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Health

Center

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College

Avenue.

EMERGENCY
Patient Name Attending Physician

ROOM

NOT
Chart #

E
Date Room #

DO\lBROWOSKl

Claudine Rape.

Douglas Harper, M.D.

\'113348

1215/00

en LK

CH I E F CO.\lPLAINT:

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;Il clune 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 hIt II: :h;: face ,,'ith a fist. There was penetration with his penis and ejaculation. She also says Dcrp('t~Jtor PUI his mouth on her \'aginal area and either bit or blew air. She does not complain pal:l She sustained a laceration to the left eyebrow which \vas sutured up in St. Marys. There ::Ol;SCl,JilSneSS There is no neck pain.

,md that the of too much was no loss of

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 HEF:\T: EXA.,:\lINATIO.'\': Tympanic membranes are clear bilaterally. There is no hemotympanum. There ecchY1TIOS1S and a sutured laceration to the left eyebrow. There is no bony stepoff 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. lL':\GS: HEART: \BDO\IE:\: Pt: L \ ICE XA.\1: ?\onrigid and nontender. bilaterally. or rubs.
IS

Clear to auscultation

Regular rate and rhythm, S 1, S2. ?\o murmurs Soft and nontender. Bowel sounds present.

The introitus and external genitalia reveal no evidence b ecchymosis There are abrasions and laceratlOns.

of acute trauma. There During the speculum

EMERGENCY

ROOM NOTE

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