General

Example of Expert Medical Report

A medical expert report describes the injuries that a person has suffered as a result of an accident or any other violent event. It is created by an expert medical expert, who reveals all his technical knowledge in an impartial and objective way, so that the document is understood and analyzed by whoever requests it: a judge, for example.

A report of this type must basically contain :

  • Medical expert data
  • The general purpose of the report
  • The identity of the affected
  • Mention and description of the events arranged chronologically
  • Sources on which the report is based (other medical reports or tests performed by the medical expert).
  • Patient’s medical history
  • Detailed diagnosis should differentiate between injuries suffered and sequelae
  • List of injuries and events
  • Damage assessment
  • Report conclusions
  • Expert’s signature
  • Report date

Example of an expert medical report

Francisco Etxeberria Gabilondo, Doctor of Medicine, Professor of Legal and Forensic Medicine at the University of the Basque Country, Specialist in Legal and Forensic Medicine, Registered Physician in Guipúzcoa No. 3538, prepares the following expert medical report at the request of Mr. D Iñigo Elkoro in relation to the injuries suffered by Mr. UNAI ROMANO IGARTUA.

It is of interest to determine the type and scope of the injuries suffered, their date and possible etiologies, as well as their relationship with the version of the events alleged by the injured person himself.

Operations practiced

  1. a) Medical examination of Unai Romano Igartua carried out on July 16, 2004.

He refers to having been subjected to ill-treatment on the night of September 6 to 7, 2001 while he was detained in Madrid. This bad treatment is preferentially described as repeated blows to the head and at different times throughout the night with special relevance in the early morning of 09/07/2001. He cannot specify the object with which he was hit as his head was covered with one or more ski masks. In any case, the blows were given to him from behind, taking into account the position he occupied most of the time in the place where he was and the position of his attackers (one or more). The blows were of different intensity and at all times they respected the face. In addition to the above, on several occasions he was forced to perform body push-ups (going up and down to the squatting position), thus experiencing great fatigue and exhaustion. Likewise, he received some scattered blows of little intensity in other parts of the body that were notably less painful than those received in the head. On at least two occasions he suffered low-intensity electric shocks that, above all, caused him great anguish at the possibility that they would be more intense and repeated. To all of the above are added the insults, humiliations and humiliations that were continuous while he was interrogated. In the moments in which he remained in the dungeon, he was alone and must have remained without sitting down. Likewise, he received some scattered blows of little intensity in other parts of the body that were notably less painful than those received in the head. On at least two occasions he suffered low-intensity electric shocks that, above all, caused him great anguish at the possibility that they would be more intense and repeated. To all of the above are added the insults, humiliations and humiliations that were continuous while he was interrogated. In the moments in which he remained in the dungeon, he was alone and must have remained without sitting down. Likewise, he received some scattered blows of little intensity in other parts of the body that were notably less painful than those received in the head. On at least two occasions, he suffered low-intensity electric shocks that, above all, caused him great anguish at the possibility that they would be more intense and repeated. To all of the above are added the insults, humiliations and humiliations that were continuous while he was interrogated. In the moments in which he remained in the dungeon, he was alone and must have remained without sitting down. To all of the above are added the insults, humiliations and humiliations that were continuous while he was interrogated. In the moments in which he remained in the dungeon, he was alone and must have remained without sitting down. To all of the above are added the insults, humiliations and humiliations that were continuous while he was interrogated. In the moments in which he remained in the dungeon, he was alone and must have remained without sitting down.

  1. b) Study of the documentation of medical interest in direct relation to the case, consisting of:

– Forensic Medical Report of Dra. Leonor Ladrón de Guevara dated 09-07-2001 (recognition carried out on 09-06-2001, at 6:45 pm).

Medical examination of Unai Romano Igartua at the Civil Guard (Madrid). A personal history is described and no injuries are observed. The detainee reports some blows to the head.

– Forensic Medical Report of Dra. Leonor Ladrón de Guevara dated 09-07-2001, time 9:45.

Medical examination of Unai Romano Igartua at the Civil Guard (Madrid). Presents hematoma in blackish glasses with large eyelid enema. Edema and inflammation at the frontal, zygomatic and nasal root levels. Very slight bilateral retroauricular ecchymosis of dark coloration. Incised-contusive wounds on both wrists, with teeth marks. Dates injuries between 4 and 8 hours. The injuries are reported by the detainee as a result of the blows he had received during the previous night, except those to the wrists, which would be self-injury due to the crisis he had when he received the false news of the death of his mother.

Urgent transfer to hospital, being discharged after study at 3:15 pm on the same day 09-07-2001. A cervical collar is fitted. Thrombocid and ice.

The Forensic Doctor recommends admission to the Nursing as the detainee does not meet the conditions to remain in a cell or give a statement before the judicial authority.

New forensic medical examination at 7:00 p.m. in which it is indicated that the swelling of the face is spreading.

Attending in an orderly manner to the existing information, we have the following data:

UNAI ROMANO IGARTUA

Age 24 years

No medical history of interest to the case under discussion

06-09-01 Arrested in Vitoria and taken to Madrid

06-09-01 18:45 h Forensic Medical Examination

Normal

07-09-01 09’45 h Forensic Medical Examination

Finding lesions on the face and frontal region

07-09-01 10’25 h Hospital Admission

Head injury without neurological involvement.

Cervical contracture.

Soft tissue, eyelid, frontal hematoma without intraocular or intracranial involvement.

Headache and neck pain.

Pericranial subgaleal hematomas.

08-09-01 22’30 Medical examination (Prison)

Conscious, oriented, reduction of facial edema with less pain and without dizziness or vomiting or neurological focus.

05-29-02 Forensic Medical Health Report

127 days to healing due to parietal and upper occipital head trauma. Necrotic scalp scale.

Admitted that there was a head injury between the night of September 6 to 7, 2001, it is debatable whether this was caused by a direct blow to the frontal region or by several blows to that and other places on the scalp. The truth is that a few hours after this trauma, the manifestations of generalized edema in the face and all the peripheral soft tissues are very ostensible (see photo of 09-08-01 upon admission to Prison).

While it is true that the most striking part of the case on that date was to rule out neurological lesions whose absence is verified in a qualified way in the Hospital by the tests carried out, the report of the Radiology Service in which the cranial level is noted existence of “pericranial subgaleal hematomas”.

This simply means that there were in addition to the obvious bruises in both orbits with an impediment to the simple opening of the eyes, as well as a rapidly progressing edema (evolution of hours appreciated by the Forensic Doctor) and the limitation of cervical mobility, other hematomas not directly visualized as a consequence of being under the scalp and whose manifestation on the skin would hardly mean more than a minor bulge given the significance of the aforementioned lesions, which are clinically relevant since they can seriously affect the prognosis and require more attention from a medical perspective.

In our opinion, a voluntary frontal trauma against a smooth wall and without interposition of other soft structures is unlikely to produce a generalized edema of the entire neurocranium. It is true that this can occur in the event of very strong head trauma, as is seen in the daily clinic, but this should be accompanied by an outbreak of the skin in the area directly affected with a striking color change at that point accompanied by, at least, with skin abrasion and / or blunt wound that in this case did not exist and would have been very objective.

The absence of this sign is essential to guide the diagnosis, taking into account, in addition, that a voluntary frontal trauma against a wall always determines a greater involvement of soft tissues in the eminent areas of the skull in that area, that is, the right frontal eminences. and left and the superciliary arches (for the frontal bone).

Conclusions

  1. The hypothesis of a strong head trauma in the frontal region seems impossible to us as a trigger for the injuries noticed in the medical examinations during the first hours.
  2. In view of this, it is reasonable to consider that there were several blows of different intensity that reached different parts of the neurocranium.
  3. This circumstance triggered subgaleal hematomas that resolved naturally except in the upper posterior region of the parietal bones, triggering a torpid evolution towards necrosis with superinfection of the scalp and in the absence of specific treatment until the formation of a wide eschar and resolution by unsightly scarring with alopecia.

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