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8/8/2019 Part 3 Rape 2001 Medical Records_7
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\ll:TC\ Health Center 0 /
EMERGENCY ROOM
College Avenue.
NOT E
Patient Name
DO\lBROWOSKl Claudine
CH 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
r;:::C"U~:' they dId not have a rape evaluation kit. The patient was accepted in transfer. She had a screenmg
::\~i;Ilclune 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 ,md
hIt II: :h;: face ,,'ith a fist. There was penetration with his penis and ejaculation. She also says that the
Dcrp('t~Jtor PUI his mouth on her \'aginal area and either bit or blew air. She does not complain of too much
pal: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 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 EXA.,:\lINATIO.'\':
HEF:\T:
lL':\GS:
HEART:
\BDO\IE:\:
Pt: L\ ICE XA.\1:
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 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. ?\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
becchymosis There are abrasions and laceratlOns. During the speculum
EM ER G EN C Y R O OM N O TE
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8/8/2019 Part 3 Rape 2001 Medical Records_7
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EMERGENCY DEPARTMENT
NURSINGASSESSMENT Page 1 DATEj~/l~iCV
m{"'!;!!Wlj'V~
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C Ol. R
~IH-PCV!.~FA'TUf '. E N . - - I E R, 1.'.~;1 '" ~,_. t..ll-j.....,
Manhattan, Kansas
EMERGENCY DEPARTMENT
NURSING ASSESSMENT Page 2
{ ( ;" '.:.''f.t""
\;'. .
DATE I ~ 1 /'5 !rJ D
, . . : (: .ClAlJDlfH
i ~/19b5 AG E 3 51 ; : ~ I ,.. -"\
~ ' , .- ,"" r
r ' : ~ C : ~li0 S 611
$[ X F
VITAL SIGNS V:';JI13348E R
Description: _
TIM E INITIALS AMOU NT & TYPE MEDI CATI O N SITE, TYPE RATE ABSOR BED Die, TIM EOF FLU ID ADDED OF NEEDLE INITIALS
,',
TIME T P R SpO, BP
INTAKE OUTPUT
TIME IV PO EMESIS URINE OTHER
a5SO ~ J
VALUABLES
o Pt. retained 0 Given to _
) Admit: Report called to ~ Room # Tlme to room _
Transport method: 0 wlc 0 Carried 0 Cat 0 02 0 IV 0 Monitor/Defib 0 Airway Support 0 Other Emergency Supplies _
PHYSI(- iA.~'~
o Other 0 Transfer paperwork completed (see attached)o Other Time O a O l)
Time ~
o Air Ambulance _
o Police 0 AMA 0 Left without being seen
OEMS 0 Other _
) Transferred to: _
o RCEMS 9 Other Ambulance) o"'hargeA Home 0 Nursing Home
~ A mbulatory 0 Carried 0 wlc
"URSES SIGNATURE IINITIALS
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NURSING NOTES
\
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IIMercy H ealtb Center
f ~ of ManhattanP.O. Box 1289
MERCY Manhattan, KS 66505HEALTH mOliege CampusC E ' J T E R
,."\;'-",., unset Campus
Family Name
P R OG R ES S N O TE S
Attending Physician Room No.
Hosp, No.
-
SOCIAL SERVICESFORM 51-0560