Tuesday, 18 December 2012

A free style medico-legal report on a case of sexual abuse

Medico-Legal Report of …………………, 11-Year-Old Female, DoB …….. of …………………………………………………………..
  1. Introduction
………………………. was produced before JMO, Teaching Hospital Ragama ….. hrs. on ………with a Medico-Legal examination form bearing No. ….issued on ……. by …… Police. 
  1. 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 
(Two pages of history in her own words in question and answer format.)
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. 
  1. 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
  1. Investigations
·         Not done
  1. 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.
  1. 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)
  1. Opinion
o   Hymenal tag is an elongated projection of tissue arising from the hymenal rim.
o   This may be an extension of a posterior vaginal ridge (normal anatomical variation)
o   Hymenal injuries (lacerations) can heal without scarring.
o   They  may also heal to leave slight notching, narrowing or mounds/projections on the hymen
o   Therefore, the presence of a hymenal ‘tag’ does not exclude or confirm vaginal sexual intercourse.
o   Absence of hymenal transections (tears) or scars does not exclude vaginal penetration.
o   It should be noted that the clinical signs must be considered with overall clinical picture, child’s statement, social and family history and detailed multi-agency assessment.
o   Child sexual abuse takes many forms and vaginal penetration is only one.
Signed
 
 
 
 
 
 
           
 
 
 

No comments:

Post a Comment