Medico-Legal Report

Medico-Legal Report

Patient Information

Patient Name:

[Your Name]

Patient ID:

123456789

Date of Birth:

January 1, 2050

Gender:

Female

Contact Information:

123-456-7890

Case Information

  • Date of Examination: October 1, 2060

  • Referral Source: Springfield Police Department

  • Case Number: PD-2060-3456

Reason for Referral

[Your Name] was referred for a medico-legal examination following an alleged assault on September 30, 2060, during which he reported sustaining multiple injuries requiring medical attention.

History of Presenting Complaint

[Your Name] presented with complaints of severe pain in the left shoulder, bruising on the right side of the abdomen, and a laceration on the forehead. The pain began immediately after the incident and has intensified over the last 48 hours, with difficulty moving his left arm.

Medical History

  1. Past Medical History:

    • Hypertension, is controlled with medication.

    • No history of surgeries or significant medical conditions.

  2. Medications:

    • Lisinopril 10 mg daily.

  3. Allergies:

    • No known drug allergies.

  4. Family History:

    • Father had a history of heart disease.

    • Mother is in good health.

  5. Social History:

    • Non-smoker, moderate alcohol use (1-2 drinks per week).

    • Works as a warehouse supervisor; no history of drug use.

Physical Examination

  1. Vital Signs:

    • Blood Pressure: 130/80 mmHg

    • Pulse: 78 bpm

    • Respiratory Rate: 16 breaths/min

    • Temperature: 98.6°F

  2. General Appearance:

    • Alert and oriented, in moderate distress due to pain.

  3. Specific Findings:

    • Left Shoulder: Limited range of motion, tenderness to palpation.

    • Abdomen: Moderate bruising was observed in the right upper quadrant, with no guarding or rebound tenderness.

    • Forehead: 3 cm laceration, edges clean, mild swelling.

Diagnostic Tests

  1. X-rays:

    • Left shoulder X-ray showed no fractures.

    • Abdominal ultrasound indicated no internal bleeding or organ damage.

  2. Laboratory Tests:

    • Complete blood count (CBC) within normal limits, no signs of infection.

Assessment

[Your Name]presents with soft tissue injuries consistent with blunt force trauma due to an assault. The bruising and laceration are typical findings in such cases, and the physical examination aligns with the reported mechanism of injury. There are no signs of fractures or internal injuries based on the diagnostic tests conducted.

Opinion

In my professional opinion, the injuries sustained by [Your Name] are consistent with the reported assault. The absence of fractures and internal injuries is a positive indicator of his recovery. I recommend follow-up care for pain management and wound care for the laceration. Additionally, psychological support may be beneficial given the trauma associated with the incident.

Limitations

This assessment is based on the examination and diagnostic tests performed on October 1, 2060. The report is limited to the injuries observed and does not encompass any psychological effects or long-term consequences that may arise post-incident. Further evaluations may be warranted based on the patient’s recovery progress.

Signature:

Dr. Gianne, MD

Forensic Medical Examiner