Physiologic Integrity

HEALTH MAINTENANCE CARE
USA a. History b. Physical Examination c. Screening Procedures d. Immunization e. Anticipatory Guidance & Health Education

GROWTH  increase in size  increase in mass  QUANTITATIVE  measured in : - cm - inches - kilograms (kg) - pounds

Growth & Development
DEVELOPMENT  Maturation  Function & skills  QUALITATIVE DATA  Developmental task - physical - psychologic - cognitive

GROWTH PARAMETERS Screening Details  weight : 3500 grams  height : 35-50 cms  HC : 33-35 cms  CC : 33-35 cms **head > chest circumference .

PHYSICAL DEVELOPMENT 1 2 3 4 5 6 : regards : smiles : turns head : holds head : rolls over : transfers object 7 : sits w/o support 8 : crawls 9 : pulls over 10 : cruises 11 : walk w/ support 12 : stands alone .

puzzle Pre-Sch Associative Trucks. blocks. outdoor gym Schooler Cooperative Games & sports Boardgames. book & TV Infancy Solitary PLAY . dollhouse Doctor & nurse kits Sandbox. swing Finger paints.Stack toys. pots Drums to bang Push & pull toys Make-believe play Toddler Parallel Rocking horse.

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First 0-4 months *Breast Feeding *Bottle Feeding Solid Foods *4-6 months Table Foods *8-12 months Nutrition Breastmilk Bottle Feeding  more nutrients  prone Sequence: to colic anti-infective properties Guidelines: STOOL: 1. 3. fruitsfood with seeds STOOL: & vegetables -no -sticky -pasty. rice cereals prevents hypersensitivity -no nuts -firm 2. meats soft -no popcorn -foul-smelling 4. egg yolks -golden-yellow -sour in odor .

Care of Neonate .

Delivery Room Care Prevent Heat Loss Check Airway Initiate Breathing Appraise Clinically *APGAR SCORE .

APGAR SCORE 0 1 Appearance Blue (Pale) Pulse Grimace Activity Respiration (-) (-) Limp. cough Full flexion Strong cry . flaccid (-) Acrocyanosis <100 Grimace Some flexion Slow irregular 2 Pink all over > 100 Cry.

Nursery Room Care
a. b. c. d. e. f. g. h. Anthropometric measurements Baby bath Vitamin K Injection Antibiotic Opthalmic Ointment Cord Care Detailed Physical Examination Vital Signs Monitoring Bonding with Mother

Genetic Disorders
(Principles of Inheritance)

Autosomal Dominant
 DOMINANT  1 parent Counselling *There is 50% chance with each pregnancy that child will have disease  Marfan Syndrome  Hereditary Spherocytosis  Huntington’s Disease  Hyperlipidemia  Neurofibromatosis  Tuberous Sclerosis  Von Willebrand’s

000 • Pathology: defective cross linking • Characterized by: ―Tallness & Thinness‖ .Marfan Syndrome (Arachnodactyly) • Autosomal Dominant USA • Defective gene : Chromosome population 15 1:10.

Features SKELETAL  Tall stature  Scoliosis  Lordosis  Dental crowding  Flexion contractures OCULAR  Ectopia lentis  Flat cornea  Severe myopia  Retinal detachment Marfan Syndrome CARDIAC  mitral valve prolapse Aortic dissection Mitral regurgitation .

Carrier  Cystic Fibrosis  Sickle Cell Anemia  Tay-Sach’s Disease Galactosemia Phenylketonuria Wilson’s Disease  Congenital Adrenal Hyperplasia (CAH) .Normal 50% .Autosomal Recessive  RECESSIVE  both parents must pass disease Counseling 25% .DISEASE 25% .

Tay-Sach’s Disease • Autosomal Recessive Features:  healthy for 2-6 mos • Common: Eastern Europe & Jewish  decreased in eye contact • most devastating lipid storage disease Pathology: Absence of hexoaminidase A  loss of vision (catabolism of  hyperreflexia ganglioside for  SEIZURE (2 years) normal cellular function)  death @ 2-4 years .

Hemophilia A&B Color Blindness  females : carrier Lesch-Neehan  males: diseased Syndrome  no male to male Duchene Muscular transmission Dystrophy  X chromosome Agammaglobulinemi a Sex-Linked Disorders .

NeuroSensory Disorders .

spina bifida occulta b.lower thoracic . spina bifida cystica .Spina Bifida (Myelodysplasia) • 2/1000 live births • multifactorial • 85% occurs in .sacral TYPES: a.lumbar .

Sac Closure . Prenatal Amniocentesis b.Spina Bifida Diagnosis a. Ultrasound 2. Post-partum 1. Myelogram Treatment a. CT Scan 3.

Provide sensory stimulation d. Prevent trauma to the sac b.Spina Bifida Nursing Care *a. Refer for rehabilitation . Provide adequate nutrition c. Emotional support e.

congenital . communicating Lateral ventricle Foramen monroe b. injury 4th ventricle 2. tumor Base of Brain 4.Hydrocephalus Choroid plexus TYPES: a. infection Luscka Magendie 3. non-communicating 3rd ventricle CAUSES: Aqueduct of Sylvius 1.

Extracranial shunts Nursing Care *a.Diagnosis a.watch out for: -infection -increase ICP .monitor neuro status c.maintain patency b. CT Scan Treatment a.

Cerebral Palsy  neuromuscular disorder that affects motor neurons  USA : 1.5-5/1000 live birth  CAUSES: a. Postnatal . Perinatal c. Prenatal b.

Cerebral Palsy Assessment -Spasticity -Tremors -Ataxia -Rigidity Associated Signs & Symptoms -mental retardation -hearing loss -defective speech -visual disturbances .

Reye’s Syndrome  acute encephalopathy with fatty liver  true pediatric emergency  unknown etiology CLINICAL STAGING I II III IV persistent vomiting. flaccidity . confusion coma. decorticate posturing deeper coma. fatigue disorientation. decerebrate posturing V seizures. absent DTR.

circulatory & hydration status b. seizure precaution . maintain fluid & electrolyte balance d.Reye’s Syndrome Management Supportive Treatment at PICU Nursing Care a. support child & family c. respiratory. assess neurologic.

Cardiovascular Disorders .

Fetal Circulation Placenta Umbilical Vein Ductus Venosus Inferior Vena Cava Right atrium Foramen Ovale Left Atrium Left Ventricle Ascending Aorta .

Fetal Circulation Blood from upper extremities Superior Vena Cava Right Atrium Right Ventricle Pulmonary Artery Ductus Arteriosus Descending Aorta .

failure to thrive b. activity intolerance e. poor feeding practices c.000 babies/year • Cause : multifactorial • Assessment a. pallor . frequent respiratory infections d.Congenital Heart Disease • USA : 40.

CYANOTIC right to left shunt  Tetralogy of Fallot  Transposition of Great Arteries  Truncus Arteriosus Types of CHD ACYANOTIC  left to right shunt  Ventricular Septal Defect  Atrial Septal Defect  Patent Ductus Arteriosus  Coarctation of Aorta .

Small (<0. Surgical Repair for large defects b. Large (>1 cm2) Treatment a.Ventricular Septal Defect Most common CHD (30-40%) Assessment a.5 cm2) b. Endocarditis prophylaxis .

Ventricular Septal Defect (VSD) . Pulmonary stenosis b. Right Ventricular Hypertrophy (RVH) c.Tetralogy of Fallot  most common ACYANOTIC 4 Components (PROV) a. Overriding Aorta d.

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exertional dyspnea Complication: Hypercyanotic Spells Treatment: a. Endocarditis Prophylaxis . Palliative : Blalock Tausig Procedure b. squatting position d. harsh holocystolic murmur c.Assessment Tetralogy of Fallot a. cyanosis b. Definitive : Surgical Repair c.

Polyarthritis c.Rheumatic Fever  AUTOIMMUNE Assessment : Jones Criteria MAJOR (SPECC) a. Carditis e. Chorea . SQ Nodules b. Erythema Marginatum d.

prolonged PR interval in ECG Diagnosis: 2 Major 1 Major + 2 minor . CR-P c. fever b. increase ESR. recent streptococcal infection d.Rheumatic Fever Minor Criteria: a. (+) ASO e.

safe environment .Nursing Care  Polyarthritis .Aspirin Chorea .comfort measures .small frequent meals Carditis .decrease stimulation .prophylactic treatment .

Respiratory Disorders .

peri-tonsillar abscess c.Tonsillitis  10-20% caused by GABS Nursing Care: a. medications as ordered b. comfort measures for enlarged tonsils Surgical Management: TONSILLECTOMY a. recurrent tonsillitis b. airway obstruction . diet: liquid to soft diet c.

age appropriate pre-op preparation Post-Op a. most common operation performed Nursing Care: a. apply ice collar d. position: side lying or abdomen b. non-red c. non-citrus. watch out for hemorrhage Tonsillectomy . cool. diet: clear. avoid trauma to the site e.

increase fluid intake c. superimposed bacterial infection . steamy bathroom then cool mist vaporizer b. bed rest Hospitalization: a. dehydrated b.LaryngoTracheoBronchitis  virus : Parainfluenza  common : <5 years old Nursing Care: a.

wants to lean forward . respiratory distress e. drooling of saliva d. Influenza type B  common: 3-7 years Assessment: a.Epiglottitis  H. fever c. inspiratory stridor b.

Epiglottitis Nursing Care  position of comfort  no direct examination  prepare tracheostomy or emergency set  give medications  mist tent with O2  reassure parents .

500  Autosomal Recessive  most common life threatening trait Four Fundamental Physiologic Defects a. paucity of water in mucus secretions c. failure to clear mucus secretions b.Cystic Fibrosis  USA : 1:2. chronic infection of respiratory tract d. maldigestion .

liver e. fecal fat : elevated c. hyponatremia Cystic Fibrosis . reproductive system d.Affected Organs a. sweat glands Diagnosis a. respiratory tract (99. Pilocarpine Iontophoresis Sweat Test b.9%) b. pancreas (85%) c.

Pancreatic Involvement -pancreatic enzymes with meals -diet: high calorie & protein. Electrolyte Involvement -add salt to all meals Cystic Fibrosis . low fat c. Respiratory Involvement -aerosolized treatment -percussion & postural drainage -deep breathing exercises b.Nursing Care a.

GastroIntestinal Disorders .

Cleft Lip/Palate  USA : 1:1000 births .

diet : liquid soft . feed in high fowler’s a. use large-hole nipple b.Treatment CHEILOPLASTY PALATOPLASTY PreOperative PreOperative a. prepare parents b. maintain patent airway b. teach on feeding or rubber-tipped syringe methods c. burp frequently PostOperative PostOperative a. don’t strain suture line injury to suture line c. prevent crying c. position: side lying a. prevent trauma or b.

Altered Connections .

position: HOB elevated 30-45’ b. maintain gastrostomy for feeding .Treatment : End to End Anastomosis Nursing Care Pre-Operative a. suction secretions c. NPO post midnight b. suction secretions PRN Post-Operative a.

olive shape mass under right rib cage b. dehydration . visible peristalsis d. vomiting c. failure to thrive e.Pyloric Stenosis *unknown cause Assessment a.

maintain IVF d. Pyloromyotomy Pyloric Stenosis . prevent vomiting b. aspiration precautions c. monitor for fluid & electrolyte balance Surgical Management Fredet-Ramstedt Procedure aka.Nursing Care a.

abdominal pain . “currant-jelly” stool c. vomiting b.Intussuception  common : 6 months & older  associated with cystic fibrosis & celiac disease Assessment a.

maintain fluid & electrolyte balance b. prevent vomiting c.Intussuception Treatment: Medical : Hydrostatic Reduction Surgical : Resection with End to End Anastomosis Nursing Care a. monitor for peritonitis .

delayed passage of meconium b. ribbon-like stools d. vomiting (fecaloid) e. diarrhea .Hirschsprung’s Disease  absence of ganglion cells in large colon Assessment a.distended abdomen c.

diet : low-residue c. digital rectal evacuation of feces b. stool softeners e.Hirschsprung’s Disease Nursing Care a. isotonic enema Surgical Management: Abdomino-Perineal Pull . do not treat loose stools d.

fat-soluble vitamins in water form c.• ―Malabsorption Syndrome‖ • common : Caucasians Nursing Care a. diet : Gluten-Free b. avoid infection Health Teaching *Stress importance of adhering to diet Celiac Disease .

GenitoUrinary Disorders .

proper hygiene e. avoid tub baths or bubble baths Urinary Tract Infection (UTI) . most common GUT problem in children  common : schooler girls Escherichia Coli Nursing Care a. acidify urine d. increase oral fluid intake c. administer medications b.

Undescended Testis  aka ―Cryptorchidism”  common : unilateral premature infants  75% descend spontaneously in 1 year Treatment : Orchipexy .

hypoprotenemia (<2. protenuria (>2 gm/day) b. hyperlipidemia (>200 mg/dl) d. edema e.5 g/dl) c. anorexia. vomiting .Nephrotic Syndrome  caused by a lot of factors problem : increase glomerular basement membrane permeability Assessment a.

corticosteroids b. avoid IM injections d.Nephrotic Syndrome Treatment a. diet : high protein. low sodium c. diuretics c. provide bed rest b. fluids maintained at 20 cc/kg/day e. protect from known sources of infection . antibiotics Nursing Care a.

hematuria (100%) b. resolves in 14 days  caused by beta hemolytic streptococcus Assessment a. lethargy . edema (98%) c. anorexia. edema e. hypertension (82%) d.Acute Glomerulonephritis  immune-complex disease  self-limiting.

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Hematologic Disorders

Iron Deficiency Anemia
 most common anemia in children  vulnerable : children on cow’s milk Nursing Care a. diet : iron rich foods b. add supplemental iron to formula c. administer iron -oral -intramuscular (IM)

Sickle Cell Anemia
 USA : most common inherited disorder  African-American Assessment a.asymptomatic initially b. colic (infancy) c. splenomegaly d. frequent infections e. leg ulcers f. pain

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Nursing Care  well hydrated & oxygenated patient  administer meds  bed rest  no tight clothing  decrease stress  avoid activities that interfere with oxygenation .

000/mm3  muco-cutaneous bleeding Nursing Care a. no contact sports . maintain safe environment e.Idiopathic Thrombocytopenic Purpura  cause : unknown  platelet count : <100. prevent bruising c. avoid intramuscular injections d. control bleeding b.

factor 8 deficient (75%) B . hematoma .factor 11 deficient Assessment a. prolonged bleeding after minor injury b.factor 9 deficient C .Hemophilia  most common congenital coagulation d/o  sex-linked disorder TYPES A . hemarthrosis (hallmark) c.

Prevent trauma e. Control acute bleeding episodes b. Provide care for hemarthrosis c. Genetic counselling . Administer cryoprecipitate d.Nursing Care a.

MusculoSkeletal Disorders .

genetic b. USA 1:1000 livebirth  most common congenital malformation Causes a. laxity of ligaments Congenital Hip Dislocation . fetal position c.

additional skin folds d. apparent shortening of affected leg c. limitation on abduction b.Assessment a. Ortolani’s click Management Goal: Enlarge & deepen the socket by pressure .

cardiopulmonary failure . back pain d. decrease in height e.Scoliosis  common : adolescent girls  75% are idiopathic Assessment a. uneven hips & shoulders b. uneven bra strap marks c.

Spinal Fusion with Insertion of rod . exercise & proper body mechanics Moderate Scoliosis (20-40 degrees) Goal : Prevent worsening of curve a. observation b.Treatment Mild Scoliosis (<20 degrees) a. Milwakee brace b. Boston jacket Severe Scoliosis (>40 degrees) a.

Boston jacket Severe Scoliosis (>40 degrees) a. exercise & proper body mechanics Moderate Scoliosis (20-40 degrees) Goal : Prevent worsening of curve a.Treatment Mild Scoliosis (<20 degrees) a. observation b. Spinal Fusion with Insertion of rod . Milwakee brace b.

Pediatric poisoning .

Which is Candy? .

Sweet Tarts vs. Ecstacy .

• Children reside lower to the ground. This puts them at higher risk for ingesting compounds heavier than air. • Inability to avoid hazards – they do not read warning labels or ―Do Not Enter‖ signs. Often adults will NOT have the same exposure. .Physiologic Differences • Increased body surface area can lead to thermoregulatory issues.

and these exposures are defined as unintentional poisonings. • Poison exposures can occur by accident without intent. poison exposures are the result of a conscious. . A poisoning is a poison exposure that results in bodily harm.Definitions • A poison exposure is the ingestion of or contact with a substance that can produce toxic effects. In some situations. willful decision. these cases are defined as intentional poisonings.

Poisoning agents

Poisoning agents

Pediatric Poisoning
 susceptible : toddlers & adolescents  modes of exposure - ingestion (majority) - ocular - skin TYPES OF POISONING a. Acute b. Chronic

Seizure precautions d. syrup of ipecac or gastric lavage is performed b. activated charcoal to decerease absorption of salicylate c. Aspirin  Analgesic cold medicines Toxic dose : 150-200 mg/kg Acute: severe toxicity occurs 300-500 mg/kg Peak Effect : 2-4 hours Salicylate Poisoning Nursing Care: a. Emotional support to child & family .

Assist in emergency management b. analgesics  anti-pyretic Toxic dose : 150-200 mg/kg Peak effects : 30 minutes-4 hours Major risk : SEVERE HEPATIC DAMAGE Nursing Care a. Administer Antidote *ACETYLCYSTEINE (Mucomyst) Dilute in juice or soda because of its offensive odor Acetaminophen Poisoning .

Eliminate conditions leading to lead ingestion . Administer chelating agents *CALCIUM EDTA & DIMERCAPROL b.toothpaste tubes Health Hazard : > 15 ug/dl Symptoms Appear : >70 ug/dl Nursing Care a. Provide nutritional counseling c.automobile emisions -pencils .Lead Poisoning -lead-based paints .newsprints -ceramics .

Can be repeated every 4-6 hours at ½ the dose. iron). ileus/perforation risk . corrosives. mercury. fruit syrup. gastric lavage that follows or preceded and follows may be more effective than charcoal alone. inorganic ions. alcohols. – Efficacy decreases over time. cola.Management Considerations • Decontamination – Priority after stabilization – Activated Charcoal is preferred method. and may be indicated even in the patient with equivocal exposure history • Adsorption of toxins to prevent their absorption • Dependant on toxin – Heavy metals (lead. hydrocarbons. caustics. and multiple doses can help interrupt enterohepatic circulation. hydrocarbons. arsenic. boric acid. and essential oils are generally not well adsorbed by charcoal • Dependant on surface area of the charcoal preparation – Use 1g/kg prepared in slurry with a cathartic and chocolate milk. – Contraindications in child with depressed levels of consciousness and non-secure airway.

foreign body. trauma to anatomic structure. but no longer the routine – Contraindicated if prior vomiting. or a highly toxic substance is ingested that is usually not well bound to charcoal gastric lavage may be attempted. . caustics.Management Considerations • Decontamination – Priority after stabilization – If ingestion has occurred within 1 hour. unprotected airway. at risk for hemorrhage – Risk includes aspiration. hydrocarbon.

Management Considerations • Whole bowel irrigation may be necessary in the ingestion of a sustained release product or toxin – Large volumes of balanced electrolyte solution used to decontaminate the GI tract – Used in fewer than 1 percent. unprotected airway . perforation. GI bleed. large ingestions of substances that are poorly bound by activated charcoal – Contraindicated in bowel obstruction. illicit drug packets. not well studied in pediatrics – Can be useful in ingestion of enteric coated pills.

– (No longer routinely recommended to be used because of its questionable effect on outcome). conscious child over 6 mo who has ingested a potentially toxic amount of poison. . ingestion of a non-toxic substance. – Can be used only in the alert. – No longer recommended for routine home use. – Contraindicated in children less than 6mo. altered mental status or airway compromise.Management Considerations • Ipecac syrup induces vomiting by stimulating central emetic centers. corrosive ingestion. hydrocarbon ingestion. GI bleed or coagulopathy.

pain. infection – Water is absolutely contraindicated with reactive metals.Management Considerations • Ocular exposure requires copious irrigation with saline using a Morgan lens.5-8 • Dermal cleansing with water or normal saline and subsequent identification: – Pay close attention to burns. use mineral oil instead – Tar can be removed safely with vaseline . measure pH and maintain at 7.

corticosteroids – Removal of offending environment • Hemodialysis and Hemoperfusion – Require anti-coagulation .Management Considerations • Inhalation injuries need fresh humidified and oxygenated air – Treatment with B-agonists.

combustibles out of reach – Dispose of partially consumed alcohol – Carbon monoxide detection system – Read labels on products carefully – Advocate for protective legislation . avoid exposure to toxic animals – Keep matches. don’t take medicine in front of kids – Child-proof latches – Avoid chemicals in the fridge. or insect traps that are accessible – Remove toxic plants.Management Considerations • Prevention Strategies/Themes-primary – Store potentially toxic substances in higher places or out of reach/sight – Store safe items within the child’s reach.

storage areas should be cool. . dry and away from living areas. • Never store food and non-food items together. In general. • Follow the directions for storage on the label.Store Products Safely • Keep all products locked up. Non-food products should be out of sight and reach of children and pets.

• Never use milk.dispose of properly. Always replace caps tightly. • Store medicine properly . soft drink or other food containers for storage. If the label is gone .liquor cabinets should be locked or have safety latches. . Store alcoholic beverages safely .• Keep products in their original containers.keep them locked up and use child-resistant containers.

vitamins.• Return products to safe storage as soon as you finish using them. especially medicines. . cigarettes and perfume in your purse. Avoid storing medicine. • Keep your purse out of reach of children and pets. • Clean out storage areas regularly. Check expiration dates and get rid of outdated products.

Ask your pharmacist how to properly dispose of unused or outdated medicines. Keep trash in covered receptacles. Read directions for disposal on the label or contact Board of Health.• Dispose of products safely. . out of the reach of children and pets.

• 1. Putting things in their mouths is one way for kids to discover the world around them. . So it’s important to teach them early on that tasting may not be the best nor the safest way for them to satisfy their curiosity. Teach children about the dangers of tasting unknown substances.

. Never store toxic substances in food and beverage containers. In a misguided effort to recycle.• 2. The most common cause of poisoning in Filipino children is accidental ingestion of kerosene. fertilizer in milk cans. A preschooler won’t be able to read the label ―gasoline‖ on a cola bottle. formaldehyde in mineral water bottles. households often put paint thinner in juice bottles. and multivitamins in candy jars. they will likely be confused if the dangerous substances are stored in food jars. Even if children are taught not to taste nonfood items.

Keep medicine out of children’s reach. Store medicines and toxic chemicals properly. or in a locked box. so it's important to store the drugs as indicated on the packaging. Also remember that the active ingredients of drugs are often sensitive to high temperatures. Some drugs become less efficacious. .• 3. in a high compartment. but there are some that become more toxic when heated.

do not use pediatric drops for older children. In particular.• 4. Do not transfer medications from one child to the other. Consult your doctor about doses. Pediatric drops are usually stronger—there are more milligrams of the drug in each unit of fluid. Giving a double or triple dose to an older child might lead to a fatal overdose. .

Remember those chemistry experiments with acids and bases? Mixing common cleaners might produce toxic gases. Don’t mix cleaning chemicals.• 5. . A cocktail of cleaning agents won’t make a more effective toilet bowl cleaner.

we often forget that these products can be toxic when ingested in large amounts by children. oils. . Know the dangers of personal care products.• 6. lotions. Some aromatic products are particularly attractive to kids. These include nail polish remover. Because we use them for our bodies. and cosmetics.

Choose the plants in your house and garden. berries. Remove all poisonous flora. or mushrooms unless under adult supervision.• 7. . Teach children not to eat wild roots.

varnish. Open windows or turn on the fan when using them. solders and flux. liquid glue. Many crafts require the use of toxic chemicals—paints and thinners. and photo developers.• 8. . Check hobby materials. Be sure their containers don’t leak.

Child Abuse .

CHILD ABUSE Emotional Neglect Physical Neglect Sexual Abuse Abuse .

severe injuries or severe bodily harm suffered by the child” Triptage of Information History Given Presenting Injuries Biomechanics . fractured bones. internal injuries.Physical Abuse Legal Definition “Physical injury includes but not limited to lacerations.

feet & anogenitals  repeated burns  symmetric or patterned burns  uniform thickness with clear borders  delay in seeking care .―RED‖ Flags PARENTAL discrepancy between history & injuries  incompatible history with development  changing or varying story  unreasonable delay in seeking care  denial of injury  hostility towards child BURNS  dorsum of hands.

> 3mm fractures . branched. symmetric .with intracrnial & visceral injury SHAKEN BABY SYNDROME *no fractures outside *baby with change in sensorium & in shocking state .complex.multiple. bilateral.repetitive at different stages .Fractures months  80% abusive in children <18 Highly suggestive of Abusive Fractures .

partial or complete transection or laceration of hymen or anus  presence of sperm presence of STD .Sexual Abuse  complete absence of hymenal tissue  recent.

Vaginalis Herpes 1 Herpes 2 (oral) Bacterial vaginosis Candidiasis Probable Probable Probable Probable Uncertain Unlikely Report Report Report Report Follow-up Follow-up . Accuminatum T.Implications of Encountered STD STD SEXUAL ABUSE ACTION Gonorrhea Syphilis Chlamydia Certain Certain Probable Report Report Report C.

Oncologic Disorders .

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