical record any explanation given by the child/adolescent for the injury, using the child/adolescent's exact words when possible.

Mouth
Inspect the oral cavity for injury or STD lesions. Note bruising or petechiae of lips, buccal mucosa, gums, palate; mucosal tears, especially of the frenula; or dental trauma. Palatal petechiae are associated with fellatio or forced insertion of a foreign body. Sexually transmitted disease lesions (herpes simplex, syphilis) are rarely found but should be considered.

Head, eyes, and ears
Check the anterior fontanelle (in infants); palpate the head for hematomas or fractures; evaluate the eye for globe injury or orbital fracture, especially when periorbital bruising is present. When head trauma is suspected in a young child, a dilated eye exam by a skilled pediatric ophthalmologist is recommended in order to document retinal hemorrhages. Check the ears for bruising on the pinnae, hemotympanum, tympanic membrane perforation, and cerebrospinal fluid otorrhea. Look for patches of alopecia as might be seen in a neglected infant or abused child.

Neck
Check the neck for ligature or other choke marks. Make sure to look in the creases in infants.

Chest
Check for costo-chondral tenderness or chest deformity. In females, record the Tanner stage of the breast development. For more information about Tanner staging, see Oski's Pediatrics: Principles and Practice.

Abdomen
Examine for bruises; palpate the abdomen for bowel sounds, tenderness, masses.

Back
Examine for bruises; palpate for costo-vertebral angle (CVA) tenderness.

Extremities
Note any tenderness, swelling, or deformity.

Neurological status
Assess mental status and other neurological findings as clinically indicated.

Development
Assess the developmental abilities and determine the developmental stage of the patient.

Behavior of the child/adolescent during the examination
Document the behavior of the child/adolescent during the examination for future reference. However, behavior during the examination may be more related to his/her comfort with the surroundings, the presence of a comforting adult, and personality traits rather than to the trauma resulting from the abuse.


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Physical Examination: Overview  Physical Examination: Considerations  Physical Examination: General Physical Examination  Physical Examination: Genital Examination  Physical Examination: Evidence Collection  Physical Examination: Reassuring the Child/Adolescent and Parent/Caregiver  Physical Examination: Additional Resources 

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