𝘿𝙤𝙢𝙖𝙞𝙣 𝙀𝙭𝙥𝙖𝙣𝙨𝙞𝙤𝙣© - A BNHA FIC

ᴍᴇᴅɪᴄᴀʟ ᴇxᴀᴍɪɴᴀᴛɪᴏɴ ʀᴇᴘᴏʀᴛ

Mention of cuts/bruises.

セントラル病院

Central Hospital

Health/Care Report

Dr Isagawa - Primary Care Physician

Dr Suzuki - Attending Care Physician

Dr Kato - Attending Care Physician

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PATIENT INFORMATION :

NAME : Y/N ???

GENDER : Female

D.O.B : No Relevant Information

AGE : 5 years (est)

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PARENT/GUARDIAN INFORMATION :

MATERNAL PARENT : No Relevant Information

PATERNAL PARENT : No Relevant Information

LEGAL GUARDIAN/S :No Relevant Information

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REPORT :

General: Small for age, appears malnourished. Child is unkempt, with dirty clothing and hair. Distant, unresponsive to verbal stimuli.

EXTERNAL INJURIES :

Multiple bruises of varying sizes and stages of healing on the arms, particularly the left forearm and upper arm. Large contusion on the right thigh, approximately 8 cm in diameter, purplish in colour. Bruises on the lower back and left ribcage, suggestive of blunt force trauma. Small lacerations on the knees, consistent with falls or abrasions, partially scabbed over. Healing laceration on the left cheek, approximately 3 cm in length. Multiple superficial cuts on both forearms, some fresh and others healing.

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INTERNAL INJURIES:

MENTAL STATUS : Withdrawn, does not follow commands or respond to questions.

CRANIAL NERVES : Grossly intact as far as can be assessed given the child's lack of cooperation.

MOTOR : Full range of motion in all extremities, though movements are guarded and hesitant.

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DIAGNOSIS :

Multiple contusions and lacerations, consistent with physical abuse.

Signs of severe neglect, with malnutrition and poor hygiene.

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The patient will remain admitted under close observation while the social and legal aspects are addressed. A multidisciplinary team has been assembled to ensure comprehensive care, including medical, psychological, and social support.

Physician Signature:

Dr. Hiro Isagawa

Primary Physician