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FORENSIC MEDICAL EXAMS

. . Purpose of exam?. Evaluate for injury/neglectObtain

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FORENSIC MEDICAL EXAMS

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    1. FORENSIC MEDICAL EXAMS Arne Graff MD RRCAC med consultant

    3. Purpose of exam? Evaluate for injury/neglect Obtain “minimal facts” Began care for acute injury Mental health evaluation

    4. Purpose of exam? Arrange testing (lab, x-ray) Photo document injuries Began healing process Document serves as legal evaluation

    5. Purpose of exam? Serve as part of the MDT

    6. Indications for exam? Sexual abuse: disclosure of penetration no disclosure; anogenital injury no disclosure; observed SA

    7. Indications for exam? Physical abuse: disclosure of abuse injuries no disclosure; witnessed injury

    8. Indications for exam? Neglect: Health tracks evaluation

    9. Old Records? All old records: hosp, clinic, public health Looking for: growth (obesity; malnutrition; head size) patterns unknown other injury history medical reasons for injury neglect/non-compliance

    10. History: Current concern Past medical history Family medical history Developmental history Dietary history CPS history Social history

    11. Family Medical History When parents not available or TERP planned: obtain FMH! Important for the future medical needs of the child as they enter adulthood to understand their risks Important for the future medical needs of the child as they enter adulthood to understand their risks

    12. Health Tracks exam: Physical exam Nutritional evaluation Mental health evaluation Eye/hearing testing Developmental evaluation Dental

    13. Contact children? Any environment where abuse/neglect has occurred, and other children live or frequent, should be considered potential victims.

    14. ND/MN law: Contact children/potential victims

    15. Can’t see injury: No Injury??? SA: Normal exam does not rule out prior injury or penetration PA: Normal exam/happy: does not rule out fractures or head injury

    16. Triage for exam: Acute injury: fracture/head trauma: today serious injury: today bruising: as soon as possible photo versus exam ???? Old injury

    17. Triage for exams: Drug exposure (acute): today ? At risk for side effects ? At risk for withdrawal ? Prevent trauma to foster parent

    18. Sexual Abuse Triage: <72 hour under 13 years old <96 hour over 13 years old Purulent discharge, bleeding, injury Unsafe home (Tammy W syndrome) Psyc/suicide risk

    19. Sexual Abuse Triage Non-acute: no disclosure touching; no injury behaviors more than 96 hours and no bleeding or infection

    20. Sexual Abuse findings ? 95% normal exam Due to: delay in exam (96hours) healing puberty lubricants other

    21. Exam: Non-threatening/friendly Head to toes Genital exam Colposcope use NO speculums Photo documentation Eye exam (dilated); ER exam

    22. Additional tests: Blue Maxx Toloudine blue Forensic Kit/Sexual assault kit

    23. Forensic kit indications: Disclosure of sexual assault (time) Observation/photo of assault No disclosure; anogenital injury NO kit: no disclosure disclosure of touch

    24. Skeletal Survey <2: all physical abuse victims all sexual abuse victims neglect and drug on case by case 2-5: if victim has disabilities severe injury otherwise specific bones >5: rarely needed; do specific bones

    26. Skeletal Survey Must have a TWO WEEK recheck (in PA 28% positive on recheck) May exclude skull series unless injury

    27. Skeletal Survey Must be read by radiologist who reads children films: dating of fracture fractures unique to abuse

    34. Head studies: Abuse: <1 CT/MRI of head >1 None if normal exam AND normal eye exam AND normal neurological exam Abnormal CT: needs MRI in 2-3 days

    35. Labs: Drug testing: urine, hair Other tests depend on injury Follow-up testing

    36. 72 hour window Sexual assault cases: HIV meds Plan B

    37. Acute immunizations: Td Hepatitis B

    38. “assessments” Bruising: can’t date No obvious injury (less than 2) can’t rule out fractures consider other organ injuries No obvious injury (less than 1) can’t rule out head injury

    39. “assessments” Sexual abuse: normal exam-can’t rule out SA or penetration Injury-consensual or assault ?

    40. Mental health evaluation 28% in high school consider suicide 8.5% in high school tried suicide 5 year old children may try suicide!

    41. Plan: Injuries care plan Testing indications/repeat testing Medications needed Hospitalize or other Safety issues: in hospital mental health 35% repeat injury in PA 5-10% will die

    42. Plan: Visit with patient about health issues Visit with non-offending caregiver Handouts on information Establish primary care provider Formal note documenting/support CPS plan of needs (EI, nutrition, etc)

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