\ll:TC\ Health Center 0/ College Avenue.

EMERGENCY ROOM NOT E

Patient Name Attending Physician Chart # Date Room #

DO\lBROWOSKl Claudine Douglas Harper, M.D. \'113348 1215/00 en
LK

CH I E F CO.\lPLAINT: Rape.

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 ,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: 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.

lL':\GS: Clear to auscultation bilaterally.

HEART: Regular rate and rhythm, S 1, S2. ?\o murmurs or rubs.

\BDO\IE:\: Soft and nontender. Bowel sounds present.

Pt: L \ ICE XA.\1: 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-:.\ I ERe E.\ Ct' ROO.\ 1 :";0 T E
Dombrowoski, 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: :\0 clubbing, cyanosis or edema,

ASSESS.\lE:'\T: Alleged rape,

PLA.\: S0c;al Services evaluation, The Pottawatomie County Police \\'ere present. The patIent \\Jll h3\C :;"]\
,:>,u:lscilT1!,'

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D&T 1::: 1500-12/19/00
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EMERGENCY ROOM NOTE

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EMERGENCY DEPARTMENT ~' , .- ,"" r

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NURSING ASSESSMENT Page 2 DATE I ~1/'5!rJD r ':~ C: ~li0 S 611
VITAL SIGNS V:';JI13348 ER
TIME T P R SpO, BP

TIM E INITIALS AMOU NT & TYPE MEDICATIO N SITE, TYPE RATE ABSOR BED Die, TIM E
OF FLU ID ADDED OF N EEDLE INITIALS
,',

INTAKE OUTPUT

TIME IV PO EMESIS URINE OTHER

VALUABLES
o Pt. retained 0 Given to _
a5SO ~J
Description: _

1) 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 _
2) Transferred to: _ Time ~

o RCEMS 9 Other Ambulance o Air Ambulance _ o Other 0 Transfer paperwork completed (see attached)
3) o"'hargeA Home 0 Nursing Home o Police 0 AMA 0 Left without being seen o Other Time Oa Ol)
~ Ambulatory 0 Carried 0 wlc OEMS 0 Other _
PHYSI(- iA.~'~

,."URSES SIGNATURE I INITIALS<:;hi<4 LJl;::rtl..I3.~/1~,_1~ __

NURSING NOTES

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MERCY
Mercy Healtb Center
of Manhattan
P.O. Box 1289
Manhattan, KS 66505
HEALTH mOliege Campus
CE'JTER
,."\;'-",., unset Campus
PROGRESS NOTES
Family Name Attending Physician Room No. Hosp, No.

SOCIAL SERVICES
FORM 51-0560