A 4-year-old boy is brought to the emergency department by his mother due to an asthma exacerbation. He has a history of poorly controlled asthma, with nonadherence to medication and follow-up visits. The mother works 2 jobs to support the family and says she has difficulty bringing the patient to appointments. On physical examination, a well-demarcated, round burn mark is seen on the patient's thigh. When asked about the burn, the patient says, "That happens every time I'm bad. My dad told me." His mother corrects him and says that it was an accident resulting from the boy "playing with the cigarette lighter in the car." Which of the following is the best next step in management of this patient?

Question

A 4-year-old boy is brought to the emergency department by his mother due to an asthma exacerbation.  He has a history of poorly controlled asthma, with nonadherence to medication and follow-up visits.  The mother works 2 jobs to support the family and says she has difficulty bringing the patient to appointments.  On physical examination, a well-demarcated, round burn mark is seen on the patient's thigh.  When asked about the burn, the patient says, "That happens every time I'm bad.  My dad told me."  His mother corrects him and says that it was an accident resulting from the boy "playing with the cigarette lighter in the car."  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec160b_3654_c878_9249_a9d59233196e_MD0001_00 This child's characteristic cigarette burn and inconsistent explanation of how the injury occurred are concerning for child abuse. Poor follow-up with medical care for the patient's asthma is also a possible sign of neglect. When evaluating an injured child, physicians must carefully screen for suspicious physical findings and any associated historical inconsistencies. Signs suggestive of abuse on examination include multiple injuries of different types and stages of healing, pathognomonic injuries (eg, cigarette burns, symmetrical buttocks scalding), retinal hemorrhages, genital trauma, signs of neglect (eg, uncleanliness, malnourishment), and significant emotional or behavioral disturbances (eg, excessive compliance, pseudomaturity). Physicians are obligated to report any suspected child abuse to Child Protective Services (CPS) for further investigation. Reporting is mandatory and reasonable medical suspicion is sufficient; confirmation of abuse is not required for reporting purposes. CPS conducts assessments, provides family counseling and rehabilitative services, and coordinates foster family placement when needed. (Choice A) It is premature to arrange for hospitalization. Children with injuries that do not require hospitalization can be discharged if CPS determines that the child's immediate safety is not at risk. (Choice B) This child has a suspicious examination finding and has already disclosed incidents of possible abuse; it is unnecessary to interview him alone prior to contacting CPS. Calling security and insisting the mother leave the room when there is already sufficient suspicion of abuse may escalate the situation unnecessarily. (Choice C) The mother has already described the injury as accidental, and doubting her account will likely be met with denial. Confronting caregivers is risky because they may become argumentative/violent or attempt to flee the emergency department. It is therefore preferable to contact CPS immediately if there are concerns for child abuse. (Choice D) There is no need to do further investigative work to confirm abuse when reasonable suspicion has already been established based on physical exam findings and patient disclosure. Educational objective: Physicians are obligated to report any suspected child abuse or neglect to Child Protective Services (CPS) for further investigation. Reporting is mandatory and reasonable medical suspicion is sufficient.

A 4-Year-Old Boy Is Brought to the Emergency Department by His