medical reports(11111111111111113222) .pdf
- 1. أ . د /. البقرى السالم عبد آمال اإلكلينيكية السموم و الشرعى الطب قسم رئيس الطب كلية – المنصورة جامعة و لإلستشارات العامة الخدمة مركز مدير التحاليل و الشرعية الطبية Medicolegal aspects of medical reports
- 2. ▪ He shall not give the medical certificate or medical report to anyone other than the patient himself (minor - disclosure of secrets). General Notes
- 3. Notes ▪ The medical certificate must contain truthful facts and information about the patient’s condition (forgery - bribery). ▪ Verifying the identity of the person requesting the medical report or medical certificate ▪ Do not give a medical certificate or medical report about a sick or injured person without seeing him
- 4. Injury reports 1.Primary reports Represents the first examination of injuries before treatments and healing. It is the base for the forensic expert later on • االحراز evidences
- 5. ▪ Medical examination is based on the referral letter issued by the police. ▪ After confirming his identity, the injured patient is presented to the specialist or assistant specialist to prove his injuries and determine the expected time for treatment. ▪ The report is signed by the specialist or assistant specialist and the emergency manager.
- 6. The report must include the following: ▪ Doctor's information (name and position). ▪ Information of the injured person (name, national ID, age, gender, residence, and ticket number). ▪ Incident data: (summary, location, date, time, time before arriving at the hospital). ▪ General medical examination (degree of consciousness, pulse, blood pressure, respiratory rate, temperature, pupil size
- 7. ▪ Accurate data on injuries (type, number, size, edges, angles, shape, tool used, etc.). ▪ Any other injuries (concussion, cerebral compression, coma, shock, bleeding, drug abuse). ▪ Necessary investigations. ▪ Any treatment given to the patient.
- 8. ▪Expected recovery time (less than 20 days or more than 20 days). ▪Any complications (if any). ▪It is preferable to attach a diagram to shade the affected area in an attempt to facilitate the matter. ▪Signature of the treating physician and director.
- 9. According to the Egyptian Criminal law, injuries are legally classified as: 1) Simple (heals in less than 20 days). 2) Serious (heals in more than 20 days/or causes permanent disability). 3) Deadly. According to this classification, penalties range from financial compensation to imprisonment or even death.
- 10. Primary medical reports ▪Issued at the time of admission to the hospital, and medical data are taken from: the initial examinations, and initial diagnosis, recorded in the patient’s ticket. ▪Signed by the specialist or assistant specialist who examined the patient, the head of the department, and the hospital director.
- 11. Final medical reports ▪ In clear language and include a statement of the injuries, the final diagnosis, details of treatment and examinations, the duration of treatment, and complications or permanent disability - if any.
- 12. Final medical reports ▪ The necessary recommendations, as well as the follow-up plan, will be the final judgment of the coroner. ▪It is sent to the prosecution upon request and with official approval.
- 15. Description of all general and local injuries. Report to the police station and the Women’s Safe Unit. Preserving the necessary samples. Sexual assaults
- 16. الوفاة شهادة
- 17. Direct cause of death The medical condition resulted in the above- mentioned cause Original disease
- 18. Direct cause of death Failure of vital brain function. Shock (acute cardiovascular failure). Respiratory failure
- 19. Example A case of stroke Direct cause of death Failure in CNS functions The pathological condition that led to the above-mentioned cause. Cerebral thrombosis The original disease Atherosclerosis Other important medical conditions that contributed to the death and were not related to the direct cause. Diabetes mellitus
- 20. A physician was suffering from frequent attacks of epigasrtic pain relieved by anti-acids. One night, he suddenly developed severe burning abdominal pain with hematemesis. Ambulance arrived while he was pale and shocked. On his way to hospital, he died. Write the death certificate. المباشر السبب : غير صدمه مرتجعه المرضية الحالة عنها نشأ التي المذكور السبب أعاله : دموي قيء األصلي المرض : بالمعدة قرحه
- 22. A child presented to the emergency department complaining from falling downstairs. You are asked to write a report. The best description of this wound is: a) Transverse split wound in the chin b) Elliptical contused wound in the chin. c) Contused wound in the face. d) Transverse contused wound below the right side of the chin. e) Transfers cut wound below the chin.
- 23. This man presented to the ED claiming injury in a quarrel. You are asked to write a report. The best description of this wound is: a) Oblique cut wound in the back of left index finger. b) Cut wound in the index finger. c) Cut wound in the back of the left hand. d) Split wound in the back of left index finger. e) Stab wound in the back of left index finger.
- 24. A woman claimed to be beaten by her husband 2 h ago and presented with the shown injury. The physician reported that it is not a recent contusion. What is your opinion? a) The physician is right as the contusion is blue in colour. b) The physician is right as the contusion is reddish in colour. c) The physician is wrong as the contusion show colour changes. d) The physician is wrong as it is the only injury found. e) The physician is right as there was no associated pain.
- 25. Finally
- 26. ▪ Initial medical reports represent the backbone on which the forensic doctor bases his opinion on the injuries. ▪ Beware of writing inaccurate or incorrect information. ▪ Reporting an assault by others.