Physical Abuse Clinical Pathway, Emergency Department, Outpatient Specialty Care and Primary Care – History and Physical

Physical Abuse Clinical Pathway, Emergency Department, Outpatient Specialty Care and Primary Care – History and Physical

History and Physical

Non-accidental trauma is difficult to detect in infants. Many present with non-specific symptoms such as irritability, BRUE, altered mental status or unexplained vomiting.

Historical Findings Suggestive of Abuse

  • No explanation/vague explanation for a significant injury
  • Important detail of the explanation changes dramatically
  • Different witnesses provide different explanations
  • Explanation is inconsistent with child’s physical and or developmental capability
  • Injury occurred as a result of inadequate supervision
  • Delay in seeking medical care without reasonable explanation
  • Witnessed inappropriate behavior to a child, placing them at risk for non-accidental trauma
  • Reported history of physical abuse
  • Siblings or household contact of child with suspected abuse
  • History of potential trauma in setting of domestic violence
  • Poisoning: Any illegal drug exposure, prescribed controlled substances, ethanol or marijuana
  Infants < 1 yr Children
HPI
  • Onset of symptoms, activity at symptom onset
  • Nature of symptoms
  • Alleviating/exacerbating factors
  • Feeding: duration, frequency of feed, intake over the past 24 hrs
  • Presence of fever
  • Irritability
  • History of injury
  • Development
  • Details of Injury
    • Time
    • Mechanism
    • Plausible considering age, development
    • Initial manifestations
    • Neurologic symptoms
    • Supervision at time of injury
    • If delay in seeking care, reason for the delay
PMH
  • Birth history
  • Prior ED visits
  • Prior hospitalization
  • Primary care MD-date of last visit
    • Immunization status
Social History
  • Household members
  • Adults who provide childcare
  • Other children in the home and their ages, including siblings and non-relatives
  • Consider other social risk factors that may assist medical decision-making
  • In household members and childcare providers:
    • History of prior CPS involvement
    • History of prior law enforcement involvement
    • History of drug/alcohol abuse concerns
    • IPV concerns among caregivers
Physical
  • VS
  • Growth chart, head circumference for infants
    • Head circumference > 85% or increased at least 2SD from prior measurement, have a concern for abuse
  • Head to toe exam
  • TEN-4 Faces P Bruising Clinical Decision Rule: If below criteria are met, have a clinical concern for abuse

Reference

The Evaluation of Suspected Child Physical Abuse