Hello, and welcome to Pediatric Adolescent Case Reviews. My name is Gail Horner. I'm a forensic nursing specialist with the International Association of Forensic Nurses. Prior to joining staff at IFN, I was a pediatric nurse practitioner in a hospital-based child advocacy center and also coordinator of a pediatric sexual assault nurse examiner program in an emergency department at a pediatric hospital, Nationwide Children's Hospital in Columbus, Ohio, for over 25 years. So again, welcome to Pediatric Adolescent Case Reviews. Planners, presenters, and content reviewers of this course disclose no conflicts of interest. You will need to attend the course in its entirety, and upon completion of the evaluation form, you will receive continuing nursing education contact hours for this activity. The International Association of Forensic Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Nursing Education. So the learning outcomes for the next hour, hour and a half or so. We will develop a plan of care for the pediatric adolescent victim of sexual abuse, sexual assault, describe antigenital exam findings, and discuss why a normal antigenital exam does not negate the possibility of sexual abuse or sexual assault. We gratefully acknowledge the Indigenous people on whom we gather and live. So let's start with case review number one. 14-year-old Melissa presents to the emergency department with a concern of sexual assault that occurred earlier this evening, perpetrated by a 16-year-old male. She's accompanied to the emergency department by her mother. Mother has notified law enforcement of the assault. So the pediatric SANE arrives in the emergency department. Melissa and her mother are together in the emergency department in her patient room. The pediatric SANE introduces herself and explains the elements of the pediatric forensic examination, including obtaining a history of assault, a head-to-toe exam with potential photodocumentation of any injuries, antigenital exam with photodocumentation, forensic evidence collection explained as looking for semen, saliva, or cells or DNA from the person who assaulted you from their body on your body or clothing. Also care will involve testing for sexually transmitted infections and pregnancy as well as prophylaxis. The pediatric SANE states that she is aware that mother has already notified law enforcement of the assault, but states that as a mandated reporter, she will also need to report to Child Protective Services. Now this will vary according to state law, but in the state that I practiced in Ohio, a concern of sexual assault between a 14 and 16-year-old would be reportable to Child Protective Services and law enforcement. So the pediatric SANE lets the mother know and also lets Melissa know that she will need to report to Child Protective Services and law enforcement. The pediatric SANE also informs Melissa that she can decline any portion of the care and if the exam is progressing and there's any part of the care that Melissa is not okay with, she just needs to let the nurse know and that portion will not be completed. Informed consent and assent is obtained. So the pediatric SANE and Melissa are alone in the room as the pediatric SANE gathers a history of assault. Melissa states that earlier today, Brian, Melissa's 14, Brian's 16, a friend of her older brother, texted her and said, hey, do you want to hang out at my house after school? Brian's a friend of her older brother's and Melissa states, I have always thought he was so cool. Melissa states she went over to Brian's after school and they were watching a movie. Brian kept telling her how pretty and hot she was. Brian started touching her breasts. SANE clarifies that the touching of the breasts was over the clothing and Melissa says, I started moving away from Brian. Melissa states Brian started kissing her on the mouth and neck and Melissa then says, then it happened. We had sex. The pediatric SANE understands state law regarding age of consent and that sex between a 14 and 16-year-old is legal and understands that she needs to elicit more information from Melissa to determine if there was force involved. History of assault is obtained with just Melissa and the pediatric SANE in the room. The medical forensic examination, for the medical forensic examination, Melissa can choose for mother or another support person to be present in the room and a chaperone will be offered and strongly recommended and the chaperone protects Melissa from sexual abuse, sexual assault from the medical, from the SANE nurse providing the exam and also protects the pediatric SANE nurse from any allegations of inappropriate touching. So the pediatric SANE, realizing that she needs to get some other information from Melissa says, tell me more about what happened after he started kissing you. Melissa states, I tried to move away, then he started taking my clothes off. I kept saying no, he was on top of me taking my underwear off. She then states I had a dress on and I tried to push him away and I think I might have scratched him as I was trying to push him away. Pediatric SANE clarifies what Melissa meant by we had sex. Melissa clarifies penis and vagina and her mouth, that there was no condom used and she's unsure of ejaculation. Melissa denies any additional contact. You can see that the pediatric SANE has gathered some crucial information. Melissa repeatedly said no and tried to push Brian away and may have scratched him. Then the pediatric SANE obtains a medical history. Melissa has no medical problems, no history of any surgeries, no hospitalizations. She's on no medications. Her immunizations are up to date, including HPV and hepatitis B. She has no known drug allergies. She began having menses at age 12. Usually her periods occur monthly and the last menstrual period was two weeks ago. Melissa denies any history of consensual sexual activity. Social history, Melissa lives with her mother, father, and older brother. Negative for all risk factors, including no past familial involvement with child protective services or law enforcement, no household intimate partner violence, no parental mental health concerns, no parental substance abuse concerns, and no parental history of child maltreatment. So the plan of care for Melissa, based upon the history that she has disclosed, includes forensic evidence collection. Now forensic evidence collection varies between states, jurisdictions, and sites of care. Some pediatric SANEs will collect a complete kit regardless of disclosure, and others will collect a more focused kit depending upon disclosures. And based upon the history that Melissa has disclosed, forensic evidence collection from oral because of kissing, face again because of kissing, external genital, vaginal, cervical, bilateral inner thighs because of the history of genital to genital contact, and fingernails because of the history of scratching him are crucial. Head-to-toe exam with photo documentation of injuries was normal. There was no trauma noted, so no need for photo documentation of injuries. And just to talk again, a chaperone is strongly indicated to protect both the patient and the pediatric SANE from any concern for inappropriate touching by the pediatric SANE. And a support person, like a parent, a mother, or anyone else who is there with the child should certainly be offered in this situation. Antigenital exam was normal. There was no acute or chronic trauma. Melissa was offered but declined a speculum exam. So when we're talking about antigenital exam findings in the pediatric and adolescent population, we need to realize normal, it's normal to be normal. There are less than 10% of children who experience sexual abuse will have any abnormal antigenital findings on exam. Now when we're talking about children and adolescents examined within an acute window, 72 to 96 hours, that percentage goes up to about 20 to 21%, but still it's normal to be normal. And there are various reasons. First of all, many sexual acts that occur to children and adolescents, you would expect a normal exam, a mouth to a vagina, a hand to a vagina. You would expect a normal antigenital exam. And then when we're talking about the genital structures, including the hymen, there is elasticity that will allow for stretching, that will allow for penetration without tearing. Now in the pre-pubertal child, there is some element of elasticity, so allow for some stretching without tearing. Children and adolescents, once they have entered adolescence and estrogen is released, that hymen and the genital structures become much more elastic, it's moistened, the hymen and genital structures are no longer sensitive to touch, the body is preparing for sexual activity, and the elasticity is very much increased. Another reason why it's normal to be normal. In the pre-pubertal population, that sensitivity of the hymen is also protective. Oftentimes there may be penetration of the labia, of the introitus, and to the point of touching the hymen, the hymen is touched, the perpetrator does not want to injure the child, cause bleeding, and risk being detected, and so perhaps full penetration as you and I would think of does not occur, and then also the perpetrator does not want to hurt the child, cause the perpetrator wants the child to engage in the activity again. And many disclosures of sexual abuse are delayed disclosures, weeks, months, or even years after the latest incident of sexual abuse, and anagenital findings heal most often without any scarring. So these are reasons why it's normal to be normal following sexual abuse. So the following STI testing and pregnancy testing plan was completed. Melissa received testing, a urine pregnancy test to test for pregnancy, a vaginal or a urine NAT for Chlamydia gonorrhea trichomonas would be indicated, an oral NAT for gonorrhea, and also HIV, syphilis, hepatitis B, and C testing would be indicated, and that's based upon her history of genital-to-genital contact. And then as far as sexually transmitted infection and pregnancy prophylaxis, Ella is indicated to prevent pregnancy, ceftriaxone, 500 milligrams IM times one is indicated for gonorrhea prophylaxis, doxycycline, 100 milligrams BID times seven days is indicated to prevent Chlamydia, and Flagyl, 500 milligrams BID times seven days is indicated to prevent trichomonas. Melissa was offered but declined HIV PEP. A report was made to Child Protective Services and law enforcement. The same nurse engaged in discharge planning with mother and Melissa. Mother stated that there will be no contact with Brian. Child Protective Services was fine with discharging Melissa to mother. As far as follow-up care that Melissa will require, she will need a repeat urine pregnancy test in two to four weeks, repeat testing for HIV, syphilis, hepatitis B and C in six weeks and three months, because when we're testing for HIV, syphilis, hepatitis B and C acutely when a patient has just been sexually abused or sexually assaulted, what we're determining is that this patient didn't have HIV, syphilis, hepatitis B or hepatitis C prior to being sexually abused. There was also a referral made for trauma-informed mental health therapy. Case review number two. Harper is a six-year-old female who presents to the emergency department with a concern of sexual abuse by her maternal grandfather. Harper said to mother earlier this day, grandpa hurt my pee-pee with his pee-pee. Harper and her one-year-old sister were babysat by maternal grandfather today. Both children were accompanied to the emergency department by mother and father. So what do we know already? First of all, this is a very concerning statement made by Harper, and this will warrant a report to Child Protective Services and law enforcement. We know that the last contact with grandfather was today, so understanding that six-year-olds can have difficulty with the concept of time and exactly when something happened, we know that forensic evidence collection is indicated. Also, one-year-old sister is at potential risk and will need a medical forensic exam. The pediatric SANE introduces herself and explains the plan of care. Plan of care will include a head-to-toe exam with photo documentation of any injuries and a genital exam with photo documentation. Forensic evidence collection, as I explained before, would be looking for semen, saliva, or cells from grandfather's body on Harper's body or clothing, sexually transmitted infection testing, and since genital-to-genital contact has been disclosed, offering HIV prophylaxis. When the pediatric SANE discussed the need for reporting concerns of sexual abuse to Child Protective Services and law enforcement, mother begins to cry and spontaneously states, this is all my fault. He did these things to me when I was a little girl. He promised me that he was different and would never harm my daughters. So the pediatric SANE talks with Harper alone in a room to obtain a history of abuse. Harper spontaneously states to the pediatric SANE, Grandpa hurt my pee-pee with his pee-pee. Pediatric SANE then asks Harper, where is her pee-pee? Harper touches her genital area. Using an anatomical drawing, Harper then identifies on a girl the vagina as a pee-pee and pee-pee as penis on a male drawing. Pediatric SANE asks Harper to tell her more about what happened with Grandpa. Harper states again, Grandpa hurt my pee-pee with his pee-pee. Pediatric SANE asks, how did Grandpa hurt your pee-pee with his pee-pee? Were your clothes off or on? Harper states, Grandpa takes my clothes off and then he takes his clothes off. Then he put his pee-pee in my pee-pee and it hurt. The pediatric SANE asks, where were you when this happened? In Grandpa's bedroom in his bed. Where was Clancy, the one-year-old sister? She was in the bed too. Grandpa put his pee-pee in her pee-pee too. And then the pediatric SANE asks, did anything come out of Grandpa's pee-pee? Harper answers, I don't know. Pediatric SANE asks, did this happen one time or more than one time? Harper answers, lots of times. You note that after Harper's spontaneous statement to the pediatric SANE of Grandpa hurt my pee-pee with his pee-pee, the pediatric SANE asks open-ended questions and then more specific close, specific clarifying questions to garner a more complete history. Medical history is unremarkable. No medical problems and no history of surgeries. No hospitalizations, no medications, no allergies to any medications. Immunizations are up-to-date, including hepatitis B. Psychosocial history. Mother disclosed that she was sexually abused by maternal grandfather. Mother states that she told her mother about it. Her mother is now deceased, but that there was no involvement of child protective services or law enforcement when she was a child. And the sexual abuse continued until she was age 12. No past familial involvement with child protective services or law enforcement. No household intimate partner violence. No parental mental health or substance abuse concerns. Again, forensic evidence collection varies between states and jurisdictions and sites of care. Some pediatric SANEs will collect a complete kit regardless of disclosures, and others will collect a more focused kit depending upon disclosures. It's important to keep in mind, especially with children, that disclosure is a process. It is always possible that additional forms of sexual abuse occur, that the child is not disclosing at the time of evidence collection. So if you were collecting a focused forensic evidence kit based upon the disclosures by Harper, you would want to make sure that you collected external genital, vaginal, meaning the inner aspect of the posterior frechette, inner aspect of the labia minora, and bilateral inner thigh. The head-to-toe exam was normal, no trauma, chaperone was offered, and a support program, a support person was in the, mother and father both were in the room with Harper. So this is what is noted on anogenital exam. No signs of trauma. The anogenital exam was free of any signs of acute or chronic trauma. But take a look at the hymen. How would you describe the hymenal opening? Is there a hymenal opening? No. This is an imperfect hymen. An imperfect hymen requires referral to pediatric gynecology, because that child will need a lysis of the hymen, a surgical procedure to create an opening in the hymen. But these are some examples of hymenal vaginal septums, duplication of the vagina, and requires further evaluation by pediatric gynecology. Microperfect hymen most likely will need lysis prior to menses and sexual activity. An imperfect hymen will definitely require lysis. Septate hymen, really a rather common variant that you will see. You should be, when you see a septate hymen, you should be able to pass a swab behind the septum or visualize behind the septum. If you can't do one of those two things, that child should be referred to pediatric gynecology, because, again, there could be a vaginal septum. Based upon the history given by Harper, the following testing for sexually transmitted infections is indicated. A urine gnat, and this is a dirty urine, for chlamydia, gonorrhea, trichomonas. Testing for HIV, syphilis, hepatitis B and C, again, to get a baseline of negative for the serology testing. HIV prophylaxis should be offered. Parents declined based on the perpetrator being grandfather, and they stated that grandfather is not HIV positive. A report to Child Protective Services and law enforcement is indicated. One-year-old sister will also need a medical forensic examination with evidence collection. There needs to be safety plan. Parents state that there will be no contact with the grandfather, and Child Protective Services is fine with discharge home to parents. Harper will also need a referral to pediatric gynecology for her imperfect hymen, a referral to trauma-informed mental health therapy for Harper, and for mother, too, since mother is a victim of sexual abuse. There needs to be repeat serology testing, HIV, syphilis, hepatitis B in six weeks and three months for both girls. Case review number three. Nine-year-old Kevin presents to the emergency department with a concern of sexual abuse by his 16-year-old male cousin. Kevin disclosed to father that Byron, his 16-year-old cousin, who is father's sister's son, put his dick in my butt. Last contact with Byron was about four days ago. The window for evidence collection in your state is 96 hours. Byron was accompanied to the emergency department by his father. Father says, I can't believe that Byron would do this, but he believes his son. From talking with father, it is determined that the last contact between Kevin and Byron was about 80 hours ago. Pediatric SANE introduces herself to Kevin and his father and explains medical forensic care. There's a discussion of mandatory reporting. Father is in support of involving Child Protective Services and law enforcement. Father is also appropriately concerned for Byron's younger siblings. Informed consent and assent is obtained. Pediatric SANE is alone in the room with Kevin and obtains the following history of assault. Pediatric SANE says to Kevin, so tell me why you are here in the emergency department tonight. Kevin is very forthright and states, Byron put his dick, Pediatric SANE clarifies, penis, in my butt. And Kevin points to his butt. Kevin goes on to say, Byron took Kevin's pants and underwear off and put his dick in his butt. He states it hurt and wet stuff came out. Kevin said it happens every time he sees Byron. Byron said he would beat him up if he told. Kevin also said, but my dad said he would not let Byron beat him up. Medical history is obtained, which is unremarkable. No medical problems, no history of surgeries, no hospitalizations or medications. No known allergies to any drugs. Immunizations are up to date, including HPV. He has not yet received the HPV vaccine. Psychosocial history, Kevin lives with his father. Has sporadic supervised visit with his mother. Dad says, I always make sure that mom comes over to my house to see Kevin and I'm there when she's there. Mom has mental health and substance abuse concerns. No history of intimate partner violence. No previous involvement with child protective services or law enforcement. And no parental history of child maltreatment. So the plan of care for Kevin, the forensic evidence collection, again, varies by state, by jurisdiction, by site of care. It may be a complete forensic evidence collection based upon the history that Kevin provided. You want to make sure that you collected anal swabs, buttocks, and bilateral thighs. The pediatric saying, though, realizes that disclosure is a process and may collect the entire forensic evidence kit. Again, a chaperone is recommended to protect Kevin and to protect the pediatric saying. And Kevin, given his young age, should have a support person, his father, in the room with him for his physical exam. The head-to-toe physical exam is normal. No injuries noted. And a genital exam is normal. No injuries noted. So based upon the history disclosed by Kevin, the following testing for sexually transmitted infections is indicated. An anal gnat for chlamydia and gonorrhea, a urine gnat for chlamydia, gonorrhea, trichomonas, and baseline HIV, syphilis, hepatitis B and C testing. Kevin has not started HPV vaccine, so he should get his first vaccine and will get his second in six months. There should be a report made to Child Protective Services and law enforcement. Discharge plan, father states that there will be no contact with Byron, and Child Protective Services is fine with discharge home with father. What about HIV PEP? There was anagenital contact. Should Kevin be offered HIV prophylaxis? No, because we're outside of the window. It's been 80 hours since the latest incident of sexual abuse. HIV PEP must be initiated within 72 hours of sexual abuse assault. Kevin will need the following follow-up. Referral to trauma-informed mental health therapy. Repeat HIV, syphilis, hepatitis B, C testing in six weeks and three months. And he'll need his second HPV vaccine in six months. Case review number four. Ten-year-old female, Violet, presents to the emergency department with a concern of sexual abuse by her stepfather. She's accompanied to the emergency department by her mother, who states that she does not believe the abuse occurred and wants the trial checked to confirm it did not occur. Violet told maternal grandmother today that stepfather put his penis in her no-no spot, which is her vagina. So the pediatric saint arrives to the emergency department. Violet and her mother are together in the emergency department room. Pediatric saint introduces herself and explains the elements of medical forensic examination, including obtaining a history of assault, head-to-toe exam with photo documentation of any injuries, and a genital exam with photo documentation. Forensic evidence collection explained as touching her body with cotton swabs or Q-tips, looking for semen, saliva, or cells from her stepfather's body on her body or clothing. Sexually transmitted infection and pregnancy testing. The pediatric saint also states that she's a mandated reporter and she will need to report to Child Protective Services and law enforcement because Violet has made some concerning statements. Mom states she's aware of this. Mother provides consent for care. Pediatric saint informs Violet that she can decline any portion of the care, and if, as the exam is progressing, she's not okay with any part of it, she just needs to let the nurse know, and that portion will not be completed. Informed consent and assent is obtained. Violet is okay with a chaperone and wants mother in the room during the physical exam, and mother can be supportive. Pediatric saint has a private conversation and explains to mother that a normal genital exam will not mean that sexual abuse did not occur. Alone in the room with Violet, the pediatric saint asks Violet, why are you here at the hospital? Violet starts to cry, and she states, Sam, who's her stepfather, does bad things to me, and today I told my grandma and she told my mom. Mom doesn't think it happened, but it did. Pediatric saint asks, what happened? Violet answers, when mom is at work, Sam comes into my bedroom and takes my clothes off. Then he puts his penis in my no-no spot. Pediatric saint clarifies that no-no spot is vagina. Pediatric saint asks clarifying questions. When was the last time it happened? And Violet responds, the night before I told grandma, which would make it last night within time frame for forensic evidence collection. Pediatric saint then asks Violet, how many times did it happen? Violet answers, almost every night mom works. Mom is a nurse and works three nights a week. Pediatric saint asks, did anything come out of his penis? Violet answers, yes, in the no-no spot. And her legs were always wet after. And Violet denies that anything like a condom was on his penis. Medical history is unremarkable. No medical problems, no surgeries, no hospitalizations or medications, no known drug allergies, immunizations are up to date, including HPV and hepatitis B. Mother denies any psychosocial risk factors. Menses, Violet has not yet started her first period. Psychosocial history, again, mother denies any psychosocial risk factors. Violet lives with mother and stepfather. Biological father has never been in her life. Mom and stepdad have been together since Violet was two years of age. Forensic evidence collection is indicated. And again, the process for forensic evidence collection varies between states, jurisdictions, and sites of care. But based on the history given by Violet, you would want to make sure if you're not collecting a complete kit that you collect from the external genitalia, vagina, bilateral inner thighs, and the legs where Violet indicated where she was wet. The head-to-toe exam was unremarkable, no injuries. However, the pediatric SANE did note that Violet has breast buds. In a genital exam was normal. However, there were some things that were noted. When you look at the genital structures, the pediatric SANE noted that there was an estrogenation that she was seeing. The hymen was beginning to thicken and become irregular, and there was a small amount of pubic hair on a genital exam, but no signs of trauma. So due to Violet's Tanner stage of two to three, so Violet's Tanner two to three, she has breast buds, she has pubic hair, and she has estrogenation of the hymen and other genital structures. Pregnancy testing and prophylaxis should be completed. Violet's mother consented to LPO times one, but declined to HIV PEP. Stated that I have had sex with him for eight years, and I don't have HIV. Mom is tearful off and on during the medical forensic exam. Other STI testing that's indicated is a urine nap for Chlamydia gonorrhea trichomonas, and blood work for HIV, syphilis, hepatitis B and C. A report to Child Protective Services and law enforcement is indicated. As far as discharge planning, Child Protective Services came to the emergency department to talk with mother. Mother agreed to have stepfather leave the home, and she will not allow contact between stepfather and Violet. Violet was discharged home with mother. She will need a repeat urine pregnancy test in two to four weeks. A repeat serologies, HIV, syphilis, hepatitis B and C, in six weeks and three months. A referral to trauma-informed mental health therapy. And mom needs parent support or a focus type of therapy to support her through this disclosure and assist her in being supportive to her daughter. Case review number five, 15-year-old Erica presents to the emergency department with concerns of possible sexual assault. She was brought to the emergency department by the police after knocking reportedly on a neighbor's door naked an hour or so ago and clearly intoxicated. Mother has been called and is on her way to the emergency department. Her blood alcohol level is indicated. Hearing this scenario, what is your immediate concern or concerns regarding this patient? First of all, her blood alcohol level is elevated. Is the patient coherent enough to consent slash assent to a medical forensic exam? We should probably have concerns for drug-facilitated sexual assault. And it's within 24 hours so we know that blood and urine collection is indicated. The pediatric SANE arrives in the emergency department. Erica and her mother are together in the emergency department room. Erica is sleeping and it is difficult to arouse her. So the pediatric SANE knows that she will need to wait for Erica's consent assent. The pediatric SANE explains concerns of possible drug-facilitated sexual assault to mother and obtains consent for drug-facilitated sexual assault testing. Pediatric SANE introduces herself and explains the elements of medical forensic care including obtaining a history of assault, head-to-toe exam with physical, with photo documentation, anogenital exam with photo documentation, forensic evidence collection, sexually transmitted infection and pregnancy testing prophylaxis. She explains all of that to mother and obtains consent. And then also she explains to Erica when Erica is awake and coherent and obtains assent. Pediatric SANE states that she is aware that law enforcement brought Erica to the emergency department. And since there are concerns of sexual assault as a mandated reporter, she will also need to report to child protective services. Now this will vary according to state law and the state that I practiced in Ohio at a referral to child protective services would be indicated as well as law enforcement. Pediatric SANE informs Erica that she can decline any portion of the care. And as the exam is progressing, if it's not okay with Erica, she just needs to let the pediatric SANE know and that portion will not be completed. Informed consent and assent is obtained. Pediatric SANE is alone in the room with Erica and asks her what happened. Why is she here at the hospital? Erica states that all I remember is that I went to a party at my next door neighbor's house. He's home from college. His friend gave me a drink and the next thing I know, I was naked on somebody's porch and the police took me here to the hospital. What are some additional questions the pediatric SANE might ask? Have you ever drank alcohol before? If the answer is yes, does it typically affect you in this way? Do you think you could have been drugged? Does anywhere on your body hurt? Erica states she has drank alcohol before and never reacted like this. And yes, she thinks she may have been drugged. So the pediatric SANE knows that she needs to have concerns for drug facilitated sexual assault and will collect blood and urine. Medical history is unremarkable. Again, no medical problems, no history of surgery, no hospitalizations, no medications, no drug allergies. Immunizations are up to date. She started having periods at age 12. They occur monthly and her last menstrual period was two weeks ago. She has no history of consensual sexual activity. Psychosocial history, Erica lives with her mom. Father is incarcerated due to drug trafficking. Mother denies any malhealth or substance concerns for herself. Mother states IPV, intimate partner violence was present in the relationship with father. Parents separated when Erica was five and she's had very limited contact with her father since then. Plan of care for Erica. Again, Erica, there's no history given. So nothing or everything could have happened to Erica. So the pediatric SANE realizing that there's a concern for sexual assault in a patient that cannot give history will collect a thorough and complete evidence kit. Erica declined a speculum exam. She was open to a chaperone and she wanted her mother present with her for the exam. And the head to toe exam was unremarkable. There was no trauma. In a genital exam was normal, no trauma noted. The pediatrics forensic nurse understands that although in a genital exam was normal, sexual assault could have still occurred. Therefore sexually transmitted infection, pregnancy testing and prophylaxis is indicated. You see the STI and pregnancy testing this indicate a urine pregnancy, a urine or vaginal map for chlamydia gonorrhea trick, serologies for HIV, syphilis, hepatitis B and C and drug facilitated sexual assault testing. And also STI and pregnancy prophylaxis are indicated. Ella to prevent pregnancy, ceftriaxone to prevent gonorrhea, doxycycline to prevent chlamydia, flagell to prevent trichomonas. And what about HIV PEP? HIV PEP should be offered. And she has a normal exam, gives no history. It still should be offered. Not sure given the fact of the normal exam, I would still offer it, but I would not as strongly encourage it as if I saw this on exam, acute trauma, acute hymenal transection at 5.30, hymenal bruising from three to six o'clock. Then I would much more strongly encourage HIV prophylaxis. Reporting of this case will be state and jurisdictionally determined. In the state of Ohio, report to both agencies is indicated. So report to Child Protective Services and law enforcement. And in discharge planning, Child Protective Services was fine with discharge home to mother. Follow-up, Erica will need a repeat pregnancy test in two to four weeks, a referral to an HIV specialist or infectious disease if HIV PEP is initiated. Repeat HIV, syphilis, hepatitis V testing in six weeks and three months, and a referral for trauma-informed mental health therapy. Case review number six. Six-year-old female, Aaliyah, presents to the emergency department for concerns of sexual abuse by her nine-year-old foster brother. She's accompanied to the ED by her foster mother. Both children were found naked in the foster brother's bed. There are some immediate concerns that must be clarified. One immediate concern is a medical forensic examination even indicated. In many states and jurisdictions, this would be concerning for problem sexualized behavior, but not sexual abuse. Both children are young, under the age of 10. Law enforcement is not going to investigate a nine-year-old child for possible prosecution. Child Protective Services is already involved and should be informed of the concern as both children are in foster care. Let's say in your facility, since the little girl is here, the policy is for the pediatric SANE to go ahead and provide care. However, forensic evidence collection is not indicated. So the pediatric SANE introduces herself, explains the medical forensic care. Child would be examined head to toe, including an anogenital exam. And there may be some testing for sexually transmitted infections. Child Protective Services will need to be informed of the concern and informed consent and assent was obtained. Forensic nurse talks to Aaliyah alone in the room. Aaliyah states she was in bed with Johnny. Both children were naked, states that they were playing and touching each other with hands all over, including penis and vagina. Denies that Johnny's penis touched her anywhere on her body. Medical history, no medical problems, no surgical problems, no hospitalizations, no medications or medication allergies. Her immunizations are up to date. Psychosocial history, there's a long involvement with Child Protective Services. Mom has substance abuse concerns. She's had several placements in foster care. The current placement has been for a year and there's a history of problems, sexualized behaviors for Aaliyah. Plan of care, forensic evidence collection is not indicated. Her head to toe exam was unremarkable, no trauma. So look at that anogenital exam. At first glance, anogenital exam is normal, but what about the perineum? What are we seeing? Is this acute trauma? No, it's failure of midline fusion. If perplexed by a finding such as this, you can do a couple of things. First of all, palpate the area with cotton swab. And if it's not an acute injury, it's not gonna be tender. And then also have the patient return in a week for another exam. If the exam is unchanged, obviously it's not acute trauma. What about this anogenital exam? What if Aaliyah had this exam? First of all, you know the pubic hair and thickened hymen. This child is only six years old. Concern for precocious puberty. Look at the hymen at six o'clock. There's missing tissue in supine and knee chest position. Hymen with non-acute transection at six o'clock extending entirely through the hymen and missing area of hymen from 5.30 to 6.30. So we know this didn't occur from being in the bed with Johnny last night, that this is non-acute trauma. And therefore STI testing is indicated probably in both scenarios because of the concern of the two children in the bed together and problematized sexual behavior. And especially with the second exam finding where there are non-acute findings that are diagnostic of penetrative injury. So collecting a dirty urine to test for chlamydia gonorrhea trichomonas is indicated. For the second exam with a hymenal transection and missing hymenal tissue, the non-acute findings, testing for HIV, syphilis, hepatitis B and C are indicated. These exam findings are diagnostic of genital trauma and consistent with sexual abuse. Also coupled with Aaliyah's problem sexual behavior, the concern for past sexual abuse is high. Child Protective Services has been notified as a concern. Discharge planning, Child Protective Services has approved discharge to foster mother. Follow-up, a referral for trauma-informed mental health therapy for Aaliyah. A referral to pediatric gynecology or pediatric endocrinology to address the concerns of precocious puberty. Also repeat serologies for HIV, syphilis, hepatitis B and C in six weeks and three months are indicated. Do you have any questions? If you do, please let me know. My email is ghornor at iafn.org. Again, any questions, please let me know. G-H-O-R-N-O-R at I-A-F-N.org. Here's a list of references that I used in completing this presentation. And again, thank you for choosing this presentation. And again, any questions, please email me.

Gail Horner

forensic nursing specialist

medical forensic examination

pediatric victims

adolescent victims

sexual abuse

assault

antigenital exam

follow-up care