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Part 3 Rape 2001 Medical Records_7

Part 3 Rape 2001 Medical Records_7

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Published by: SilenceIsOppression on Nov 01, 2010
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07/28/2013

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 \ll:TC
Health Center
0 / 
EMERGENCY
ROOM
College Avenue.
NOT E
Patient Name
DO\lBROWOSKl ClaudineCH 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
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they dId not have a rape evaluation kit. The patient was accepted in transfer. She had a screenmg
::\~i;Il
clune there and her lacerations sewn up.
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IS
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35-year-old female who was assaulted by a known assailant. She was draggec ,mdhIt II:
:h;:
face ,,'ith a fist. There was penetration with his penis and ejaculation. She also says that theDcrp('t~Jtor
PUI
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.
RE\IE\\ 
Of S'r'STL\1S: In general, there has been no \veakness, fatigue, or fever. HEE."\T: There
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no
:CuCuc
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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.'\':
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 \BDO\IE:\:
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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 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
1,
S2. ?\o murmurs or rubs.Soft and nontender. Bowel sounds present.The introitus and external genitalia reveal no evidence of acute trauma. There
b
ecchymosis There are abrasions and laceratlOns. During the speculum
EMERGENCY ROOM NOTE
 
1-:.\IERe E.\ Ct'
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EDombrowoski, Claudine
Page 2
exam. there was evidence of intravaginal trauma, A small amount of bleeding is notcd ,The rope evaluatJOn was penormed per protocol.
EXTRE.\lITIES:
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clubbing, cyanosis or edema,
ASSESS.\lE:'\T:
Alleged rape,PLA.\: S0c;al Services evaluation, The Pottawatomie County Police
\\'ere 
present. The patIent
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