Case history
Case history #1
A 6-year-old boy is noticed by his teacher to have a black eye. When asked how he sustained the injury, the child states that his stepfather punched him. He is referred to social services and brought to the pediatrician for further assessment. On examination he has a bruise to the outer aspect of his left orbit. On careful inspection, there are 2 linear bruises to the left cheek extending toward the ear, a bruise to the anterior and posterior aspect of the right pinna, and 4 small bruises to the outer aspect of the upper arm. On close questioning, the boy states that his stepfather grabbed him by the arm and slapped him on the face after he had disturbed him when he was watching television. The boy also states that there are lots of arguments in the home, that his stepfather is frightening and has hit his mother, and that if he is naughty, his stepfather will grab his ear and twist it until it hurts.
Case history #2
A 5-month-old infant is brought to the emergency room by ambulance. His mother states that he has not been feeding and has been irritable for the past 24 hours. She states that he vomited any food he was given and subsequently went "blue" and appeared to stop breathing, prompting her to call an ambulance. In the emergency room, the infant appears lethargic but responsive. Examination is unremarkable with the exception of a small bruise to the right cheek and a torn frenum (or frenulum). The mother is anxious about the infant. She is 19 years old and had a previous infant who died of SIDS. She had this infant with her second partner who has recently left her. The patient is admitted to the pediatric intensive care unit for observation and investigation. A modified Glasgow coma scale of 8 is recorded and the patient has a generalized seizure. CBC, platelets, a clotting screen, a septic screen, and the biochemical profile are normal. Bilateral extensive retinal hemorrhages are noted on indirect ophthalmology. The skeletal survey shows healing posterior rib fractures on the left side to ribs 7 to 10. A CT brain scan shows multiple small subdural hemorrhages over the convexity and in the interhemispheric fissure, with diffuse hypoxic ischemic injury. A diagnosis of abusive head trauma seems most likely and a referral is made to police and social services.
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