4-1.

Which of the following statements is correct, based on epidemiologic data collected

about child abuse?
a. Most child maltreatment occurs outside the home.
b. Females are equally likely as males to be perpetrators
of sexual abuse.
c. Of substantiated child abuse cases, neglect is the most common type.
d. If all types of child abuse are included, males are the most likely perpetrators of child
abuse.
e. Females are more commonly perpetrators in child abuse death cases.
4-2. A single mother brings a developmentally normal 16-month-old child to the emergency
department for an upper respiratory illness and a laceration. The child has a healing
laceration on his forehead above the left eyebrow that is open and healing and will likely
leave a scar. It is too late to stitch or glue the laceration closed. The mother states the child
sustained this laceration when he fell while running in the house 4 days ago. She states that
it was hard to stop the bleeding. When asked by the nurse when alone whether somebody
hit him, the child replies “no.”
Which of the following factors makes this injury most suspicious for child abuse?
a. The mother is single and thus is at increased risk for abusing her child.
b. The history of falling while running is not within a 16-month-old child’s developmental
abilities.
c. The mother delayed seeking care for the child soon after the injury.
d. The child’s response when asked by the nurse when alone whether somebody hit him.
e. The child appears very fearful and cries when even experienced pediatricians try to
examine him.
4-3. A 3-month-old boy is brought to the hospital with a history of falling off a couch onto a
carpeted floor. He has been having seizures, and on CT scan of the head he is noted to have
subdural hemorrhages and swelling of the brain. He has bilateral posterior rib fractures and
extensive retinal hemorrhages. In reviewing the parents’ background, which of the following
factors that are identified is not associated with an increased risk of abusing their child?
a. The mother is a teenager.
b. Both the parents are strongly religious.
c. The father has a substance abuse problem.
d. There is a history of intimate partner violence in the family.
e. The mother was maltreated as a child.
4-4. A 2-year-old boy is brought to your clinic by child protective services for a clearance
examination. The child is noted to have a bruise on the glans of his penis with some
swelling. The child can urinate. Urinalysis reveals no blood. There are no other injuries to
the child’s genitals or anus noted. The child is also noted to have multiple bruises on the
abdomen and buttocks and cheeks. Nucleic amplification tests of the urine for chlamydia
and gonorrhea, and complete blood count, PT, PTT, INR, and blood tests for HIV, syphilis,
and hepatitis B and C are also negative. This child’s findings would be best classified as
which of the following types of maltreatment?
a. Exploitation
b. Emotional abuse c. Neglect
d. Physical abuse
e. Sexual abuse
4-5. A 14-month-old child comes into your clinic for hot water burns. There are scalding
water burns on both the infant’s feet. The second-degree burns cover the feet and the
lower part of the legs. On each leg, there are straight, well-demarcated burn lines
approximately 2 cm above the ankles. The child is developmentally normal, and was born
full-term. He has no past medical history, and his immunizations are up to date. His parents
have missed 2 appointments since birth that had to be rescheduled. The father reports that
the bathtub was running with hot water as he prepared the bath for the child. He went into
another room to clean up the child’s soiled underwear. He also reports he and the child’s
mother have been trying to potty train their child. He reports when he came back into the
bathroom, the child had climbed into the bathtub, and was found crying in the water. The
father did not bring the child in for care until he noticed blistering of the burn site later in
the evening. The factor that most makes this burn suspicious for abuse is:
a. The delay in bringing in the child for care
b. The unlikely ability of the 14-month-child to climb
into the bath
c. The fact that the child was potty training and soiled his underwear
d. The history of missed appointments
e. Sharply demarcated lines of the burn
4.6 A 2-year-old child is brought in for buttock bruising noticed by a day care worker when
changing their diaper. In clinic, the child is acting developmentally normally for their age,
and they do not seem fearful or in pain.
After complete history and physical, the best workup for this patient would be which of the
following?
a. Complete blood and platelet count, prothrombin, and partial thromboplastin time
b. Skeletal survey
c. Bleeding time and a von Willebrand factor (vWF)
d. Computed tomography scan of the head and neck without contrast
e. Ophthalmology examination with dilated pupils
4-7. An accurate statement about violence exposure is that:
a. A child’s exposure to intimate partner violence (IPV)
increases the likelihood of being abused.
b. Peer violence is more likely to be chronic than sibling violence.
c. Over 95% of victims of IPV are women.
d. Teen pregnancy is a protective factor for IPV.
e. A child’s exposure to violence affects mental, but not physical, health.
4-8. You are referred a 3-month-old nonambulatory child from a day care center staff who
noticed bruising on the infant’s buttocks during a diaper change. The parents and other
caretakers deny any history of trauma. The child appears well on examination, and is
interactive and playful. Although you are concerned about abusive injuries given the
location of the bruising, you create a differential diagnosis.
Your differential diagnosis would most likely not include which of the following?
a. Henoch-Schonlein purpura
b. Idiopathic thrombocytopenic purpura
c. Acute lymphocytic leukemia
d. Dermal melanocytosis
e. Vitamin A deficiency
4-9. You see a 3-year-old girl brought in for possible sexual abuse. The mother says the girl
has made statements about being touched by her father’s brother, who lives in the house
with the family. The girl is well appearing. The mother denies any bleeding, itching, dysuria,
and frequency. The girl has otherwise been acting her normal self per the mother’s report.
You perform a physical examination, including a genital examination. Laboratory testing is
done for sexually transmitted infections, including HIV, syphilis, gonorrhea, and chlamydia.
The finding most indicative of sexual abuse in this case would be which of the following?
a. A confirmed genital human papilloma virus (HPV) wart on the child’s labia majora
b. A crescentic hymen through which the vaginal mucosa can be seen
c. A 1-cm circular bruise on the inner thigh
d. A confirmed case of Neisseria gonorrhoeae
vulvovaginitis
e. The child’s statement that the uncle touched her “down there
4-10. A 30-month-old developmentally normal boy presents to your clinic with a chief
complaint of not walking and inability to bear weight on his right leg. The parents noted this
yesterday, and are bringing the child in today because the apparent pain with weight
bearing has not resolved. The parents give no history of falls or trauma. The child has not
had any other complaints. On contacting their primary pediatrician, you learn that there
have been no previous fractures or other significant past medical history concerning for
abuse. On physical examination of the entire body, there is
no evidence of bruising or other concerning findings, and neurologic and mental status
examinations are normal. You are not able to obtain an adequate retinal examination. In
examining the right leg, there are no obvious bruises. There is full range of motion, with a
question of some point tenderness over the distal tibial plateau on the right side. The child
is reluctant to walk, and cries when prompted to do so, with a noticeable limp on the right
leg. There are no other significant physical examination findings. A radiograph reveals a
nondisplaced spiral fracture of the distal right tibia. The next best diagnostic procedure for
this child is:
a. Check levels of calcium, phosphorus, alkaline phosphatase, and 25-hydroxyvitamin D.
b. No further workup is indicated given the information at this point.
c. Obtain a CT scan of the head looking for subdural hemorrhages.
d. Get an ophthalmology consult to look for retinal hemorrhages.
e. Perform a full skeletal survey, looking for unsymptomatic abusive fractures.
4-11. A 6-month-old developmentally normal infant is referred to the ED for radiographs.
The baby presented at the primary pediatrician’s office with a swollen left thigh. There was
pain on examination when the left lower extremity was moved. There are no bruises, and
the leg is distally neurovascularly intact. There are no other concerning signs on the baby’s
body on physical examination, and the baby appears to be neurologically normal.
The baby was at home with a baby sitter, and mother noted the baby being fussy that
evening after the sitter went home. The mother decided to bring the infant
in the next day when the fussiness continued, and she noticed the left thigh swelling. The
radiograph shows an oblique/spiral nondisplaced fracture through the left
femoral diaphysis, with associated soft tissue swelling noted. The baby sitter reports no
history of falls or trauma, and the mother reports none either.
Which of the following is the most accurate statement concerning the likelihood of abuse
associated with this fracture?
a. Oblique/spiral fractures without a trauma history in 6-month-old children are concerning
for abuse.
b. Over 50% of fractures in children less than 3 years of age are from abuse.
c. Undiagnosed osteogenesis imperfecta accounts for 1% of unexplained fractures in infants.
d. The mother should have noticed the fracture right away and brought in her child earlier.
e. A skeletal survey is not indicated as the child is asymptomatic in other parts of the body.
4-12. A 3-month-old baby is admitted for suspicion of abusive head trauma. The caretaker
gives a history of the baby falling off a couch. The baby cried immediately, but then became
lethargic and unresponsive. The baby was rushed to a nearby hospital, where they were
stabilized. A CT scan of the head shows a thin layer subdural hemorrhage over the right
hemisphere. A chest radiograph reveals a number of posterior rib fractures that appear
acute. On ophthalmology examination, retinal hemorrhages are noted.
The most accurate statement regarding retinal hemorrhages would be which of the
following?
a. Retinal hemorrhages can be from birth, and these usually persist for months.
b. Only 1 type of retinal hemorrhage is associated with abusive head trauma.
c. Retinal hemorrhages usually cause irreversible blindness for the child.
d. Retinal hemorrhages only occur near the macula due to presence of retinal blood vessels.
e. Retinal hemorrhages can result from certain types of infections.
4-13. A 14-month-old developmentally normal boy is brought into the hospital with
concerns for abuse by his mother. The mother states she has noticed marks on the child
over the past several days when picking him up from day care. At first she thought these
were normal bruises from the child playing, but she has been more concerned recently
given the number and type. The child also seems to be crying and scared when dropped off
at day care, which is a new phenomenon. On physical examination the child is noted to have
a number of cutaneous findings.
Which of the following findings would be most concerning for abusive injuries?
a. Bruises on the shins
b. Red and green color bruises indicating different ages
c. Bruises on the forearms
d. Bruises on the lower back
e. A bruise on the right forehead, just above the eye
4-14. A 17-month-old boy is admitted for suspicions of abuse. The boy was noted to have
multiple bruises on the buttocks, upper arms, trunk, and ears. On physical examination, the
child is interactive and otherwise well appearing. A complete blood count revealed normal
platelets, and coagulation factors are normal as well.
A skeletal survey is done to evaluate for possible fractures.
Which of the following statements about a skeletal survey is most accurate?
a. Is a series of x-rays of the long bones, chest, and spine, but not the skull
b. Usually shows evidence of any fractures within the last year
c. Should be obtained for every child with suspicious fractures less than 7 years old
d. Is sometimes repeated in 2 weeks to look for additional fractures not initially observed
e. Can rule out abuse if it is found to be negative
4-15. A 15-year-old girl is brought in for possible sexual assault by an adult man. She met
the man on the Internet, and eventually agreed to go to his apartment to meet him. She
became intoxicated while drinking alcohol with him, and eventually “blacked out.” She does
not recall anything else, except waking up in a park, where police officers found her and
brought her into the hospital. Her blood alcohol level was 0.02 on arrival at the ER.
Examination was otherwise unremarkable, except for some abrasions over her knees and
right shoulder, and several 1 to 2 cm circular bruises on her left arm. The girl complains of
pain in the genital area. A sexual assault examination is performed. The examination is
found to be normal. The girl tests positive for chlamydia on the urine
test and culture performed on the day of the possible sexual assault.
Which of the following statements is correct?
a. The normal genital examination does not rule out a sexual assault.
b. The positive chlamydia test is proof that the girl was raped.
c. The bruises suggest that the girl was assaulted.
d. The girl would not benefit from postexposure
prophylaxis.
e. The blood alcohol level suggests the girl was raped.
4-16. A previously full-term 4-month-old girl presents to the ED with an apparent life-
threatening event (ALTE). The baby was sleeping with mother and was noted to turn blue
and stop breathing for over 1 minute. Mother reports starting CPR before the baby
responded. The baby was brought in by ambulance with the mother. EMTs reported a well-
appearing baby when they got to the house. In the ED, physical examination was normal,
and a history and review of symptoms was unremarkable. The baby was observed in the
hospital over the next several days, and had 6 more “events” of stopping breathing over the
next several days, and continues to be observed in the hospital. Workup for infections
including blood and urine cultures, RSV, and pertussis was negative. An EKG was normal, as
was a pH probe, and the events do not seem to be associated with feeding. There is no
reported seizure activity, and an EEG is normal. Head CT scan is unremarkable.
Before further workup is initiated, one of the members of your team points out that the
only time the events occur are when mother is with the baby alone in her room. You
suspect medical child abuse (Munchausen syndrome by proxy).
Which statement about medical child abuse is most accurate?
a. Medical child abuse rarely is fatal.
b. Medical child abuse is usually straightforward to
diagnose.
c. ALTEs are most likely to be from medical child abuse.
d. Perpetrators of medical child abuse are often nonparent caretakers.
e. Fever is a common presentation of medical child abuse.
4-17. A recently turned 3-year-old boy is being evaluated for poor weight gain. The child has
crossed 2 percentile lines for weight in the last 6 months, going from
50th percentile at 32 lb to between 5th and 10th percentiles at 27 lb. Height and head
circumference have not crossed percentile lines. There are multiple family stressors,
including a recent divorce, and the primary caregiver has been struggling with finances and
employment. The child also has had multiple URIs over the past several months, though has
never been hospitalized. On physical examination, the child seems thin and is active and
cooperative, although he has a flat affect. He has multiple bruises over his left and right
shins, has 2 café au lait spots on his trunk, and is noted to have a faint 1/6 systolic ejection
murmur at the left sternal border, which mother says was noted in previous visits since the
age of 18 months, and she was told it was a “Still’s murmur.” His examination is otherwise
unremarkable. You are concerned about neglect, but realize you must also evaluate the
child for other possible causes of poor weight gain.
The most appropriate next step is which of the following?
a. Obtain an EKG and 4 limb blood pressures. b. Get baseline electrolytes prior to feeding.
c. Obtain a skeletal survey.
d. Obtain a careful feeding history.
e. Obtain a head CT scan.
4-18. A 5-month-old baby fell onto a hard wood floor from a 4 ft high changing table when
mother’s boyfriend was reaching to get the diapers. The boyfriend brings the child
immediately into the emergency department as the mother is working. The baby is noted to
have slight superficial soft tissue swelling with erythema noted over the right parietal area.
Otherwise, the child’s examination is normal. The ED doctor decides to get a skeletal survey,
because they “don’t have a good feeling about the boyfriend.” Of these possible acute
fractures found on the survey, the most specific for abuse is:
a. A linear skull fracture of the right parietal bone
b. A classic metaphyseal lesion of the right distal radius
c. An oblique fracture of the right femoral diaphysis
d. A buckle fracture of the left distal tibial metaphysis
e. A mid-diaphyseal transverse fracture of the right clavicle
4-19. A 3-month-old baby presents with apnea and unresponsiveness at home under the
care of a babysitter. The sitter says they went to get a bottle
for the baby, and when they returned, the baby was
blue and not breathing. CPR was performed by the sitter while waiting for EMTs to arrive,
and the baby responded and became alert. On arrival by EMTs,
the baby appeared alert and responsive, but began to have seizure activity in the ambulance
on the way to the hospital. In the ER, the baby was stabilized, and apparent seizures
resolved with medication. On chest x-ray, several acute posterior rib fractures were noted.
A head CT scan showed a right subdural hemorrhage layering over the hemisphere and into
the convexity. Otherwise the baby appeared to have an unremarkable physical examination,
with no bruising or other signs of head trauma. The next step that would be most helpful in
supporting the diagnosis of abusive head trauma would be to obtain which of the following?
a. Liver function tests
b. Coagulation studies and a complete blood count
c. A dilated retinal examination by ophthalmology
d. Serum Ca2+, PO −, and alkaline phosphatase 4
e. Serum amino acids
4-20. A 2-year-old girl is brought in when her divorced mother gets concerned after picking
her up from a weekend visit with father. The mother noted blood in the girl’s underwear,
and called the father to ask if he had noticed this as well. The father says the girl fell and
banged her perineal area while straddling a toy horse while playing in the house. She
reportedly cried when this occurred, but settled down and consoled easily. The father
reports he did not notice any bleeding, and did not think anything more of it, as the girl
continued to play without problems. On genital examination of the girl, the most concerning
finding for sexual abuse would be which of the following?
a. Bruise and laceration on the labia majora
b. Urine test positive for chlamydia
c. Prolapsed urethra with bleeding
d. Thinning of the skin with subepidermal hemorrhages of the vulva
e. Perianal group A streptococcal infection with bleeding
Key
1. C
2. C
3. B
4. D
5. E
6. A
7. A
8. E
9. D
10. B
11. A
12. E
13. D
14. D
15. A
16. E
17. D
18. B
19. C
20. B