History and Physical

Social History Related to Foster Care Placement

Physical Examination

Conduct a complete physical examination with attention to the following:

General

• Identification of caregivers present in room, including relationship to child, length of relationship, and how the child refers to them so that you can use the same terminology
• Date of foster care placement
• Circumstances leading to placement
• Adjustment to placement to date
• What visitation, if any, child has with biological family
• Availability of medication and equipment (e.g., spacer, eyeglasses)

Trauma-related Symptoms

• Sleep problems:
  • Difficulty falling or staying asleep, nightmares
• Toileting problems:
  • Constipation, enuresis, encopresis, regression of toileting skills
• Eating issues:
  • Rapid eating, food hoarding, loss of appetite, lack of satiety
• Externalizing behaviors:
  • Aggressive behaviors, anger, irritability
• Internalizing symptoms:
  • Depression, withdrawal, difficulty sustaining attention, somatic complaints
• Attachment problems:
  • Fear of separation, excessive clinging
• Regressive behaviors
  • Thumb sucking, fear of darkness

Tips for Obtaining Medical Review of Systems from Youth

• Use open-ended questions
• Use developmentally appropriate language
• If a child makes a spontaneous disclosure of abuse, respond by telling the child that they can talk to you
• Document statements word for word in medical record

Vital Signs

• Assess for failure to thrive, obesity

Oral Exam

• Dental – lack of routine dental care and dental caries are prevalent among children in foster care
• Examine frenula, especially in non-mobile children

Skin Exam

• Assess for signs of recent or remote trauma on physical exam unclothed
• Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising  
• Patterned bruising
• Bruising in the TEN-4-FACES area:
  • Torso
  • Ear
  • Neck
  • Frenulum
  • Angle of the jaw
  • Cheeks
  • Eyelids
  • Subconjunctival or bruising anywhere in children less than 4 months of age and younger

Photodocumentation of Injuries

• Practical tips to consider:
  • Take a photograph of the injury zoomed out that includes an anatomic landmark (knee, elbow) as well as a more zoomed-in picture
  • Include a measuring device in the picture if possible
  • Use a neutral background if possible

Genital Exam

• Considerations when there is a reported history of sexual abuse; most victims of sexual abuse have normal anogenital examinations. For discussion of the approach to interpreting physical and laboratory findings in suspected child physical abuse, see Interpretation of Medical Findings in Suspected Child Sexual Abuse: An Update for 2018  
• Chaperone should be present
• Ask older children to identify a support person in addition to medical providers to be present if they desire during the examination
• Do not force examinations if patients refuse
• Genital exam positions:
  • Supine frog leg – useful for younger, prepubertal patients
  • Supine lithotomy – for patients who are older/taller
• Genital exam techniques:
  • Labia majora are easily visible
  • To visualize the vestibular structures, labial separation and traction are used
• Concerning findings should be confirmed using another technique (e.g., a second exam position such as knee-chest). Referral to a child abuse specialist may also be considered.
• Exam techniques are detailed and illustrated in Has This Prepubertal Girl Been Sexually Abused?