Strangulation Assessment

🧍‍♀️ Presenting Complaint: The patient presents today following an incident of strangulation. She reports being strangled by her partner during an argument. 🗣️ History (Subjective): Chief concern: "He tried to kill me." Date/time of incident: The incident occurred on 31 October 2024 at approximately 22:00. Location: The incident occurred at the patient's private home. Assailant: The assailant was the patient's partner. Mechanism of strangulation: - Pressure type: ☐ Manual (hands) ☐ Ligature (cord, rope, clothing) ☒ Forearm/chokehold - Duration of pressure: 30 seconds. Consciousness: - Loss of consciousness: ☒ Yes ☐ No ☐ Unsure - Memory of event: ☐ Fully intact ☐ Partial ☒ Amnesic for part/all Symptoms during/after strangulation: - ☒ Shortness of breath / Difficulty breathing - ☒ Voice change - ☒ Neck pain - ☒ Headache - ☒ Dizziness Other history: - Any blows to head or body: ☐ Yes ☒ No - Current medications: Sertraline 50mg daily. - Past medical history: No significant past medical history. Patient’s current concerns: The patient is fearful for her safety and is concerned about the possibility of future violence. 🩺 Examination (Objective): General appearance: The patient appears distressed and tearful. Vital signs: - BP: 130/80 - HR: 90 - RR: 20 - Temp: 37.0 - SpO₂: 98% Head and neck exam: - ☒ Neck tenderness - ☒ Bruising or abrasions - ☐ Ligature mark or pattern injury - ☐ Swelling or redness - Voice: ☒ Hoarse ☐ Normal - Neck range of motion: Reduced due to pain. ENT findings: - Petechiae in oral cavity: ☐ Yes ☒ No - Tympanic petechiae: ☐ Yes ☒ No - Other trauma: ☐ Yes ☒ No Neurological exam: - GCS: 15 - Cranial nerves: Normal. - Motor/sensory: Normal. - Balance/gait: Normal. 🧪 Investigations: - ☒ CT neck with contrast ordered - ☒ Photographs taken (with consent) 🧾 Assessment: The patient's symptoms and clinical signs are consistent with her account of non-fatal strangulation. There are no immediate red flags or signs of vascular or airway injury. Trauma-informed care was provided. 🧠 Plan: - ☒ Radiology referral for CT neck (vascular protocol) - ☒ Analgesia - ☒ Medical monitoring if indicated - ☒ Mental health support offered - ☒ Safety plan discussed - ☒ Referral to crisis services / police (with consent) - ☐ Oranga Tamariki notified (if under 18 or vulnerable adult) - ☒ Follow-up with GP 📝 Legal / Consent Notes: - Informed consent obtained for examination and photography. - Factual documentation completed. - Referral pathway activated as per forensic protocol.