Private Finished Ariel's Reports

DATE OF ADMISSION: 09/20/2017

PATIENT NAME: Ariel Rowe
PATIENT DOB/AGE: Nineteen/May 12, 1998
PATIENT GENDER: Female

CHIEF COMPLAINT: Extensive physical trauma. Possible Sexual assault

HISTORY OF PRESENT ILLNESS: Patient was brought in by her older sister. Bruising and blunt force trauma consistent with physical assault present upon immediate examination. Further examination reveals trauma consistent with violent sexual trauma. Patient insists that she was not raped and that she had consensual sex.

REVIEW OF SYSTEMS: Unavailable.
ALLERGIES: None.
MEDICATIONS: None.
PAST MEDICAL HISTORY: Unavailable.
CURRENT MEDICATIONS: None.
ALLERGIES: None.

SOCIAL HISTORY: Rarely consumes alcohol, None smoker, No drug abuse

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 146/80, pulse 96, respirations 21, temperature is 97.5 and O2 saturation is 94% on room air.
SKIN: Skin is pale, warm and dry. Turgor is good. There are no lesions, rashes or ecchymoses.
NECK: Extensive bruising around the throat consistent with strangulation
CHEST: Clear with good breath sounds, inspiratory and expiratory. Multiple bruises along the rib line. Possible rib fracture.
CARDIAC: Regular rate and rhythm without murmur, gallop or rub.
PELVIS: Exam revealed sexual trauma. Tear in hymen. Multiple signs of intercourse

INTERVENTION: The patient will be discharged to home. Has been advised to avoid any and all heavy lifting while recovering. The patient is to remain on bed rest and follow up with her family physician as soon as possible. Recommend STD test. Recommended that the patient seeks to counseling for psychological trauma.

INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT
Full Name: Ariel Rowe
Home Address: Starlight Academy, Female Dorms, 301
Student Employee  Visitor  Vendor 
Phone Numbers: Home: ——--NA-——- Cell: (555) 555-1991 Work: ——--NA-——-

INFORMATION ABOUT THE INCIDENT
Date of Incident: 09/24/2017
Time: 10 pm
Police Notified: Yes  No
Location of Incident: Downtown Apartments. Actual Address unknown.

Description of Incident:
-Victim Claims she was attacked by an unknown assailant.
-Ariel was on her way to see her boyfriend Jason Todd. Shortly after exiting the bus she was attacked and pushed into an alley. She was struck several times all over the body, including her inner thighs, her ribs, and her face. Was also severely choked before the assailant fled on foot.
-Ariel can provide no description of the assailant and has no idea what may have motivated an otherwise random assault.
-Stated her boyfriend was angry with her.
-Stated she does not want to cause problems for her boyfriend.
-After assault occurred Ariel went home to sleep. Her sister took her to the hospital the next morning where she was treated.

Were there any witnesses to the incident?  Yes No
If yes, attach a separate sheet with names, addresses, and phone numbers.
-No Witnesses to the actual incident, however, Victims sister possibly has more information. Will follow up.

Was the individual injured? If so, describe the injury (laceration, sprain, etc.), the part of body injured, and any other information known about the resulting injury(ies).
-Extensive bruising on torso, thighs face and throat.
-Multiple shallow lacerations on back and thighs.
-Possible sexual Trauma

Was medical treatment provided? Yes No  Refused 
If yes, where was treatment provided: on-site  Urgent Care  Emergency Room Other 

REPORTER INFORMATION
Individual Submitting Report (print name): Roldan Drakenhardt
Signature:
Date Report Completed: 09/26/2017


FOR OFFICE USE ONLY

Document any follow-up action taken after receipt of the incident report.

[xtable=skin1|704x145]
{tbody}
{tr}
{td}Date{/td}
{td}Action Taken{/td}
{td}By Whom{/td}
{/tr}
{tr}
{td}09/26/2017{/td}
{td}Contacted Hospital to Obtain Medical Report (Attached to Report){/td}
{td}Roldan Drakenhardt{/td}
{/tr}
{tr}
{td}09/27/2017{/td}
{td}Contacted Brigid Rowe (Sister of Victim){/td}
{td}Roldan Drakenhardt{/td}
{/tr}
{tr}
{td}09/27/2017{/td}
{td}Attempted to locate Jason Todd for questioning (Unsuccessful){/td}
{td}Roldan Drakenhardt{/td}
{/tr}
{tr}
{td}09/28/2017{/td}
{td}Attempted to locate Jason Todd for questioning (Unsuccessful){/td}
{td}Roldan Drakenhardt{/td}
{/tr}
{/tbody}
[/xtable]

INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT
Full Name: Ariel Rowe
Home Address: Starlight Academy, Female Dorms, 301
Student Employee  Visitor  Vendor 
Phone Numbers: Home: ——--NA-——- Cell: (555) 555-1991 Work: ——--NA-——-

INFORMATION ABOUT THE INCIDENT
Date of Incident: 10/10/2017
Time: 7:45 pm
Police Notified: Yes No 
Location of Incident: Downtown Apartments. Actual Address unknown.

Description of Incident:

-Victim (Ariel Rowe) Was attacked by her boyfriend when she revealed that she was pregnant.
-He viciously beat her, kicking at her stomach and hitting her repeatedly.
-According to the victim, this was not the first time.
-A previous police report confirms that it was the Alleged Jason Todd who attacked her prior, as well as now.
-Assailant threatened Victims Life if she did not leave his home.
-The victim fled the scene to get help.
-Medical report confirms the victim is pregnant.

Were there any witnesses to the incident?  Yes No
If yes, attach a separate sheet with names, addresses, and phone numbers.
-No Witnesses to the actual incident.

Was the individual injured? If so, describe the injury (laceration, sprain, etc.), the part of body injured, and any other information known about the resulting injury(ies).
-Extensive bruising on torso, face, and throat.
-Extensive and deep bruising of lower abdomen

Was medical treatment provided? Yes No  Refused 
If yes, where was treatment provided: on-site  Urgent Care  Emergency Room Other 

REPORTER INFORMATION
Individual Submitting Report (print name): Roldan Drakenhardt
Signature:
Date Report Completed: 10/09/2017


FOR OFFICE USE ONLY

Document any follow-up action taken after receipt of the incident report.

[xtable=skin1|704x145]
{tbody}
{tr}
{td}Date{/td}
{td}Action Taken{/td}
{td}By Whom{/td}
{/tr}
{tr}
{td}10/09/2017{/td}
{td}Attempted to contact and locate Jason Todd (Unsuccessful){/td}
{td}Roldan Drakenhardt{/td}
{/tr}
{tr}
{td}10/09/2017{/td}
{td}Issued city wide arrest warrant for Jason Todd{/td}
{td}Roldan Drakenhardt{/td}
{/tr}
{tr}
{td}10/09/2017{/td}
{td}Followed up with Victim for further questioning{/td}
{td}Roldan Drakenhardt{/td}
{/tr}
{tr}
{td}10/10/2017{/td}
{td}Continued to attempt to locate Jason Todd for questioning (Unsuccessful){/td}
{td}Roldan Drakenhardt{/td}
{/tr}
{/tbody}
[/xtable]

DATE OF ADMISSION: 10/09/2017

PATIENT NAME: Ariel Rowe
PATIENT DOB/AGE: Nineteen/May 12, 1998
PATIENT GENDER: Female

CHIEF COMPLAINT: Extensive physical trauma. Possible Sexual assault

HISTORY OF PRESENT ILLNESS: Patient arrived with her sister for treatment in regards to an assault. She does have multiple older injuries consistent with abuse, as well as previous medical reports that confirm history. Patient has also stated that she is pregnant as per the results of a home pregnancy test.

REVIEW OF SYSTEMS: Unavailable.
ALLERGIES: None.
MEDICATIONS: None.
PAST MEDICAL HISTORY: Unavailable.
CURRENT MEDICATIONS: None.
ALLERGIES: None.

SOCIAL HISTORY: Rarely consumes alcohol, None smoker, No drug abuse

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 153/84, pulse 102, respirations 23, temperature is 98.5 and O2 saturation is 96% on room air.
SKIN: Skin is pale, warm and dry. Turgor is good. There are no lesions, rashes or ecchymoses.
NECK: Extensive bruising around the throat
CHEST: Clear with good breath sounds, inspiratory and expiratory. Multiple bruises along the rib line. Possible rib fracture.
CARDIAC: Regular rate and rhythm without murmur, gallop or rub.
PELVIS: Multiple bruises along pelvic region, consistent with blunt force trauma.
LAB: Confirmed Positive for pregnancy

INTERVENTION: The patient will be discharged to home. Has been advised to avoid any and all heavy lifting while recovering. The patient is to remain on bed rest and follow up with her family physician as soon as possible. The patient is to follow up with OBIGyn as well as register for prenatal classes. Follow up therapy recommended