Concluded Case

Draft for injury writing

A 61yrs old female.of physical assult came in opd with c/o pain on head and tight shoulder due to beatten by someone. more pain shoulder. she is not able to lift hand. plz write some draft for Medico legal purpose.

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Concluded answer
Patient Particulars: Name Age Sex Identification marks Address: Vill PO / Ward, Police Station. Brought by-His/Her full details. Relationship with patient. Date and time of Assault. Place of assault ( Police Station must be included). Nature of wound. Site of wound. Which weapon used- Details of weapon in length etc. Details of wound- like abrasion,cut Injury ( type ,grade, diameters) etc. Examination by Medical personnel: Date time of Examination. Place. In presence of. Vitals. Wound examination proper- cut Injury, blunt injury etc. Treatment accordingly. (In this case treatment: Analgesic. PPI. Ice Compress. X-ray shoulder. Consult with Orthopaedician.) Sign of Doctor Full signature Designation Registration no Date Time Place Sign of a One or two witnesses. Thank you very much. Hopefully it will helpful.
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Patient Particulars: Name Age Sex Identification marks Address: Vill PO / Ward, Police Station. Brought by-His/Her full details. Relationship with patient. Date and time of Assault. Place of assault ( Police Station must be included). Nature of wound. Site of wound. Which weapon used- Details of weapon in length etc. Details of wound- like abrasion,cut Injury ( type ,grade, diameters) etc. Examination by Medical personnel: Date time of Examination. Place. In presence of. Vitals. Wound examination proper- cut Injury, blunt injury etc. Treatment accordingly. (In this case treatment: Analgesic. PPI. Ice Compress. X-ray shoulder. Consult with Orthopaedician.) Sign of Doctor Full signature Designation Registration no Date Time Place Sign of a One or two witnesses. Thank you very much. Hopefully it will helpful.
She is asulted Go for police complaints Do thorough medicolegal examination Note down her age and confirm by dob Note dow her id Take her thumb impression and contact numbers Locally examine the asulted area and note down extent and nature of inury if it is minor you attend or if it is grevious send to medicolegal expert Get xrays of injured area and look for bone injuries You can give her first aid Inj tt Some analgesics and supportive treatmen
Agree@Shivraj Agarwal
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A Medico-Legal Case can be defined as a case of injury or ailment, etc., in which investigations by the law-enforcing agencies are essential to fix the responsibility regarding the causation of the injury or ailment. ... Or a legal case requiring medical expertise when brought by the police for examination.
Without X-ray if shoulder joint &Head unable to write medico legaldraft
Both the X ray is normal
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Agree@Shivraj Agarwal