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
This outline may be used as a prompt to assist with a “dot-phrase” in the electronic medical record and does not include perineal or genital examination (see below).
- General 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.
- Vital Signs
- Measure and document respiratory rate, blood pressure, and heart rate.
- Growth parameters
- Measure and record using a standardized growth chart height, weight, Body Mass Index (BMI), and in children under two, head circumference.
- Skin
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Record the presence of any secretions (potential saliva or semen), 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.
Document all potential 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 examples of burn surface area charts, see Burn Assessment - Rule of Nines.
Include in the medical record any explanation given by the child/adolescent for a finding, using the child/adolescent's exact words when possible. - Mouth
- Inspect the oral cavity for lesions and injuries. Note bruising or petechiae of lips, buccal mucosa, gums, palate; mucosal tears, especially of the frenula; or dental trauma. Palatal petechiae may be associated with fellatio or forced insertion of a foreign body, as well as infectious diseases such as group A Streptococcus (GAS or Streptococcus pyogenes) https://publications.aap.org/redbook/book/755/chapter/14081903/Group-A-Streptococcal-Infections. Check for lesions caused by sexually transmitted infections (herpes simplex, syphilis).
- Head, eyes, ears, and nose
- Check the anterior fontanelle (in infants); palpate the head for hematomas or fractures; Look for patches of alopecia as might be seen in a neglected infant or abused child. 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 to document retinal hemorrhages. Check the ears for bruising on the pinnae, hemotympanum, tympanic membrane perforation, and cerebrospinal fluid otorrhea. Check the nose for any injuries or foreign bodies.
- Neck
- Check the neck for ligature or other findings that may represent choke marks. Make sure to look in the creases of infants for injuries or lesions.
- Chest
- Listen to lungs and document any abnormal sounds. A cardiac examination should be performed including documentation of heart sounds, murmurs, and perfusion. Check for costochondral tenderness or chest deformity. Record the Tanner stage of the breast development. For more information about Tanner staging, see Bright Futures curriculum for pediatric providers: https://www.brightfutures.org/wellchildcare/toolkit/maturity.html.
- Abdomen
- Examine for bruises; listen for bowel sounds if indicated; and palpate the abdomen to check for tenderness and masses.
- Back
- Examine for bruises; palpate for tenderness.
- Extremities
- Note any tenderness, swelling, or deformity.
- Neurological status
- Assess mental status and other neurological findings as clinically indicated including reflexes, strength, tone, sensation and gait. Consider the use of evidence-based depression screening tools for mental health assessments such as Guidelines for Adolescent Depression in Primary Care (GLAD-PC): https://publications.aap.org/pediatrics/article/141/3/e20174081/37626/Guidelines-for-Adolescent-Depression-in-Primary.
- Musculoskeletal Examination
- Check for limb deformities, pain on palpation, range of motion.
- Development
- Assess the developmental abilities and determine the developmental stage of the patient. The CDC website has useful guides for developmental milestones: https://www.cdc.gov/ncbddd/actearly/milestones/index.html.
- 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.
