Part 3 Rape 2001 Medical Records_7

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\ll:TC\ Health Center 0 /

EMERGENCY ROOM

College Avenue.

NOT E

Patient Name

DO\lBROWOSKl Claudine

CH IE F CO.\lPLAINT: Rape.

Attending Physician

Douglas Harper, M.D.

Chart #

\'113348

Date

1215/00

Room #

en

LK

HISTORY Of PRESENT ILLNESS: This is a 35-year-old female without any medical problems. So:: \\;1S

~-:i::'T~c ',ere from St. Mar:-"s Emergency Room by Mike Trouse. The patient was referred to this hosplul

r;:::C"U~:' they dId not have a rape evaluation kit. The patient was accepted in transfer. She had a screenmg

::\~i;Ilclune there and her lacerations sewn up.

: ' : lL ' ;1.1~:C;j: IS i : l 35-year-old female who was assaulted by a known assailant. She was draggec ,md

hIt II: :h;: face ,,'ith a fist. There was penetration with his penis and ejaculation. She also says that the

Dcrp('t~Jtor PUI his mouth on her \'aginal area and either bit or blew air. She does not complain of too much

pal:l She sustained a laceration to the left eyebrow which \vas sutured up in St. Marys. There was no loss of

::Ol;SCl,JilSneSS There is no neck pain.

RE\IE\\ Of S'r'STL\1S: In general, there has been no \veakness, fatigue, or fever. HEE."\T: There 1S no

:CuCuc I'~ rleck p3in. blurred \'lsion, or sore throat. Respiratory: There is no cough or congestion.

Cardio\3scular: There is no chest pain or palpitations. Abdomen: There is no abdominal pain. nausea.

. :: ',,::; ,J; dIarrhea. There IS no back pain. ~eurologic: There has been no fainting, blackouts, or selzures

PHYSICAL EXA.,:\lINATIO.'\':

HEF:\T:

lL':\GS:

HEART:

\BDO\IE:\:

Pt: L\ ICE XA.\1:

Tympanic membranes are clear bilaterally. There is no hemotympanum. There IS

ecchY1TIOS1Sand a sutured laceration to the left eyebrow. There is no bony step-

off Pupils are equal, round and reactive to light. Extraocular muscles intact

There is minimal tenderness to palpation to the left zygoma. A small amount uf

ecchY1TIosis is noted on the right side of the lower lip.

Supple. ?\onrigid and nontender.

Clear to auscultation bilaterally.

Regular rate and rhythm, S 1, S2. ?\o murmurs or rubs.

Soft and nontender. Bowel sounds present.

The introitus and external genitalia reveal no evidence of acute trauma. There

becchymosis There are abrasions and laceratlOns. During the speculum

EM ER G EN C Y R O OM N O TE


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EMERGENCY DEPARTMENT

NURSINGASSESSMENT Page 1 DATEj~/l~iCV

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~IH-PCV!.~FA'TUf '. E N . - - I E R, 1.'.~;1 '" ~,_. t..ll-j.....,

Manhattan, Kansas

EMERGENCY DEPARTMENT

NURSING ASSESSMENT Page 2

{ ( ;" '.:.''f.t""

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DATE I ~ 1 /'5 !rJ D

, . . : (: .ClAlJDlfH

i ~/19b5 AG E 3 51 ; : ~ I ,.. -"\

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r ' : ~ C : ~li0 S 611

$[ X F

VITAL SIGNS V:';JI13348E R

Description: _

TIM E INITIALS AMOU NT & TYPE MEDI CATI O N SITE, TYPE RATE ABSOR BED Die, TIM EOF FLU ID ADDED OF NEEDLE INITIALS

,',

TIME T P R SpO, BP

INTAKE OUTPUT

TIME IV PO EMESIS URINE OTHER

a5SO ~ J

VALUABLES

o Pt. retained 0 Given to _

) Admit: Report called to ~ Room # Tlme to room _

Transport method: 0 wlc 0 Carried 0 Cat 0 02 0 IV 0 Monitor/Defib 0 Airway Support 0 Other Emergency Supplies _

PHYSI(- iA.~'~

o Other 0 Transfer paperwork completed (see attached)o Other Time O a O l)

Time ~

o Air Ambulance _

o Police 0 AMA 0 Left without being seen

OEMS 0 Other _

) Transferred to: _

o RCEMS 9 Other Ambulance) o"'hargeA Home 0 Nursing Home

~ A mbulatory 0 Carried 0 wlc

"URSES SIGNATURE IINITIALS


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NURSING NOTES

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IIMercy H ealtb Center

f ~ of ManhattanP.O. Box 1289

MERCY Manhattan, KS 66505HEALTH mOliege CampusC E ' J T E R

,."\;'-",., unset Campus

Family Name

P R OG R ES S N O TE S

Attending Physician Room No.

Hosp, No.

-

SOCIAL SERVICESFORM 51-0560

Part 3 Rape 2001 Medical Records_7

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