by Michael P. Poirier, MD and Leonard R. Friedland, MD
HISTORY OF PRESENT ILLNESS:
A 3 year old female, accompanied by her mother, presents to the Emergency Department with the chief complaint of "bleeding from her private parts." The mother noticed blood in her underwear, and also noticed that when giving the child a bath, something did not look right in her vaginal area. The child attends daycare, was picked up by the mother earlier in the afternoon, and had been with the mother since that time. The mother was initially concerned about the possibility of sexual abuse and came to the Emergency Department for help.
Further history reveals the child complains of dysuria, frequency and a sensation of vaginal irritation for one day. There were no recent fever, chills, nausea, vomiting, diarrhea, constipation, or upper viral respiratory infection complaints. There was no history of any vaginal discharge, except for the blood. The child was eating and drinking as normal. The child denied anyone abusing or touching her, and the mother had no specific suspicion of any perpetrator.
Past medical history reveals a full term child without history of prenatal or postnatal complications. There are no chronic medical illnesses and no recent medications. Immunizations are up to date and there are no allergies. The child was developmentally appropriate for age and the social history was unremarkable.
On review of systems, pertinent negatives included no history of chronic constipation, no recent abdominal trauma, no easy bruising or bleeding, and no history of the mother being treated with DES during the pregnancy of this child.
PHYSICAL EXAMINATION:
Physical exam reveals a playful and interactive child in no distress. Vital signs and growth parameters all are within normal limits. Pertinent positives on exam were limited to the genitalurinary system. The child was Tanner SMR Stage 1. The patient had obvious spots of bright red blood in her underwear. There was mild erythema and bruising of the labia majoria. There were no external lacerations. On vaginal examination in the supine position the urethral orifice was obscured secondary to edema and erythema with a centrally located blood tinged mass about 2.0 millimeters in diameter. See figure 1. The hymeneal membrane was intact and smooth. External rectal examination was normal.
LABORATORY EVALUATION:
No labs or ancillary studies were obtained.
From Academic Emergency Medicine 2(6)
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