Department of Obstetrics and Gynecology

Women and Children Protection Unit

MEDICO-LEGAL CERTIFICATE
DERMOGRAPHIC DATA
Patient’s Name JAMILE, ALYA SHUANA GRAE Age 3Y DOB 10/10/2020 Sex F
Address
BANTAYAN, KABANKALAN CITY, NEG. OCC.
Civil Status CHILD Occupation NA Nationality FILIPINO
Requesting Party PARENTS Place, Time CLMMRH, BACOLOD CITY
& Date of 6:00 PM, DECEMBER 27. 2023
Exam
□ Acute Evidentiary Examination (within 72 hours of incident) □ Non-acute Examination
FINDINGS
GENERAL PHYSICAL FINDINGS
Height 96 CM Weight 15.5 KG
General Survey PATIENT IS SEEN AWAKE, ACTIVE, AMBULATORY
Mental Status CONSCIOUS, ORIENTED TO TIME, PERSON, AND PLACE
UNCOOPERATIVE
Pertinent Physical UNREMARKABLE
Findings
ANOGENITAL EXAM
External Genitalia TANNER STAGE 1
NO EVIDENT INJURY AT THE TIME OF EXAMINATION.

Urethra and NO EVIDENT INJURY AT THE TIME OF EXAMINATION.

Periurethral Area
Perihymenal Area NO EVIDENT INJURY AT THE TIME OF EXAMINATION.
& fossa navicularis
Hymen NO EVIDENT INJURY AT THE TIME OF EXAMINATION.

Perineum NO EVIDENT INJURY AT THE TIME OF EXAMINATION.

Discharge NONE

Internal and
Speculum Exams NOT DONE DUE TO PATIENT’S AGE AND ANATOMY

Anal Examinations NO EVIDENT INJURY AT THE TIME OF EXAMINATION.

DIAGNOSTICS AND EVIDENCE GATHERING

Forensic Evidence
and laboratory
results VAGINAL SWAB FOR CULTURE, GRAM STAIN, AND KOH SENT TO LABORATORY,
PENDING RESULTS.

IMPRESSIONS

NO EVIDENT INJURY AT THE TIME OF EXAMINATION BUT MEDICAL EVALUATION CANNOT

EXCLUDE SEXUAL ABUSE

Attending Physician

JOY GRACE A. RUIZ, MD.

LIC. NO. 0151617
MEDICAL OFFICER IV

Medico-legal Certificate
CLMMRH-OB.F.007
Issued date: 3/16/2015
Issued No. 001
Medico-legal Certificate
CLMMRH-OB.F.007
Issued date: 3/16/2015
Issued No. 001