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Clinical PUZZLE, courtesy of Robodoc

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  • Clinical PUZZLE, courtesy of Robodoc

    [Please see "disclaimers" in the thread "Question for Robodoc".]

    4-year old female sexual assault victim
    Topic created Sep 13, 2003 by Ragster (Robodoc)

    "A 4-yoa black female presents to ED for sexual assault exam. Mother has rushed child in to ED after returning home from grocery shopping to find child crying & holding her groin complaining of pain. Mom's boyfriend was babysitting, and has been detained by police for interrogation at the scene.

    Mom states child has no medical history. And has been complaining that "her pee-pee hurts". Child is crying, hysterical, hyperventilating and holding her groin refusing initial examination. Initial BP = not obtained; temp = not obtained; R=50; P=142; SaO2 = 99% RA

    Limited exam reveals no bruising or external trauma to torso or extremities. Lungs are clear, but patient withdraws to stethescope exam making CV & lung exam difficult. Similarly, child resists abdominal exam - no obvious organomegaly. Bowel tones are present. No rigidity.

    Limited genital exam reveals a swollen external clitoris there is generalized erthema of the vulva without obvious tears or penetration trauma.

    Contact is made with Pediatric Sexual Assault Team who recommend immediate transport to their facility for forensic examination.

    Care to comment?"

  • #2
    Chronology please. How long has the child had urogenital pain? How long has the boyfriend been around and in care of the child?

    Are there any other children in the house? Lastly, does the mother have similar symptoms (STDs)?
    Did-a-chick? Dum-a-chum? Dad-a-cham? Ded-a-check?


    • #3
      Toilet training hx? I would like a temperature. Let's give some pain meds (tylenol, ibuprofen, assuming no allergies), and try to reassure the parent and patient to see if those vitals can be normalized before this pt is "medically cleared". Also more history.


      • #4
        LOL. If that was a slight on psych jammer I wished I had thought of it. Ze auld toilet training stereotype! Ha.
        Did-a-chick? Dum-a-chum? Dad-a-cham? Ded-a-check?


        • #5
          Ragster (Robodoc) - 02:06am Sep 15, 2003 (#10 of 97)
          "Blood pressure was not recorded but patient was awake, ambulatory, and fighting ED staff tooth & nail during attempts at triage and later MSE by ED doc!"


          • #6
            Contact is made with Pediatric Sexual Assault Team who recommend immediate transport to their facility for forensic examination.

            Ragster (Robodoc) - 02:09pm Sep 14, 2003 (#3 of 97)
            "Patient transferred by BLS to "SANE" facility. Enroute, patient suffers code arrest and dies.

            Any thoughts or comments?"


            • #7
              Plenty of both. But aimless at present. Trying to avoid certain horrific thoughts. I see too much of the results of abuse by day.

              Jammer, you there? Waht hoppened to you?
              Did-a-chick? Dum-a-chum? Dad-a-cham? Ded-a-check?


              • #8
                One more try to engage some this particular case with a disturbingly sad outcome. Will wait a little bit more...a few more days...then I will post, for conclusion's sake, the results of the autopsy. The real discussion actually started back on POL AFTER the clinical dg. was uncovered, and re. how was it even possible for the "system" to fail this young child. (on POL, however, since there were SO many docs participating in the ER section, which was back then one of the most actively frequented subsections on POL), one particularly astute physician had an idea about the clinical considerations, before the autopsy results were finally posted confirming his hunch).
                The whole discussion wasn't really about the "failure" of one particular person, since the actual cause of death was due to a relatively infrequent presentation of a specific illness. It was mostly re. how things cascaded towards this sad outcome. Obviously, in an ER, the buck stops with the ER doc...this is an awsome responsibility...and there ARE so many variables to be considered, some of them systemic in nature, some even OUTSIDE of the scope of a particular ER or a particular ER doc. The "conclusion" of the discussion on POL was re. how to better improve the system re. responding to particularly difficult/ambiguous it was mostly an educational discussion over-all...


                • #9
                  For what it is worth, after your 05-07-2004, 11:28 PM post, my differential started with toxic shock syndrome, followed by rupture of the pelvic structures, foreign object in pelvic structures, ingestion to start.
                  Did-a-chick? Dum-a-chum? Dad-a-cham? Ded-a-check?


                  • #10
                    OK .. I'll bite .... The initial post really has only two clues that something bad could be happening (besides the fact that this is a "clinical Puzzle"!) 1) The extreme distress of the patient 2) clitoromegaly... without any more data. the differential is so broad I won't even list. But that's not the real issue here is it? (if you want my guess at what happened to the girl(?) it's Adrenal insufficiency secondary to atypical CAH or adrenal malignancy).

                    The real issue seems to be how to not get burned when faced with the pressures to "medically clear" a patient with a " non-medical" diagnosis handed to you from triage (e.g. depression, sexual assault, panic attack, "drunk",acting out). The irony for me in this case is that when I chose my first job I was coming from a hospital where we were responsible for the evidence gathering for sexual assault victims. Thbis usually tied us up for 90 - 120 min and I dreaded the ithought of having to do this when I was the only attending on with a full waiting room. (of course all of these unfortunates present at 3 AM). The idea of having a SANE team come in and whisk the pt away was a big plus for me when evaluating possible positions.

                    This case illustrates the problem that you trade for when you have such a system... now you have pressure to signoff and get back to work. Being "thorough" in the private world will at the least cost you money and at the worst cost you your job. That being said, I think that the without some normalization (and completion(!)) of the vital signs I would be VERY uncomfortable transferring this patient.

                    PS.. HD -- You ascribe to me the wit and wisdom of the average Da Vinci posting on this board... sorry to disappoint you but I was just thinking about vulvitis secondary to incontinence.
                    Last edited by jammer; 05-14-2004, 06:19 PM. Reason: paragraphs


                    • #11
                      Before I will post the autopsy results (still waiting a little for maybe others to chime in for a few clinical speculations maybe), I will post one of Robodoc's comments, which actually echoes what you said, Jammer. (in this particular case, the complete set of vitals was not even recorded before the child was whisked away by SANE):

                      Robodoc quote:

                      "The lessons I see here are more easily illustrated with other more common conditions:

                      1) Narrow diagnostic focus

                      2) A better history and a full set of vitals is an important lesson for the adequacy of the MSE, but would that alone have tipped the ED doc to the correct Dx in this case?"

                      Addendum...there were other further comments brought on afterwards re. other "lessons to be learned", some of them coming from docs from other specialties than ER, and I will post those too in a little while.


                      • #12
                        OK 3b my breath is baited


                        • #13

                          "Autopsy tox screen negative
                          No oral or vulvar swelling noted on autopsy.
                          The pathologist felt the superficial genital area erythema was due to nothing more than the child rubbing her crotch because of the clitoral pain.

                          Here are some of the autopsy & post-mortem findings:

                          1) No evidence of blunt abdominal trauma, retroperitoneal bleed, or intraperitoneal bleed. No evidence of ruptured hollow viscus or solid viscus, although spleen was enlarged and "swollen". Microscopic exam of spleen revealed extensive microinfarcts of mixed ages.

                          2) No evidence of intracranial bleed or structural pathology.

                          3) No cutaneous rashes.

                          4) post-mortem blood, urine, CSF, tissue & vitreous cultures negative for growth.

                          5) CXR obtained during resuscitation (& post intubation) at hospital to which paramedics diverted after code arrest in route revealed ETT in right mainstem, no pneumothorax, bilateral lower lobe infiltrates with bilateral pleural effusions.

                          6) ABG's & ISTAT labs obtained at diversion hospital included Hgb=6 Hct = 15 WBC=35K platelets 65K; K=6 ph=6.9 PaO2=32 (probably venous stick); PaCO2=61 Base deficit = -26. Core temp (temp probe foley) = 102 degrees F.
                          Also at autopsy, total bilirubin = 9.

                          7) Autopsy lung findings showed extensive fibrin thromboembolism in larger arteries with scattered areas of infarction, and extensive thrombosis in smaller arteries (in-situ thrombosis). Bronchoalveolar lavage fluid = 9% lipid-laden macrophages.

                          Dr. J was correct - patient had sickle cell disease (previously undiagnosed) and was in sickle cell crisis with acute chest syndrome. This patient presented to the ED with priapism of the clitoris.
                          A most unusual and most unfortunate case, but it does illustrate how easy it is for physicians to fall into the trap of "narrow diagnostic focus" and fail to consider the DDx's to the "obvious" presenting complaint.

                          Additional info obtained post-factum:

                          Mother does not have SS dz and is currently being tested for sickle cell trait. Biologic father (not boyfriend) is in prison in New York State and according to patient's mother was "healthy".

                          There is no info in the record regarding SS testing at birth. From my review of the record, it seemed pretty clear that the ED staff wanted to do more in terms of vitals, exam, etc but the child was so hysterical and the allegation of abuse so persuasive, that these routine assessment parameters were not pursued vigorously.

                          There is nothing wrong with considering sexual abuse in this clinical context as a primary working diagnosis. The problem, as I see it, is in thinking of nothing else! (aka "Narrow Diagnostic Focus")

                          I teach the residents to consider 3 basic categories in their differential when approaching a patient's problem:

                          1) What's likely (Sexual abuse certainly fits this category for this patient)

                          2) What's treatable

                          3) What's deadly

                          Prospectively, I do not know if applying a disciplined ddx approach to this patient would have changed the presumptive dx or the outcome."


                          • #14
                            Very interesting case 3b
                            I am the witchdoctor and I approve this message


                            • #15
                              Weird stuff, Maynard. Way out of the purview of my typical patients, but the message is heard loud and clear. Keep all senses open, and don't assume ANYTHING!