Components of a MLR Identification Injury or illness Signature and date
Identification Requesting party Physician’s name and specialty or degree Patient’s information: N.A.A.S.I: name, age (or date of birth), address, sex, ID Date, time, and place of examination
Traumatic Non-traumatic Identification Identification Injury: Illness Injury description: number, site, size, shape, edges, type Chief signs(s) Instrument and force used Cause Investigations Investigations Intervention Intervention Prognosis: healing period Severity: mild, moderate, (<,> 20 d) and permanent infirmity severe Legal type of injuries: Prognosis: current and simple, dangerous, fatal expected Signature and date Signature and date
Opinion - Trauma Upon the request of the Forensic Medicine Department of ASU, I (physician name) , fourth year student, examined and reviewed records of (person’s name), (persons age) years old male/female patient who lives in (address) with ID (number); on (date) in (place) at (time). I found that he had injury(ies) in the form of (complete description) caused by (instrument description). The following investigation(s) was/were done and showed (findings). Intervention in the form of (…). This injury requires more/less than 20 days for healing with/without leaving a permanent infirmity. The patient has recovered/in recovery/died. He was discharged/is still hospitalized. This injury is simple/dangerous/fatal. Signature and date
Opinion – non trauma Upon the request of the Forensic Medicine Department of ASU, I (physician name) , fourth year student, examined and reviewed records of (person’s name), (persons age) years old male/female patient who lives in (address) with ID (number); on (date) in (place) at (time). I found that he had (chief signs) caused by (disease or agent). The following investigation(s) was/were done and showed (findings). Intervention in the form of (…). The patient has recovered/in recovery/died. He was discharged/is still hospitalized. The case is mild/moderate/severe. Signature and date
Cases You are the attending resident at El Demerdash surgical hospital. At 2 pm, Ahmed Ali 55 year-old male, engineer was brought to the reception room by his son . The son stated that his father received a blow on the head by a stick during a quarrel , he felt down and lost consciousness. On examination you found that the patient was in coma. Vital data were: Pulse 55 beat/min, blood pressure 200/100 with slow respiration. Local examination of the scalp revealed the following lesion. Urgent CT was done showing this finding. Patient was urgently operated upon. Write a full medico legal report for this case.
Ahmed youssef kamel, 22 years old male, alleged that he was beaten by one of his friends today. The police referred him to you in order to write a 1ry medico- legal report & to give your opinion about his allegation.Write the 1ry medico legal report & your opinion about the truthfulness of his allegations.The following slide demonstrate the injury:
Akram Fouad 25-years-old male rush to the ER of El Demerdash Hopital. He was complaining of this lesion, after falling from his motorcycle. He reported that he lost consciousness for 5 min after the fall. Plain X ray skull was done ,it revealed no abnormality. 1) Write a full medico legal report for this lesion. 2) Mention the next investigation which must be done for this special case. 3) What is the medico-legal responsibility of the doctor in this case.
You are the attending resident at El Demerdash hospital. At 4 pm, Ahmed Fouad 25-years-old male, worker in a motor workshop rushed to the reception room accompanied by two of his friends. They stated that Ahmed was injured during a quarrel at the workshop. General examination revealed pallor, tachycardia, hypotension and the following lesion. Urgent X ray was done showing this finding. Urgent treatment started. What are your duties in this case?(main items in short)
Engineer Sami Gaber El-Ashry arrived to El-Demerdash causality, on 16th of May 2011 telling that 2 hours ago, while he was working at the building construction site, a piece of block accidentally fell on his head. Examination revealed the lesion shown in the next slide. He was admitted for observation (suspected brain concussion). He had CT scan on the brain with no remarkable abnormality. He received wound care in the form of stitching, analgesics and antibiotic. He was discharged 48 hours after. Write down a full medico-legal report .
This case was presented to you in Eldemerdash University hospital emergency room. The patient is Mrs. Hala Maged Gouda, 45 years old, housewife from Kalyoubeya who fell off the stairs and complaining of pain and swelling in her left leg. An x-ray was done and her leg was bandaged. An analgesic was prescribed and she was advised to rest in bed. Write down a full medico-legal report .
Fahmy El-Kazzaz is a 50 years old man who was presented to the ER two days ago after a hit-and-run accident by about 30 minutes. According to the patient, he was first hit in the thighs then thrown up on the front bonnet then fell to the ground. O/E a single irregular bruise (20x15 cm) was found on lateral aspect of the right thigh with edema and tenderness. An x-ray for that thigh was obtained and revealed two irregular fractures of the right femur. He was operated upon and a nail was inserted. He is still in the hospital.
Eman Farouk Naguib is 34 years old housewife referred to you from the police station to issue a medical report. She claimed that during an argument with her neighbor, she was hit by a stick on her left forearm 3 hours ago. O/E two wounds were observed on the lateral aspect of the left forearm about 7 and 10 cm long. Edges were regular with gaping and no bridging, bruises or abrasions. The wound was sterilized and sutured.
Atef Abdel Naeem is 59 years old diabetic hypertensive man with chronic renal failure who is doing regular sessions of hemodialysis. He was presented to the ER an hour after his colleague pushed him on the stairs in the workplace. O/E multiple abrasions and contusions (smallest 2x2 cm, largest 15x10 cm) were observed on forearms, ankles and forehead. Skin of abdomen was normal, but abdominal US revealed abdominal fluid collection and ruptured left kidney for what it was surgically removed. Patient was discharged a week later.
Saly Ibrahim Salama is a 21 years old medical student. She was presented to Poison Control Center 6 hours after ingesting 40 Aspirin 325 mg tablets. She was presented by repeated vomiting, abdominal pain and air hunger. O/E she was obtunded, pale, hypotensive, tachypnic, tachycardic with moist skin. Chest auscultation showed bilateral fine basal crepitations. Epigastric tenderness was also found. Hyper-reflexia and muscle twitches were observed that rapidly progressed into seizures. ABG revealed metabolic acidosis with salicylate level of 85 mg/dL. She was admitted to the ICU where she is sedated, mechanically ventilated and kept on vasopressors and inotropics.
Esraa Ali Nasef is a 29 years old, 36 weeks pregnant housewife who was presented to ER with heroic vaginal bleeding. O/E she was obtunded, pale, hypotensive, tachypnic, tachycardic with moist skin. Pelvic-Abdominal U/S revealed placenta previa. She was immediately blood transfused and underwent caesarian section. Then, she was admitted to ICU where she stayed for 3 days. Afterwards she moved to inpatient and discharged from hospital after another 3 days.
This injury wasfound on theanterior chest wallof a 40 y oldpatient calledSayed El Arabiwho died in thehospital on the daythe photographwas taken. Itmeasured 10x5 cm.
Ali Ahmed El-Foulyis 6 years old boywho was presentedto you at the ER withleft arm edema, painand loss ofmovement. Youdecided an x-ray onthat arm.You treated him andthen he wasdischargedimmediately.