Child Abuse

Overview

Definition

Child abuse refers to an act or failure to act that results in actual or potential harm to a minor’s health, development, or dignity by the parent or caregiver responsible for the child’s welfare. In the majority of the United States, a minor is defined as a child below 18 years of age, unless emancipated by law.

Classification

There are 4 main types of child abuse:

• Neglect:
  • Inability to meet a child’s physical, medical, or educational requirements
  • Most common type of child abuse
• Physical (battered child syndrome):
  • Intentional injury causing severe pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
    • Impairs physical functioning 
    • May leave a physical mark
  • Examples: burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns, beating, shaking, biting
  • Shaken baby syndrome:
    • Traumatic brain injury Traumatic brain injury A form of acquired brain injury which occurs when a sudden trauma causes damage to the brain. Le Fort Fractures secondary to shearing forces Shearing forces Vascular Resistance, Flow, and Mean Arterial Pressure when an infant is shaken
    • Results in subdural hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception or diffuse axonal injury Diffuse axonal injury A relatively common sequela of blunt head injury, characterized by a global disruption of axons throughout the brain. Associated clinical features may include neurobehavioral manifestations; persistent vegetative state; dementia; and other disorders. Head Trauma
  • Medical:
    • Also known as factitious disorder by proxy
    • A caregiver falsely presents a child for medical attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment by fabricating a history or directly causing a child’s illness by exposing them to a toxin, medication, or infectious agent.
• Sexual:
  • Involvement of a child (< 16 in many states) in sexual activities that they can’t comprehend or consent to
  • Includes sexual activity, fondling, and contact of anal, genital, or oral regions
• Emotional: 
  • An act that would terrorize a child resulting in negative affect and future psychological illness
  • Includes verbal abuse, humiliation, threats of violence, rejection
  • Least reported because difficult to document

Epidemiology

• The WHO estimates (2014):
  • 23% of children worldwide report being physically abused.
  • 18% of girls and 8% of boys worldwide experience sexual abuse Sexual Abuse Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. Sexual Abuse.
  • Infanticide: 2 times greater in low-income compared to high-income countries
• Greater incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency in lower socioeconomic groups, but affects all races, ethnicities, and socioeconomic groups
• Neglect: the most common form of abuse
• Physical:
  • Usually carried out by primary caregiver
  • Greatest cause of mortality Mortality All deaths reported in a given population. Measures of Health Status: 70% of victims are < 3 years old.
  • Shaken baby syndrome carries significant morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status. 
• Sexual:
  • Peaks in girls aged 9–12
  • Perpetrator usually known to the victim
• Emotional:
  • 80% of victims develop a psychiatric illness in adulthood.
  • Rarely reported in childhood 

Risk factors

• Caregiver factors:
  • History of abuse during childhood
  • Substance use disorder
  • Mental illness
  • Domestic violence in the parental relationship
  • Sudden major life crisis (e.g., loss of job or financial security, loss of home, loss of spouse)
  • Emotional and social isolation
• Victim factors:
  • Younger than 3 years old
  • Separated from the mother at birth (impaired bonding)
  • Has a disability Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits. ABCDE Assessment, congenital Congenital Chorioretinitis abnormality, or is a colicky infant
  • Child in foster care
  • Perceived as defiant or oppositional
  • Emotional problems
  • ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder
• Societal factors:
  • Poverty
  • Inability to afford good, high-quality childcare products and services
  • Lack of government support for social welfare programs, healthcare
  • Dangerous neighborhoods
  • Lack of recreational facilities and community activity for children

Clinical Presentation

Failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive is the most common presentation of child abuse. Frequent emergency department visits or a delay in presentation with injuries inconsistent with history are red flags. The following features in history and physical examination increase the likelihood ratio of abuse:

Physical abuse

History:

• Changing or inconsistent events leading to injury, with conflicting accounts by caregivers
• Recurrent “accidents” or injuries and hospitalizations
• Delay in seeking or providing medical care Medical care Conflict of Interest
• Incompatible injury with milestones (e.g., bruising anywhere on a child not crawling or walking)

Physical examination:

• Observation of child–caregiver interaction demonstrating lack of eye contact and apathy Apathy Lack of emotion or emotional expression; a disorder of motivation that persists over time. Wernicke Encephalopathy and Korsakoff Syndrome
• Old and recent, extensive bruises:
  • In unexposed or unusual areas (e.g., buttocks, genitalia, flexor surfaces, ears)
  • Patterned, usually in the shape of an object (e.g., hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy, knuckles, belts, cords, footwear)
• The following fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures sites are highly suggestive of abuse:
  • Posterior aspect of ribs Ribs A set of twelve curved bones which connect to the vertebral column posteriorly, and terminate anteriorly as costal cartilage. Together, they form a protective cage around the internal thoracic organs. Chest Wall: Anatomy
  • Scapula
  • Spinous processes
  • Sternum Sternum A long, narrow, and flat bone commonly known as breastbone occurring in the midsection of the anterior thoracic segment or chest region, which stabilizes the rib cage and serves as the point of origin for several muscles that move the arms, head, and neck. Chest Wall: Anatomy
• Bite marks (1 or 2 opposing arches)
• Burn marks:
  • Shape of the inflicting object (e.g., steam iron Iron A metallic element with atomic symbol fe, atomic number 26, and atomic weight 55. 85. It is an essential constituent of hemoglobins; cytochromes; and iron-binding proteins. It plays a role in cellular redox reactions and in the transport of oxygen. Trace Elements, curling iron Iron A metallic element with atomic symbol fe, atomic number 26, and atomic weight 55. 85. It is an essential constituent of hemoglobins; cytochromes; and iron-binding proteins. It plays a role in cellular redox reactions and in the transport of oxygen. Trace Elements, hot plate, cigarette burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns (round marks))
  • Symmetrical Symmetrical Dermatologic Examination pattern with equal burn depth
  • Due to immersion in hot liquids (sparing creases) with clear demarcation
• Abdominal pain Abdominal Pain Acute Abdomen
• Oral lesions (e.g., torn frenulum, bruises, fractured dental pieces)

Shaken baby syndrome:

• Retinal hemorrhage
• Lethargic 
• Tense fontanelle Fontanelle Any of six membrane-covered openings between the cranial sutures in the incompletely ossified skull of the fetus or newborn infant. The fontanelles normally close sometime after birth. Skull: Anatomy
• Seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures

Sexual abuse Sexual Abuse Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. Sexual Abuse

History:

• The child’s statement of events is the most important feature. 
• Knowledge of explicit sexual behavior
• Sexual behavior inappropriate for age, such as undressing or touching others’ genitals
• Recurrent urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
• Presence of sexually transmitted disease Sexually Transmitted Disease Sexually transmitted diseases (STDs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Sexually Transmitted Infections (STIs)

Physical examination (always done with a chaperone):

• The majority (96%) of cases have a normal anogenital examination.
• Examination has to be done within 24–72 hours of the event (specimen collection).
• Fissuring or tears at the corner of the mouth
• Gingival and palatal contusions
• Contusions, erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion, tears, abrasions Abrasions Corneal Abrasions, Erosion, and Ulcers, or lacerations of genitals and/or anal sphincter
• Vaginal discharge may be:
  • Seminal secretion Secretion Coagulation Studies
  • Indicative of a sexually transmitted infection Sexually Transmitted Infection Sexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Sexually Transmitted Infections (STIs)
• Condylomata acuminata Condylomata Acuminata Condylomata acuminata are a clinical manifestation of genital HPV infection. Condylomata acuminata are described as raised, pearly, flesh-colored, papular, cauliflower-like lesions seen in the anogenital region that may cause itching, pain, or bleeding. Condylomata Acuminata (Genital Warts) ( CA CA Condylomata acuminata are a clinical manifestation of genital HPV infection. Condylomata acuminata are described as raised, pearly, flesh-colored, papular, cauliflower-like lesions seen in the anogenital region that may cause itching, pain, or bleeding. Condylomata Acuminata (Genital Warts)) ( HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) infection)

Emotional abuse

History:

• Poor school performance
• Aggressive, defiant behavior Defiant behavior Oppositional Defiant Disorder
• Frequent physical complaints

Physical examination:

• Detached from primary caregiver
• Shows signs of low self-esteem, anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder, or depression

Neglect

History:

• The caregiver is unaware of medical history or lack of follow-up.
• The child is frequently placed in the care of adults with no blood relation.

Physical examination:

• Child unkempt
• Failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive
• Dental caries
• Dehydrated and malnourished
• Extensive diaper rash Rash Rocky Mountain Spotted Fever
• Uncleaned wounds

Mnemonics

Red flags that specify a nonaccidental trauma can be best remembered by the mnemonics TEN-4 and FACES P:

• Bruising: on Torso, Ears, Neck in children aged 4 or younger and any bruising on an infant < 4 months old
• The Frenulum, Auricular area, Cheeks, Eyes, Sclera, and Patterned bruising must be examined in cases of suspected abuse.

Diagnosis

Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship must have a high index of suspicion in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with risk factors and red flags as determined from the history and physical examination. To confirm suspicion, a thorough physical examination, including ophthalmological and neurological exam, must be done.

To gather as much information as possible, the physician must:

• Have a non-judgmental approach
• Obtain an organized sequence of events
• Allow the child to recall on their own to avoid implantation Implantation Endometrial implantation of embryo, mammalian at the blastocyst stage. Fertilization and First Week of ideas and revictimization
• Lead with open-ended questions that give the child the freedom to retell events as a story at their own pace

Investigation includes:

• A skeletal survey:
  • 21 dedicated views →  anteroposterior (AP) and lateral aspects of the skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy; lateral spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy; AP, right posterior oblique, left posterior oblique of chest, AP pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy; AP of each femur; AP of each leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy; AP of each humerus Humerus Bone in humans and primates extending from the shoulder joint to the elbow joint. Arm: Anatomy; AP of each forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy; posterior and anterior views of each hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy; AP (dorsoventral) of each foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy
  • Fractures at multiple sites and multiple stages of healing are suggestive of physical abuse.
• Noncontrast CT scan of the head → intracranial /subdural hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception (shaken baby syndrome)
• Coagulation studies Coagulation studies Coagulation studies are a group of hematologic laboratory studies that reflect the function of blood vessels, platelets, and coagulation factors, which all interact with one another to achieve hemostasis. Coagulation studies are usually ordered to evaluate patients with bleeding or hypercoagulation disorders. Coagulation Studies to rule out a bleeding disorder for extensive bruising
• In cases of sexual abuse Sexual Abuse Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. Sexual Abuse:
  • Urinalysis Urinalysis Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically. Urinary Tract Infections (UTIs) in Children
  • Beta-hCG (b-hCG) for pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
  • STD panel

In cases of sexual abuse Sexual Abuse Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. Sexual Abuse:

• The child may have difficulty conveying information verbally.
• Consider having the child draw what happened, demonstrate events with anatomically correct dolls, or write about the events.
• Specimen collection must be done:
  • Rape kits commonly used in emergency departments
  • Vaginal or penile secretions
  • Unwashed clothing used after the events
  • Fingernail scrapings
  • Hair samples
  • Blood sample
  • Saliva Saliva The clear, viscous fluid secreted by the salivary glands and mucous glands of the mouth. It contains mucins, water, organic salts, and ptyalin. Salivary Glands: Anatomy sample
  • Document with photos and videos as much as possible.
  • Any elements found on the victim, or provided by them, must be packaged and labeled on collection and introduced in the chain of evidence.

Management

Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship are legally mandated to report all cases to child protective services. Documentation Documentation Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature. It often involves authenticating or validating information. Advance Directives at every step and visit is essential to support suspicion.

Management

• Goal: Remove the child from harm and danger.
• Ensure the patient is stable and all life-threatening injuries are managed.
• In cases of sexual abuse Sexual Abuse Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. Sexual Abuse, prophylaxis Prophylaxis Cephalosporins for STDs, including HIV HIV Anti-HIV Drugs, within 72 hours of incident
• Multidisciplinary team approach including physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship, pediatricians, nurses, psychologists, psychiatrists, and social workers
• Long-term follow-up is required to ensure the child reaches all developmental milestones Developmental milestones Developmental milestones are the skills or abilities that most children are able to perform when they reach a certain age. Understanding the appropriate milestones and at what age they are reached helps clinicians identify symptoms of delayed development. Developmental milestones are divided into 5 important domains: gross motor, fine motor, language, social, and cognitive. Developmental Milestones and Normal Growth and is not suffering from any psychiatric illness.

Prevention

• Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship may use the SEEK (safe environment for every kid) model to screen caregivers with a questionnaire and guide those with high-risk factors for abuse to appropriate resources, such as pamphlets and community and hospital-based programs.
• Caregivers of children with a chronic medical disease or developmental disability Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits. ABCDE Assessment would benefit from anticipatory guidance and closer follow-up.

Clinical Relevance

The following conditions are part of the differential diagnosis of child abuse and must be kept in mind when documenting to report:

• Failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive: suboptimal weight gain Suboptimal Weight Gain Failure to Thrive and growth in infants and toddlers on standardized growth charts. Although neglect is a major cause, physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship must look for organic causes of lack of weight gain.
• Osteogenesis imperfecta Osteogenesis imperfecta Osteogenesis imperfecta (OI), or “brittle bone disease,” is a rare genetic connective tissue disorder characterized by severe bone fragility. Although OI is considered a single disease, OI includes over 16 genotypes and clinical phenotypes with differing symptom severity. Osteogenesis Imperfecta (OI) or brittle bone disease Brittle bone disease Osteogenesis imperfecta (oi), or “brittle bone disease,” is a rare genetic connective tissue disorder characterized by severe bone fragility. Although oi is considered a single disease, oi includes over 16 genotypes and clinical phenotypes with differing symptom severity. Osteogenesis Imperfecta: a spectrum of disorders of connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue: Histology characterized by impaired bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types formation and severe bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types fragility. Children with OI classically have a history of fractures during low-impact activities (e.g., diaper change) since birth.
• Ehlers-Danlos syndrome Ehlers-Danlos syndrome Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited connective tissue disorders that are characterized by hyperextensible skin, hypermobile joints, and fragility of the skin and connective tissue. Ehlers-Danlos Syndrome (EDS): a connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue: Histology disorder that causes easy bruising Easy bruising Chédiak-Higashi Syndrome due to defective collagen Collagen A polypeptide substance comprising about one third of the total protein in mammalian organisms. It is the main constituent of skin; connective tissue; and the organic substance of bones (bone and bones) and teeth (tooth). Connective Tissue: Histology production. Presence of hyperextensible skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions and hypermobile joints, along with a genetic test, confirms this syndrome.
• Hemophilia Hemophilia The hemophilias are a group of inherited, or sometimes acquired, disorders of secondary hemostasis due to deficiency of specific clotting factors. Hemophilia A is a deficiency of factor VIII, hemophilia B a deficiency of factor IX, and hemophilia C a deficiency of factor XI. Patients present with bleeding events that may be spontaneous or associated with minor or major trauma. Hemophilia: an inherited deficiency of factor 8, 9, or 11 resulting in bleeding within deep tissues that may mimic extensive bruising. Usually, there is no history of minor trauma. Blood work looking for the specific factor diagnoses hemophilia Hemophilia The hemophilias are a group of inherited, or sometimes acquired, disorders of secondary hemostasis due to deficiency of specific clotting factors. Hemophilia A is a deficiency of factor VIII, hemophilia B a deficiency of factor IX, and hemophilia C a deficiency of factor XI. Patients present with bleeding events that may be spontaneous or associated with minor or major trauma. Hemophilia.
• Mongolian spots Mongolian Spots Physical Examination of the Newborn: a congenital Congenital Chorioretinitis birthmark seen most commonly over the lumbosacral area. Mongolian spots Mongolian Spots Physical Examination of the Newborn mimic bruising, as they are bluish-green to black in color and usually irregularly shaped. History and follow-up of the spot can differentiate it from a nonaccidental bruise.
• Xeroderma pigmentosum Xeroderma pigmentosum A rare, pigmentary, and atrophic autosomal recessive disease. It is manifested as an extreme photosensitivity to ultraviolet rays as the result of a deficiency in the enzyme that permits excisional repair of ultraviolet-damaged DNA. Lentigo Maligna: an X-linked X-linked Genetic diseases that are linked to gene mutations on the X chromosome in humans or the X chromosome in other species. Included here are animal models of human X-linked diseases. Common Variable Immunodeficiency (CVID) genetic disorder that causes extensive burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns to skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions exposed to UV light UV light That portion of the electromagnetic spectrum immediately below the visible range and extending into the x-ray frequencies. The longer wavelengths (near-uv or biotic or vital rays) are necessary for the endogenous synthesis of vitamin D and are also called antirachitic rays; the shorter, ionizing wavelengths (far-uv or abiotic or extravital rays) are viricidal, bactericidal, mutagenic, and carcinogenic and are used as disinfectants. Bullous Pemphigoid and Pemphigus Vulgaris due to the lack of a DNA DNA A deoxyribonucleotide polymer that is the primary genetic material of all cells. Eukaryotic and prokaryotic organisms normally contain DNA in a double-stranded state, yet several important biological processes transiently involve single-stranded regions. DNA, which consists of a polysugar-phosphate backbone possessing projections of purines (adenine and guanine) and pyrimidines (thymine and cytosine), forms a double helix that is held together by hydrogen bonds between these purines and pyrimidines (adenine to thymine and guanine to cytosine). DNA Types and Structure repair mechanism. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship usually suffer from extensive sun burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns, freckling Freckling Neurofibromatosis Type 1, and excoriations Excoriations Excoriation is a linear abrasion produced by mechanical means (scratching, rubbing, or picking) that usually involves only the epidermis but can reach the papillary dermis. Secondary Skin Lesions. 
• Normal anatomical variants of male and female genitalia and of the anal sphincter in young children: includes variants of hymenal configuration, septal remnants, intravaginal ridges, anal fissures Anal fissures A painful linear tear at the margin of the anus. It appears as a crack or slit in the mucous membrane of the anus and is very painful and difficult to heal. Constipation, and perianal skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions tags ( constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation), which may simulate signs of sexual abuse Sexual Abuse Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. Sexual Abuse.