Comprehensive Child Abuse Evaluation Consult

PATIENT INFORMATION

NAME OF PATIENT: [Patient Name] DATE OF EVALUATION: [Click here to enter a date.] DATE OF BIRTH: [Patient DOB] PATIENT NUMBER: [Patient Number] PRIMARY CARE PHYSICIAN: [Name of the primary care physician] PERSON ACCOMPANYING PATIENT: [brought in by] EXAMINING PHYSICIAN: Carol Chervenak, MD ATTENDANT: [Name of Attendant]

CHIEF COMPLAINT

[Document the patient's age and gender, and the reason for today's clinic visit.] This [X year old] [gender], is brought to the clinic today for evaluation of [Chief Complaint].

HISTORY OF THE ALLEGATION

[Provide a detailed history of the allegation, including contact with relevant personnel and any screening reports or medical records reviewed.] The ABC House personnel were contacted about the above concerns by [Referral] The following report are [reviewed/not available] 1) ODHS Screening Report # [Report Number], dated [date of screening report [Short summary of the Verbal reports from the patient] 2) Samaritan Health Services medical records: Reviewed. Most recent well child check was [Click here to enter a date.] with [provider] at age [Age]. Concerns include [Concerns]. 3) ABC House medical records for [NAME & DOB] are reviewed. With the [brought in by] privately, current concerns and medical history are reviewed. Present for the review are [Interviwer] and this examiner Carol L Chervenak, MD.

PAST MEDICAL HISTORY

[Life of past medical History if mentioned]

PATIENT INTERVIEW

Medical indications for comprehensive examination are discussed in detail and agreed upon. [Patient NAME & AGE] is invited to the examination room with this examiner, following an introduction and explanation of my role as the physician. In the examination room, privately, current concerns and medical history are reviewed. I asked [NAME] to tell me why [she/he] is at ABC House today. Following History provided by [Brought in by, such as Biological mother, father etc...] [NAME of BIB]

PAST SURGICAL HISTORY

[PAST SURGICAL HISTORY if mentioned]

BIRTH HISTORY

[Birth History, If mentioned]

DEVELOPMENTAL HISTORY

[List of developmental history if mentioned]

IMMUNIZATION HISTORY

[Immunization status, such as up to date per Oregon Immunization records, No immunizations received, no immunizations by parent's informed choice, and delayed per oregon immunization records' needs]

ALLERGIES

[Allergies if mentioned, otherwise No known hospitalizations/operations]

HOSPITALIZATIONS/OPERATIONS

[List if mentioned, other wise No known hospitalizations/operations.]

OB/GYN HISTORY

[List of OB/GYN HISTORY if mentioned] Menarche: [If mentioned] Onset: [If mentioned] Duration: [If mentioned] days

CURRENT MEDICATIONS

[List of current medications]

GENERAL HEALTH

[List if mentioned, otherwise state the child's general health is good]

REVIEW OF SYSTEMS

[For each system, provide a detailed narrative of the child's recent history, including any symptoms or lack thereof. Ensure to cover all relevant aspects of each system as outlined below. Use a narrative paragraph style consistent with the input content.] - Gastrointestinal: [Summarize the child's recent history regarding toilet training, constipation, abdominal pain, blood in stool, GI symptoms, rectal bleeding, and encopresis.] - Allergic/Immunologic: [Summarize the child's recent history regarding allergic or immunologic symptoms and seasonal allergies.] - Constitutional Symptoms: [Summarize the child's recent history regarding accidental ingestion, constitutional symptoms such as fever, headache, nausea, dizziness, nausea and vomiting, and sleep problems.] - Ears, Nose, Mouth, Throat: [Summarize the child's recent history regarding bleeding gums, ear infection, and symptoms involving ear, nose, mouth, or throat.] - Eyes: [Summarize the child's recent history regarding eye or vision problems.] - Genitourinary: [Summarize the child's recent history regarding accidental injury to the anogenital area, anogenital bleeding, anogenital discharge, blood in urine, dysuria, GU symptoms, invasive medical procedures of the anogenital area, urinary incontinence, urinary tract infection, vaginitis, and enuresis.] - Hematologic/Lymphatic: [Summarize the child's recent history regarding bleeding problems and easy bruising.] - Integumentary: [Summarize the child's recent history regarding cultural practices resulting in skin injury, skin-related symptoms, and acne problems.] - Musculoskeletal: [Summarize the child's recent history regarding fractures.] - Psychiatric: [Summarize the child's recent history regarding nightmares, depression, and intentional overdose.] - Respiratory: [Summarize the child's recent history regarding breathing difficulties, respiratory symptoms, cough, recent asthma attack, and wheezing.]

FAMILY HISTORY

[Document relevant family medical history.]

SOCIAL HISTORY

[list the following per instruction, and list none if not mentioned] - BIOLOGICAL MOTHER: [Name, Date of Birth] - BIOLOGICAL FATHER: [Name, Date of Birth] - SIBLINGS: [Name(s), Date(s) of Birth] - PARENTAL PARTNER HISTORY: [Details about the biological parents' relationship, current partners, and duration] - CURRENT HOUSEHOLD MEMBERS: [List all current household members, including names, relationships to the patient, and relevant details.] - CUSTODY INFORMATION: [Custody arrangement and any significant history] - RESIDENCE HISTORY: [Details of all living arrangements, including with whom and for how long.] - CARETAKERS: [List of caretakers involved in the child’s life and their relationships to the patient.] - DAILY CARE: [Details on independence in daily activities like toileting, bathing, and sleeping.] - PRIOR CONCERNS OF ABUSE: [State As per HPI] - PRIOR AGENCY INVOLVEMENT: [List details of agency involvement, including specific dates, allegations, and findings] - DISCIPLINE METHODS: [Details about the discipline methods used in the household] - DRUG AND ALCOHOL USE IN FAMILY: [History of drug/alcohol use of all family members including onset, current usage, treatment history, storage of substance,s and other details] - DRUG AND ALCOHOL USE BY PATIENT: [Details or “None.”] - WEAPONS EXPOSURE: [Details or “None.”] - DOMESTIC VIOLENCE EXPOSURE: [Details of any domestic violence exposure.] - PORNOGRAPHY or ADULT SEXUAL ACTIVITY EXPOSURE: [Details or “None identified.”]

PHYSICAL EXAM

Present during the exam are the medical assistant [Medical Assistant's Name], the examiner Dr. Carol Chervenak, and patient X. During the examination the patient is relaxed and cooperative. GENERAL: BP sitting: [Blood Pressure] Height: [Height] Weight: [Weight] BMI: [BMI] [Patient's age, gender, ethnicity, appearance, and general condition, e.g., "Patient is a [age]-year-old [ethnicity and gender] in no apparent distress, well-developed, and well-nourished."] HEENT: [Describe the head, eyes, ears, nose, and throat examination findings. Include details such as head shape, eye response (PERRLA), extraocular movements (EOMI), fundoscopic findings, nasal examination, oropharyngeal mucosa, and tympanic membranes.] NECK: [Describe the neck examination findings. Include details such as the presence or absence of adenopathy, thyromegaly, and neck suppleness.] LUNGS: [Describe the lung examination findings. Include details such as air movement, presence or absence of wheezes, rales, or rhonchi, and overall lung clarity.] CARDIOVASCULAR: [Provide a detailed summary of the cardiovascular examination findings. Include information about the heart rate and rhythm, presence of heart sounds (S1, S2), and absence or presence of additional sounds such as S3, S4, or murmurs. Use a narrative paragraph style to maintain consistency with the input content.] CHEST/BREASTS: [Provide a detailed description of the chest or breast examination. Include whether the breast exam was deferred, declined, or refused by the patient. If the exam was conducted, describe the findings, such as normal male chest, sexual maturity rating (1-5) for female breasts, and note any skin abnormalities, nipple discharge, or dominant nodules.] ABDOMEN: [Describe the condition of the abdomen, including details about softness, tenderness, bowel sounds, and presence or absence of hepatosplenomegaly.] NEUROMUSCULAR: [Summarize the neuromuscular findings, including movement of extremities and presence or absence of focal findings.] EXTREMITIES: [Detail the condition of the extremities, noting the presence or absence of clubbing, cyanosis, edema, or deformity.] SKIN: [Detail of Skin inspection, including unusual scars, lesions, or bruising.] GENITALIA: [Provide a detailed description of the genital examination if performed. Include the Sexual Maturity Rating, hygiene status, presence or absence of groin lymphadenopathy, and the condition of the inner thighs, mons pubis, clitoral hood, labia majora, urethral opening, labia minora, posterior fossa, and posterior fourchette.] [Describe the hymen, including its shape, estrogenization, vascularization, edge, and width. Mention the presence or absence of scars, clefts, or tears. Specify if saline was applied for improved visualization and the positions used during the examination (e.g., frog-leg position, knee/chest position).] ANAL: [Provide a detailed description of the anal examination if performed. Include the condition of the perineal body, buttocks, and the pattern of anal rugae. Describe the findings of the anal exam, noting the presence or absence of unusual structures, scars, fissures, bruises, discharge, or abnormal dilation.]

ADDITIONAL COMMENTS

HISTORY FROM THE CHILD

DIAGNOSTIC FINDINGS

[Summarize the diagnostic findings from the reported history, today's exam, and any specific examinations conducted.] Reported History: [Details] History from the child in today’s exam: [Details] General Physical Exam: [Details] Anogenital Exam: [Details]

SUMMARY

Based on the history available to me today and today’s examination, [Summary of findings and conclusions] Additional Concerns or Diagnosis: 1. [Concern/Diagnosis In a detailed narrative style] 2. [Concern/Diagnosis In a detailed narrative style]

PLAN

DHS, Law Enforcement, and the patient’s primary care provider have been notified regarding this evaluation and the concerns for the child. Counseling options and resources for the non-offending caretaker were discussed. Discipline strategies were discussed. Caretaker education was done around issues of child sexuality, activity and trauma. Caretaker education was done regarding [diagnoses like ADHD and PTSD] Parenting classes to address issues of appropriate discipline and supervision are recommended. The child is referred back to her primary care physician for further care. It is recommended that the patient have no further contact with the alleged offender pending further evaluation. [Any additional recommendations specific to the child’s situation.]