DO\lBROWOSKl ClaudineCH IE F CO.\lPLAINT: Rape.
Douglas Harper, M.D.
HISTORY Of PRESENT ILLNESS: This is a 35-year-old female without any medical problems. So::
',ere from St. Mar:-"s Emergency Room by Mike Trouse. The patient was referred to this hosplul
they dId not have a rape evaluation kit. The patient was accepted in transfer. She had a screenmg
clune there and her lacerations sewn up.
i : l
35-year-old female who was assaulted by a known assailant. She was draggec ,mdhIt II:
face ,,'ith a fist. There was penetration with his penis and ejaculation. She also says that theDcrp('t~Jtor
his mouth on her \'aginal area and either bit or blew air. She does not complain of too muchpal: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.
Of S'r'STL\1S: In general, there has been no \veakness, fatigue, or fever. HEE."\T: There
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 selzuresPHYSICAL EXA.,:\lINATIO.'\':
Tympanic membranes are clear bilaterally. There is no hemotympanum. There
ecchY1TIOS1Sand a sutured laceration to the left eyebrow. There is no bony step-off Pupils are equal, round and reactive to light. Extraocular muscles intactThere 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
S2. ?\o murmurs or rubs.Soft and nontender. Bowel sounds present.The introitus and external genitalia reveal no evidence of acute trauma. There
ecchymosis There are abrasions and laceratlOns. During the speculum
EMERGENCY ROOM NOTE