Strangulation Assessment

🧍‍♀️ Presenting Complaint: [describe the patient's reason for visit, including any incidents or events leading to the consultation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) 🗣️ History (Subjective): Chief concern: "[insert patient's own words]" (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in quotation marks using the patient’s exact phrasing.) Date/time of incident: [insert date and approximate time of the incident] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) Location: [describe the setting of the incident, e.g. private home, public place, other – specify] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) Assailant: [Indicate if known or unknown. Specify relationship, e.g. partner, ex-partner, acquaintance, other] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) Mechanism of strangulation: - Pressure type: ☐ Manual (hands) ☐ Ligature (cord, rope, clothing) ☐ Forearm/chokehold - Duration of pressure: [insert time in seconds/minutes or state “unknown”] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) Consciousness: - Loss of consciousness: ☐ Yes ☐ No ☐ Unsure - Memory of event: ☐ Fully intact ☐ Partial ☐ Amnesic for part/all (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) Symptoms during/after strangulation: - ☐ Shortness of breath / Difficulty breathing - ☐ Voice change - ☐ Difficulty swallowing - ☐ Painful throat - ☐ Tongue swelling - ☐ Neck pain - ☐ Headache - ☐ Dizziness - ☐ Loss of vision or blurry vision - ☐ Auditory changes - ☐ Incontinence (urine/stool) - ☐ Vomiting - ☐ Confusion or disorientation (Only include symptoms if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Convert checked items into full sentences.) Other history: - Any blows to head or body: ☐ Yes ☐ No - Current medications: [insert medications] - Past medical history: [insert relevant history, especially bleeding/clotting disorders] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) Patient’s current concerns: [insert patient’s current concerns — e.g. fear for safety, ongoing symptoms, intention to report, etc.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) 🩺 Examination (Objective): General appearance: [describe appearance e.g. Alert / Distressed / Tearful / Anxious / Other] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) Vital signs: - BP: [insert] - HR: [insert] - RR: [insert] - Temp: [insert] - SpO₂: [insert] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write each parameter in full sentence.) Head and neck exam: - ☐ Neck tenderness - ☐ Bruising or abrasions - ☐ Ligature mark or pattern injury - ☐ Swelling or redness - Voice: ☐ Hoarse ☐ Normal - Neck range of motion: [insert findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Convert checked items into full sentences.) ENT findings: - Petechiae in oral cavity: ☐ Yes ☐ No - Tympanic petechiae: ☐ Yes ☐ No - Other trauma: ☐ Yes ☐ No (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write findings as full sentences.) Neurological exam: - GCS: [insert score] - Cranial nerves: [Normal / Abnormal – specify] - Motor/sensory: [Normal / Abnormal – specify] - Balance/gait: [Normal / Abnormal – specify] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write each item in full sentence.) 🧪 Investigations: - ☐ CT neck with contrast ordered - ☐ Photographs taken (with consent) (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write findings and orders as full sentences.) 🧾 Assessment: Alleged non-fatal strangulation. [Summarise whether symptoms and/or clinical signs are consistent with the patient's account.] [Note whether red flags or signs of vascular/airway injury are present or absent.] [Include statement that trauma-informed care was provided.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) 🧠 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 / forensic service / ED] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Convert checked items into full sentences.) 📝 Legal / Consent Notes: - Informed consent obtained for examination and photography. - Factual documentation completed. - Referral pathway activated as per forensic protocol. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)