Pediatric Examination and Board Review (193 page)

(A) call the neighbor to corroborate the history

(B) inform the caretaker you are a mandated reporter and obligated to contact the regional child welfare agency

(C) call the regional child welfare agency and not inform the aunt about the report so she does not have time to contact her neighbor

(D) admit the child and have the hospital social worker continue the investigation

(E) perform a skeletal survey; if the skeletal survey is negative, the suspicion of abuse is ruled out

7.
You elect to admit this child and have a consultation with a burn specialist. On your examination, the child is well nourished and developmentally appropriate and there are no other cutaneous lesions of concern. The specialist concurs that the burn is a superficial partial-thickness burn that involves all surfaces of the skin, with the bottom of the foot minimally involved. Treatment will include hydrotherapy and wound management. What tests with respect to the child abuse investigation are warranted at this point?

(A) skeletal survey, head CT, and ophthalmologic eye examination

(B) a complete trauma evaluation, including a CBC, coagulation studies and sickle cell screen, liver function, pancreatic enzymes, and urinalysis

(C) a vaginal culture

(D) skeletal survey and magnetic resonance imaging (MRI)

(E) skeletal survey

8.
The mother comes to the hospital and is appropriately upset about her child’s injury. Her interaction with the child appears appropriate. Upon obtaining more information from the mother, you learn an aunt has been caring for this child for more than 2 years and they are well bonded. The child is in the midst of toilet training and doing very well under the aunt’s guidance. You also learn that the aunt cares for 3 other children during the week, all in the preschool age group. Which of the following statements about risk factors for child physical abuse is false?

(A) children with child-related stressors including developmental disability or behavior problems are at increased risk for child abuse

(B) developmentally related stressors (eg, colic and toilet training) appear to be related to child abuse

(C) unrelated caretakers are more likely to abuse children than relatives

(D) social or situational stressors that are risk factors for physical abuse of children include social isolation, poverty, family discord, and violence

(E) parental stressors include prior abuse, depression, and substance abuse

9.
All are true statements about inflicted burns except

(A) inflicted cigarette burns are round, vary in depth, and are often seen on the distal extremities; once healed, one can often appreciate a crater effect

(B) a burn with a symmetric stocking or glove distribution without splash marks is highly suspicious of being inflicted

(C) noninflicted spill or splash burns often show an inverted tree-like pattern, with the depth of the burn worse at the initial site of contact

(D) the classic inflicted burn lesion is the immersion burn where the buttocks and/or extremities are held and restrained from moving in hot water

(E) patterned contact burns are the most common forms of inflicted burn injury

10.
Which of the following statements regarding electrical burns in children is incorrect?

(A) the most serious form of electrical burn in children is exposure to high-voltage electric shock (>1000 V)

(B) electrical burns in the home are from contact with low-voltage alternating household current (120 V)

(C) current preferentially flows through tissues with less resistance (eg, blood vessels, nerves, and muscles), and moisture decreases the resistance

(D) a common injury to toddlers occurs when they suck on extension cords and sustain an electrical burn to the lip and mouth

(E) management of burns is directed by the total surface area and depth of the sustained burn for all types of burns

11.
The skeletal survey is negative and your review of the prior medical history reveals no prior injuries and normal development along the 75th percentile. The police and child welfare system interview the neighbor and the 911 emergency responders and investigate the scene. They corroborate that the water heater was not working at the time of the injury. When determining whether an injury is accidental versus inflicted, the following directly impact your determination except

(A) type of injury

(B) age and developmental ability of the child

(C) physician’s experience and training in the treatment of children with suspected child abuse

(D) mechanism provided by the caretaker to explain the injury

(E) prior involvement of the caretaker with the child welfare system

12.
Which characteristic should not be taken into consideration when differentiating between inflicted and noninflicted bruises?

(A) age of the child

(B) pattern of the lesions

(C) location of the bruise(s) on the child’s body

(D) depth of the bruise(s)

(E) skin disorder or condition

13.
Doctors are often asked to date bruising. Which is the most accurate statement regarding this issue?

(A) bruises of the same age in the same individual will be the same color at the same time

(B) skin color, location, amount of force, and local healing effects all impact the color changes as a bruise heals

(C) there is a predictable order of color change progression as bruises heal

(D) a bruise with yellow coloration must be at least 6 hours old

(E) mongolian spots are a form of healed bruise

14.
A new patient has blue-gray discoloration over the lower sacral area and the side of the head. You note no pattern to these lesions, and the mother states they have been there since birth. You are concerned that they are bruises. To aid in your diagnosis, you

(A) send the child to a dermatologist for an assessment

(B) order a CBC and a coagulopathic workup

(C) reexamine your patient in 2 weeks

(D) apply topical steroid cream

(E) order a skeletal survey

15.
Which is an incorrect statement regarding human bites?

(A) human bites may be a manifestation of child abuse

(B) dental impressions are an important tool to aid in the identification of the person who caused the bite in suspected cases of abuse

(C) adult bite marks look different than those of a child

(D) swabs of the bite marks should be obtained to assess the flora of the perpetrator’s mouth

(E) the physician is advised to obtain photo documentation of the bite mark in suspected child abuse cases

16.
One form of child abuse is medical child abuse, also known as Munchausen syndrome by proxy (MSBP): this is when a child receives unnecessary, harmful, or potentially harmful medical care at the instigation of a caretaker who fabricates an illness in the child. All of the following define medical child abuse except

(A) the mother, in most of the cases, is the perpetrator

(B) in most cases the child has a history of prematurity or a chronic disease

(C) the illness is produced or simulated (symptoms are fabricated) by a parent or someone who is
in loco parentis

(D) the child repeatedly presents for medical care, inevitably resulting in multiple medical procedures that are unnecessary

(E) the parent denies knowledge of the cause of the illness

17.
True statements regarding the diagnosis and outcome of MSBP include all of the following except

(A) separation of the child from the parent-perpetrator will result in the symptoms disappearing

(B) covert video is a strategy to diagnose MSBP when the method of production of the symptoms is a result of an overt act by the parent (eg, smothering, contaminating IV lines)

(C) in most cases the mother confesses to simulating the illness

(D) siblings are often at risk

(E) most cases go undiagnosed

18.
The intention of foster care is to be a temporary situation that provides respite to a family in crisis. Which of the following is true regarding foster care?

(A) parents must terminate their guardianship or custodial rights at the time a child is placed in foster care

(B) the goal of foster care includes family reunification

(C) the length of stay a child has in foster care does not impact the likelihood of family reunification

(D) children who have been abused by their parents feel safer in foster care

(E) reimbursement for foster care parents is based on the care difficulty and mental health demands of the child

ANSWERS

1.
(B)
The most consistent description of this burn is a 3-5% partial-thickness (second-degree) scald burn involving the lower left extremity in a stocking distribution. The percentage surface area involved is based on age. At 16 years of age the rule of 9s can be used to estimate involved surface area. The rule of 9s at 16 years old is that surface area is 9% for the head and neck, anterior trunk 18%, and the posterior trunk 18%. Each leg is 18%, each arm is 9%, and the anorectal region is 1% (see
Figure 108-2
). Use of a body reference chart to estimate surface area is important to guide subsequent management for patients younger than 18 years.

2.
(D)
Fourth-degree burns are burns that are third degree but also involve the fascia, muscle, or bone (see
Figure 108-3
). Deep partial-thickness burns involve the epidermis and most of the dermis. These burns can be paler, less tender, and speckled because of edema, sensory receptors, and thrombosed vessels. They are difficult to distinguish from full-thickness burns and can evolve into full-thickness burns if they are hypoperfused or become infected. Scarring often occurs, and these burns can take weeks to heal. Evolution into a full-thickness burn can occur secondary to infection or hypoperfusion.

3.
(D)
Burns involving the hands, face, eye, ears, feet, or perineum are considered major burns and warrant a surgical evaluation. IV hydration requirement is based on the burn’s percentage surface area and depth as well as other factors (eg, pain control). In general, IV fluid resuscitation is warranted for children with either a 15% partial-thickness or a ≥10% full-thickness burn. In this particular case, the combination of pain management and burn location justifies placement of an IV. Patients with burns that are minor or moderate (eg, <10% body surface area or full-thickness <2%) where there are no concerns for child abuse, compliance, or other health risks may be discharged home with follow-up.

4.
(E)
Decreasing the temperature of water heaters to 120°F (48.8°C) is a preventive strategy that decreases the risk of thermal injury. At 130°F (54.4°C) it takes 10-30 seconds of exposure to cause a partial- to fullthickness burn. Reduction to 120°F (48.8°C) increases the exposure time to several minutes to cause a thermal burn. Children make up one-third to one-half of hospitalizations for burn injury annually, and the most common burn types in children younger than 4 are scald burns. Approximately 3-5% of all burn injuries in children are life threatening.