Medico-Legal Report of …………………,
11-Year-Old Female, DoB …….. of …………………………………………………………..
- Introduction
………………………. was produced before JMO, Teaching Hospital Ragama ….. hrs.
on ………with a Medico-Legal examination form bearing No. ….issued on ……. by ……
Police.
- History
2.1
Salient Features of
History Relevant to My Examination
She alleged that her uncle used to touch her private parts since she
was a small girl even before she started schooling.
She claimed that three years ago she had sexual intercourse with
Patty uncle and Michael uncle.
2.2
History from the girl
2.3 Gynaecological and sexual History
o
She hasn’t attained menarche
yet.
o
Apparently she did not have
sexual relationship before and after this alleged incident.
- Examination
3.1 General examination
o
Unremarkable
3.2 Systemic examination
o Cardiovascular, Respiratory and Nervous System are unremarkable.
3.3 Vulvo-vaginal examination
o
Vulva, labia majora &
minor, clitoris, vestibule, posterior navicularis, posterior foruchette and
perineum are normal.
o
Hymen is thick, vascular and annular.
o
No fresh or old tears.
o
A hymenal tag at 5 ‘O’ clock
position
3.4 Anal examination
o
Not done
- Investigations
·
Not done
- Referrals
o
She was referred to Dr. …..,
Consultant Psychiatrist, Teaching Hospital Ragama. According to him, due to
this incident she had no major psychiatric sequalae. Also at the time of
examination she was not suffering from a psychiatric disorder. But she appeared
mature than her stated age during the interview.
o
She was referred to STD clinic.
She was negative for sexually transmitted diseases.
- Conclusions
o
She gave a history of vaginal
sexual intercourse with two different persons three years ago.
o
Vulvo-vaginal examination
revealed annular hymen with a ‘tag’ at 5 ‘O’ clock position.
o
There were no hymenal
transections or notches (old healed injuries)
- Opinion
Signed
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