SBC Forensics

Examiner:

Name/Credentials

________________________________________________________________________________________________________________________________

Date of Forensic Consult

Patient's First Last Name

Patient's Date of Birth:

Gender

Female

Male

Facility Requesting Consult

________________________________________________________________________________________________________________________________

Presentation History / Medical Decision Making (HPI/MDM):

History of Present Illness (HPI):

________________________________________________________________________________________________________________________________

Review of Allergies, Medications, Medical History:

I confirm the following items have been reviewed:

allergies

medications

past medical history

diagnostics performed prior to exam

________________________________________________________________________________________________________________________________

Review of Systems (ROS):

ROS comment:

________________________________________________________________________________________________________________________________

Physical Exam:

VITAL SIGNS:

Vital Signs:

VS hemodynamically stable

See VS comment below

Vital Sign Comment:

INTAKE / OUTPUT

Intake/Output

Not reviewed/not pertinent to forensic examination

See Intake/Output comment below:

Intake/Output Comment:

GENERAL EXAM:

Constitutional Findings

no acute distress, well developed, cooperative for exam

see constitutional comment below

Constitutional Comment:

HEAD/SCALP:

Head and Scalp Physical Exam:

No bony step offs or crepitus on palpation to scalp, forehead, orbital rims, zygomata, maxilla or mandible. There is no postauricular ecchymosis (Battle's sign). Nasal septum is midline. No nasal septal hematoma. No midface instability. No abrasions, lacerations, contusions, ecchymoses, or hematomas of the scalp or face. There is no clear or sanguinous drainage from bilateral nares

Please reference forensic diagrams for more details

See head/scalp comment below

Head/Scalp Exam Comments

EYES:

Eyes Physical Exam

PERRLA, sclera white. Without conjunctival hemorrhage or injections. There is no ptosis. Sclerae anicteric. Bilat sclera, conjunctiva & eyelids without erythema or edema. No bilateral eye drainage

Please reference forensic diagrams for more details

See eyes comment below

Eyes Exam Comments:

NARES:

Nares Physical Exam:

Nares patent b/l. 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. Dentition noted in forensic record. No pharyngeal erythema, edema or exudate. No tonsillar hypertrophy. 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 bony cervical spine tenderness or step-offs. No abrasions, lacerations, contusions, ecchymoses, or hematomas of the neck. Trachea midline. Palpable carotid pulses bilaterally. Neck is supple. No masses, tracheal deviation or thyromegaly appreciated

Please reference forensic diagrams for more details

See neck exam comment below

Neck Exam Comment

CARDIAC:

Cardiac Physical Exam:

Regular rate and rhythm appreciated on radial pulse palpation and apical pulse auscultation. No murmur. Without murmur, rubs or gallops. +2 pulses to extremities as applicable. Without evidence of cyanosis. Without appreciable edema

Please reference forensic diagrams for more details

See cardiac comment below

Cardiac/Chest Exam Comment:

PULMONARY / TORSO:

Pulmonary/Torso

Equal rise and fall to chest. Easy work of breathing. Without tenderness, crepitus on palpation. No flail segments or gross chest wall deformities. CTA. Without conversational dyspnea or intercostal retractions or accessory muscle use. Development appropriate for age.

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:

Soft. Abdomen is non-tender, non-distended. Without rebound or pain with palpation. No HSM appreciated. Bladder non-palpable on exam. No suprapubic tenderness or fullness. Absent Grey-Turner/Cullen sign. Absent fluid wave

Please reference forensic diagrams for more details

See GI/GU comment below

GI/GU Exam Comment

FEMALE GENITALIA :

Female Genitalia Comment

MALE GENITALIA :

Male Genitalia Exam Comment

PERINEUM - ANAL:

Perineum/Anal Physical Exam:

Skin with expected pigmentation changes, without lesions, fissures, excoriations, inflammation, lacerations, abrasions, erythema, strictures, hemorrhoids or prolapse. External anal sphincter tone intact

Please reference forensic diagrams for more details

See perineum / anal comment below

Perineum/Anal Exam Comment

SKIN:

Skin Physical Exam:

Without cyanosis, clubbing, ulcerations, purpura, petechiae, necrosis, papules, caruncles, pustules

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:

Calves soft and non-tender to palpation. Without palpable cords. +2 pulses bilaterally. Toes are warm and well profused without evidence of cyanosis. Full ROM 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. Working memory intact. CN II through XII intact. Speech is fluent without dysarthria

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

HEMATOLOGICAL / LYMPHATIC:

Hematological/Lymphatic Physical Exam

No cervical, pre/ post-auricular, occipital, submandibular or axillary lymphadenopathy. Without evidence of purpura, acute uncontrolled blood loss

See heme/lymph exam comment

Hematological/Lymphatic Exam Comment

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Plan:

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