Proficient Homework

How would you document your interview (history) and examination findings (physical)?

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You are a medicolegal death investigator for a Medical Examiner’s Office.  The Chief Medical Examiner wants to have her office become involved in “clinical forensic medicine” (something the Spitz text calls clinical forensic pathology) — the application of forensic medicine and pathology to the living.  The CME makes a deal with a local university teaching hospital:  The ME’s Office will provide autopsy reports on all trauma deaths, and others as requested, to the physicians or surgeons treating said patients, and will present interesting cases once per month at Forensic Autopsy Rounds for the residents in Emergency Medicine and General Surgery.  In addition, residents will rotate through the ME’s Office for 2 weeks as part of their specialty training.  In exchange, medicolegal death investigators will be able to spend training time in the emergency department seeing trauma in the living patient, and also interviewing patients, with a view to developing the skills to see such patients in the future, when the medicolegal investigator will conduct an examination, render an opinion as to the type and probable cause of injury, document same, and give expert testimony in court.  You will be registered as a “Visiting Allied Health Professional,” and pursuant to the laws of your state, may function within your scope of practice, which has been agreed to by the CME and the hospital’s Chief of Medical Education.

While on a Clinical Forensic Medicine rotation, an Emergency Medicine attending physician approaches you and asks your opinion on a 37-year-old female who came into the emergency department for treatment of complaints of neck pain.  The EM attending states “The resident who saw her says her story doesn’t jive with the physical findings.  I told the patient I wanted a ‘Forensic Investigator’ to see her (although I didn’t say you were a ‘Death Investigator’ because I thought it would scare the daylights out of her).  She agreed to talk with you and submit to a non-invasive examination.”

a)   What would be your approach to this patient?

b) What do you say to this patient?

c) What do you want to find out?

d) For what specific examination findings would you search?

e) How would you document your interview (history) and examination findings (physical)?

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