SBC Forensics

Examiner:

Name/Credentials

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Date of Forensic Consult

Patient's First Last Name

Patient's Date of Birth:

Gender

Female

Male

Facility Requesting Consult

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Examination Details/Comments:

Examiner Comments:

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Review of Allergies, Medications, Medical History:

I confirm the following items have been reviewed:

allergies

medications

past medical history

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Physical Exam:

VITAL SIGNS:

Vital Signs:

VS hemodynamically stable

See VS comment below

Vital Sign Comment:

PHYSICAL EXAM:

General Information

no acute distress, well developed, cooperative for exam

see general comment below

Constitutional Comment:

HEAD/SCALP:

Head and Scalp Physical Exam:

No tenderness, deformity, missing hair. Forehead is without findings. No ecchymosis behind the ears or clear drainage from ears.

Please reference forensic diagrams for more details

See head/scalp comment below

Head/Scalp Exam Comments

EYES:

Eyes Physical Exam

Pupils are equal and reactive to light, sclera is white. Without conjunctival hemorrhage Bilateral eyes without erythema or edema or drainage.

Please reference forensic diagrams for more details

See eyes comment below

Eyes Exam Comments:

NARES:

Nares Physical Exam:

Nasal septum is midline. No nasal septal hematoma. No midface instability. No clear or sanguineous drainage from bilateral nares.

Please reference forensic diagrams for more details

See nares comment below

Nares Exam Comment:

MOUTH / ORAL CAVITY:

Mouth/Oral Vacity Physical Exam

Mucous membranes pink and moist. Oral mucosa without petechiae, lacerations.

Please reference forensic diagrams for more details

See mouth/oral exam comment below

Mouth/Oral Cavity Exam Comment

NECK / THROAT:

Neck Physical Exam:

No abrasions, lacerations, contusions, ecchymoses, or hematomas of the neck. Trachea midline.

Please reference forensic diagrams for more details

See neck exam comment below

Neck Exam Comment

PULMONARY / TORSO:

Pulmonary/Torso

Easy work of breathing. Without tenderness on palpation. Without respiratory distress.

Anterior and Posterior torso assessment unremarkable

Please reference forensic diagrams for more details

See pulmonary/torso comment below

Pulmonary Torso Exam Comment

GI / GU:

GI/GU Physical Exam:

Abdomen is non-tender, non-distended.

Please reference forensic diagrams for more details

See GI/GU comment below

GI/GU Exam Comment

FEMALE GENITALIA :

Female Genitalia Physical Exam:

NA - MALE PATIENT

Labia: symmetric color appearance

Hair: hair pattern congruent with sex characteristics

Labia Majora: symmetric, without excoriation, lesions. Even color distribution

Cervix: 2-3 cm in diameter, pink with even color distribution. OS is midline to cervix.

Fornix: anterior, posterior, lateral fornixes unremarkable

Please reference forensic diagrams for more details

See female genitalia exam comment below

Female Genitalia Comment

MALE GENITALIA :

Male Genitalia Physical Exam:

NA - FEMALE PATIENT

Hair pattern congruent with sex characteristics

Urethral Meatus: without discharge, lesions, ecchymosis.

Glans: urethral opening midline, without excoriation, drainage, lesions.

Shaft: even pigmentation, without lesions.

Foreskin: circumcised

Foreskin: non-circumcised,

Please reference forensic diagrams for more details

See male genitalia exam comment below

Male Genitalia Exam Comment

PERINEUM - ANAL:

Perineum/Anal Physical Exam:

External sphincter intact without ecchymosis, lacerations. Normal sphincter tone.

Please reference forensic diagrams for more details

See perineum / anal comment below

Perineum/Anal Exam Comment

SKIN:

Skin Physical Exam:

Skin is warm and dry without diaphoresis

Please reference forensic diagrams for more details

See skin comment below

Skin Exam Comment

***SKIN NOTE: do not repeat documentation of injuries if already detailed and noted on diagrams. Check the "Please reference forensic diagrams for more details"

MUSCULOSKELETAL:

Musculoskeletal Physical Exam:

Full range of motion to all extremities

Please reference forensic diagrams for more details

See musculoskeletal comment below

Musculoskeletal Exam Comment

NEUROLOGICAL:

Neurological Physical Exam:

Alert, oriented and appropriate. Speech is fluent without dysarthria. Mood and affect appropriate.

See neurological comment below

Neurological Exam Comment

PSYCHIATRIC:

Psychiatric Physical Exam:

Pt seems to have appropriate judgement & insight into current medical condition & issues

See psychiatric exam comment below

Psychiatric Exam Comment

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Provider Report

Recommendations made to provider:

Provider Recommendation Comments

DISCHARGE INSTRUCTIONS:

Follow Up Recommendations Provided to Patient

F/U in 3-5 days with PCP/OBGYN

Complete all prescribed medications

Contact our office or alternative if no PCP/OBGYN

Victim Witness/Advocate information given

All questions answered

Return to the ED for urgent concerns

See patient recommendations below

F/U recommendation comments