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Is it a request to examine the patient and to prepare a report on present condition and prognosis? Is it a request for an expert opinion on the management of another practitioner for the purposes of a medical negligence claim? The request should be studied carefully to ascertain what is required and clarification sought where necessary in the case of any ambiguity cheap dostinex 0.5mg line menstruation after tubal ligation. The fee or at least the basis on which it is to be set should also be agreed in advance of the preparation of the report dostinex 0.5mg discount women's health clinic ucla. If necessary 0.25mg dostinex with mastercard pregnancy day by day, the appropriate consents should be obtained and issues of confidentiality addressed order dostinex 0.25mg free shipping womens health 3 day cleanse. A medicolegal re- port may affect an individual’s liberty in a criminal case or compensation in a personal injury or negligence action. A condemnatory report about a profes- sional colleague may cause great distress and a loss of reputation; prosecuting authorities may even rely on it to decide whether to bring homicide charges for murder (“euthanasia”) or manslaughter (by gross negligence). Reports must be fair and balanced; the doctor is not an advocate for a cause but should see his or her role as providing assistance to the lawyers and to the court in their attempt to do justice to the parties. It must always be conisdered that a report may be disclosed in the course of legal proceedings and that the author may be cross-examined about its content, on oath, in court, and in public. A negligently prepared report may lead to proceedings against the author and perhaps even criminal proceedings in exceptional cases. Certainly a civil claim can be brought if a plaintiff’s action is settled on disadvantageous terms as a result of a poorly prepared opinion. The form and content of the report will vary according to circumstances, but it should always be well presented on professional notepaper with relevant dates and details carefully documented in objective terms. Care should be taken to address the questions posed in the letter of instructions from those who commissioned it. If necessary, the report may be submitted in draft before it is finalized, but the doctor must always ensure that the final text represents his or her own professional views and must avoid being persuaded by counsel or solicitors to make amendments with which he or she is not content: it is the 54 Palmer doctor who will have to answer questions in the witness box, and this may be a most harrowing experience if he or she makes claims outside the area of expertise or in any way fails to “come up to proof” (i. In civil proceedings in England and Wales, matters are now governed by the Civil Procedure Rules and by a Code of Practice approved by the head of civil justice. Any practitioner who provides a report in civil proceedings must make a declaration of truth and ensure that his or her report complies with the rules. Additionally, the doctor will encounter the Coroners Court (or the Procurators Fiscal and Sher- iffs in Scotland), which is, exceptionally, inquisitorial and not adversarial in its proceedings. A range of other special courts and tribunals exists, from eccle- siastical courts to social security tribunals; these are not described here. The type of court to which he or she is called is likely to depend on the doctor’s practice, spe- cialty, and seniority. The doctor may be called to give purely factual evidence of the findings when he or she examined a patient, in which case the doctor is simply a professional witness of fact, or to give an opinion on some matter, in which case the doctor is an expert witness. Usually the doctor will receive fair warning that attendance in court is required and he or she may be able to negotiate with those calling him or her concerning suitable dates and times. Many requests to attend court will be made relatively informally, but more commonly a witness summons will be served. A doctor who shows any marked reluctance to attend court may well receive a formal summons, which compels him or her to attend or to face arrest and proceedings for contempt of court if he or she refuses. If the doctor adopts a reasonable and responsible attitude, he or she will usually receive the sympathetic understanding and cooperation of the law- yers and the court in arranging a time to give evidence that least disrupts his or her practice. However, any exhibition of belligerence by the doctor can induce a rigid inflexibility in lawyers and court officials—who always have the ability to “trump” the doctor by the issuance of a summons, so be warned and be reasonable. A doctor will usually be allowed to refer to any notes made contemporaneously to “refresh his memory,” although it is courteous to seek the court’s agreement. Demeanor in Court In the space available, it is not possible to do more than to outline good practice when giving evidence. Court appearances are serious matters; an individual’s liberty may be at risk or large awards of damages and costs may rely on the evidence given. The doctor’s dress and demeanor should be appro- priate to the occasion, and he or she should speak clearly and audibly. As with an oral examination for medical finals or the defense of a writ- ten thesis, listen carefully to the questions posed. Think carefully about the reply before opening your mouth and allowing words to pour forth. Answer the question asked (not the one you would like it to have been) concisely and carefully, and then wait for the next question. There is no need to fill all silences with words; the judge and others will be making notes, and it is wise to keep an eye on the judge’s pen and adjust the speed of your words accordingly. Pauses between questions allow the judge to finish writing or counsel to think up his or her next question. If anything you have said is unclear or more is wanted from you, be assured that you will be asked more questions. Be calm and patient, and never show a loss of temper or control regard- less of how provoking counsel may be. An angry or flustered witness is a gift to any competent and experienced counsel, as is a garrulous or evasive wit- ness. Stay well within your area of skill and expertise, and do not be slow to admit that you do not know the answer. Your frankness will be appreciated, whereas an attempt to bluff or obfuscate or overreach yourself will almost certainly be detrimental to your position. Doctors usually seek consensus and try to avoid confrontation (at least in a clinical setting). They should remember that lawyers thrive on the adversarial process and are out to win their case, not to engage on a search for truth. Thus, lawyers will wish to extract from witnesses answers that best sup- port the case of the party by whom they are retained. However, the medical witness is not in court to “take sides” but rather to assist the court, to the best of the expert witness’ ability, to do justice in the case. Therefore, the witness should adhere to his or her evidence where it is right to do so but must be prepared to be flexible and to make concessions if appropriate, for example, because further evidence has emerged since the original statement was pre- pared, making it appropriate to cede points. The doctor should also recall the terms of the oath or affirmation—to tell the truth, the whole truth, and nothing but the truth—and give evidence accordingly. The essential requirements for experts are as follows: • Expert evidence presented to the court should be seen as the independent product of the expert, uninfluenced regarding form or content by the exigencies of litiga- tion (30). If the expert cannot assert that the report contains the truth, the whole truth, and nothing but the truth, that qualification should be stated on the report (32). In England and Wales, new Civil Procedure Rules for all courts came into force on April 16, 1999 (34), and Part 35 establishes rules governing experts. The expert has an overriding duty to the court, overriding any obliga- tion to the person who calls or pays him or her. An expert report in a civil case must end with a statement that the expert understands and has complied with the expert’s duty to the court. The expert must answer questions of clarifica- tion at the request of the other party and now has a right to ask the court for Fundamental Principals 57 directions to assist him in conducting the function as an expert. The new rules make radical changes to the previous use of expert opinion in civil actions. Most pit- falls may be avoided by an understanding of the legal principles and forensic processes—a topic of postgraduate rather than undergraduate education now. The normal “doctor–patient” relationship does not apply; the forensic physi- cian–detained person relationship requires that the latter understands the role of the former and that the former takes time to explain it to the latter.

Abdominocentesis and localized enlargement with irregular borders is most ultrasound can be used to differentiate between commonly associated with a neoplasm dostinex 0.5 mg fast delivery menstrual rage, although ab- causes of abdominal fluid (Figure 12 generic dostinex 0.25mg without prescription womens health kalispell. A solitary mass with smooth discount dostinex 0.25 mg on line menopause 2 years got period, well Contrast Procedures defined margins is suggestive of a cyst; however order dostinex 0.25mg amex pregnancy 6 months, biopsy is the only definitive way to differentiate cysts, neoplasms and abscesses. Intravenous excretory uro- graphy is necessary to confirm renal disease when Administration of contrast agents can be used to severe nephromegaly obliterates the air space and enhance visualization of intraluminal abnormalities creates a positive silhouette sign with other viscera. The safe in birds, although limited studies have been testes of a reproductively active male are easily dis- performed to assess specific contrast media reac- tinguishable and should not be misinterpreted as 6,14 tions. The presence of concurrent disease and a patient’s Testicular abnormalities causing radiographic signs age, size and state of hydration should all be consid- are uncommon. Severely enlargement, and functional sertoli cell tumors may debilitated and seriously ill birds should be stabilized cause polyostotic hyperostosis. Orchitis is most easily and any fluid and electrolyte imbalances corrected diagnosed through laparoscopy, and radiographically prior to the study. Contrast studies are often stress- cannot be distinguished from physiologic hypertrophy. If anesthesia is used, it will abdomen just ventral to the kidneys represents the slow the passage of contrast media, which should not oviduct (Figure 12. The most common radiog- be misinterpreted as a pathologically induced de- raphically detectable abnormalities involving the fe- crease in transit time. Mineralized eggs are easily visualized and often lo- cated in the terminal oviduct. Dilution of the contrast medium with intraluminal fluid may compromise the study Gastrointestinal studies are the most frequently per- and interfere with defining the region of perforation. They are useful These agents do not coat the mucosa like barium does in delineating the position, structure and function of and are not recommended for routine gastrointesti- the gastrointestinal tract and associated organs. Indications for barium follow-through examination In juvenile birds, barium should be warmed prior to are acute or chronic vomiting or diarrhea that is administration. This is not necessary with adult nonresponsive to treatment, abnormal survey radio- birds. To administer barium, the head and neck are graphic findings suggestive of an obstructive pat- extended and a soft, flexible feeding tube is passed tern, unexplained organ displacement, loss of ab- into the crop (see Figure 15. Small species do not dominal detail suggesting perforation, hemorrhagic require a speculum for passage of the tube; however, diarrhea, history of ingestion of foreign material and 11 larger species need the beak held open either with a chronic unexplained weight loss. Measuring the distance from the should be rehydrated before administration of con- beak to the crop and marking the tube helps ensure trast media to prevent the material from forming that the tube is within the crop and not accidentally concretions within the gastrointestinal tract. The tube should be Gastrointestinal motility may be altered by patho- palpated within the crop prior to the administration logic conditions, stress and medications. The contrast media should be administered slowly until the crop is comfortably distended. Placing a Obtaining survey radiographs prior to beginning a finger over the distal portion of the cervical esopha- procedure will ensure proper technique as well as gus may help prevent reflux of barium sulfate while provide a method of re-evaluating any changes in the it is being administered. Slow re- The best contrast study can be performed when the moval of the tube may also help reduce reflux. Excess fluid in the regurgitation occurs, the administration of contrast ingluvies should be removed with a gavage tube prior media should cease in order to reduce the risk of to the administration of contrast media. The pres- ence of ingesta or fluid interferes with the quality of the study and may obscure lesions. The gastrointestinal tract may be tinal contrast studies include: empty at the time of presentation in birds that are Change in location, size or shape of abdominal organs regurgitating. Differentiation between the gastrointestinal tract and other organs Commercial barium sulfate suspensions provide the Altered motility (increased or decreased) best studies. Chemical grade barium is difficult to Increased or decreased luminal diameter mix properly and may flocculate. If perforation of the Mucosal irregularities gastrointestinal tract is suspected, an organic iodine Filling defects is recommended; however, these preparations are Changes in wall thickness hypertonic and can cause dehydration, especially in Extravasation of contrast media small patients. Mechanical obstruction occurs with been used for bronchography in non-avian species intraluminal or extraluminal masses, foreign body because it is less irritating than other contrast ingestion, helminthiasis and stricture. Mu- cosal irregularity and ulceration may aid in differen- Radiographic sequence may vary depending on the tiating neoplasia from more benign processes, but species and condition under investigation; however, fungal disease and neoplasia can be difficult to dis- in general, radiographs should be taken immediately tinguish radiographically, and biopsy is the only de- after administration of contrast media and at 0. The traluminal masses involving the thyroid gland, temporal sequence may vary if a lesion is identified spleen, gonads, oviduct or kidney may compress the during the study. If the crop is the only area of concern, a double contrast ingluviography may be performed in asso- Functional ileus occurs most frequently with ciation with a barium follow-through study or as a neuropathic gastric dilatation and most often in- separate procedure. Double contrast studies allow volves the proventriculus and ventriculus, although enhanced visualization of the crop wall for irregulari- portions of the intestines may also be involved (see ties such as thickening, mucosal defects, masses and Figure 32. Half of the total volume is given as air and the Displacement of the gastrointestinal tract may occur rest as barium. The air should be administered first with organomegaly, accumulations of fluid in the to prevent air bubbles from forming within the con- intestinal peritoneal cavity, adhesions or hernia. Although double contrast cloacography Hepatomegaly causes dorsal elevation of the proven- can also be performed, direct visualization with en- triculus and caudal movement of the ventriculus. Masses originating from the cra- nial division of the left kidney may push the ventricu- Contrast Study Findings lus cranially. Adhesions associated with egg-related Delayed transit time may be caused by functional or peritonitis may result in abnormal positioning of mechanical ileus. Mechanical ileus, depending on the portions of the gastrointestinal tract, with a fixed level of obstruction and degree of luminal compro- appearance and changes in luminal diameter. Her- mise, usually causes segmental dilation of the gas- nias, usually in hens, cause caudoventral displace- trointestinal tract. Fungal diseases and neoplasia can cause nar- Small Large rowing of the lumen due to mural infiltration. In- Stomach Cloaca Intestines Intestines flammatory changes can also increase wall thickness African Grey Parrot 10-30 30-60 60-120 120-130 and influence motility (see Figure 36. Mucosal Budgerigar 5-30 30-60 60-120 120-240 defects are most pronounced with aggressive dis- Racing pigeon 5-10 10-30 30-120 120-240 eases such as neoplasia or fungal infections. Spicula- Indian Hill mynah 5 10-15 15-30 30-90 tion of the contrast column due to a hyperemic mu- Hawk 5-15 15-30 30-90 90-360 cosa, stringing out of barium from mixing with Amazon parrot 10-60 60-120 120-150 150-240 mucus, diminished bowel distensibility and in- Canary 5 10-15 15-30 30-90 creased transit times occur with inflammation (see Pheasant 10-45 45-120 120-150 150-240 Figure 19. In the ing tubes or inflexible catheters can result in iatro- normal kidney, the three divisions are readily dis- genic perforation of the gastrointestinal tract if im- cernible. Mural erosion in association with neoplasm, abscess or granuloma are less frequent Mass lesions such as renal tumors and cysts cause causes of perforation (see Figure 25. If a perfora- changes in the size, shape and contour of the kidneys tion is suspected, an organic iodine contrast agent is and are distinguishable from gonadal lesions be- recommended to prevent contamination of the cause of the contrast enhancement. Cysts tend to Repeatability of a lesion on multiple views is impor- have smooth, well defined borders. Biopsy is neces- tant when attempting to identify intraluminal sary to definitively differentiate between tumors and masses. Abnormalities of the ureters are rare, but they that mimic mucosal defects and can lead to an incor- may be compressed in birds with egg binding and rect diagnosis. Radiographic changes in the excretory urogram are most striking when the renal disease is unilateral Intravenous Excretory Urography because the unaffected kidney is usually hypertro- In birds, the absence of a urethra, bladder, renal phied. In contrast, obstruction of a ureter may in- pelvis or division between the medulla and cortex, as crease the radiodensity of the ipsilateral kidney by well as the glomerular filtration rate, tubular resorp- delaying the washout from the kidney. If urine con- tion and the renal portal system make contrast uro- taining contrast medium is discharged into a pool of graphy of limited value.

If the forensic science laboratory is not made aware of this requirement purchase dostinex 0.5 mg visa menopause essential oils, potential evidence could be inadvertently destroyed during labo- ratory processes 0.5 mg dostinex for sale menstrual cycle chart. Many factors may affect the length of time that a lubricant will persist on skin or in a body orifice order 0.25mg dostinex otc breast cancer lanyard. Condom lubricant has been detected on a swab taken from an unwashed penis 50 hours after intercourse and order dostinex 0.25 mg line women's safety and health issues at work, in a different case, on a vaginal swab (also when the complainant had not washed or douched) taken 24 hours after intercourse, but detection after such prolonged periods would appear to be exceptional (Black, R. Reason for Analysis When drugs or alcohol have been consumed or possibly administered before or during a sexual assault, consideration should be given to the need to obtain samples of blood and urine for toxicological analysis. The length of time that a drug or its metabolites remain detectable in blood or urine depends on several factors, including the quantity taken, the individual’s metabolism, and the sensitivity and specificity of the analytical methods employed by the laboratory (196). Although the metabolites of some sub- stances may be excreted for up to 168 hours in the urine (196), many are detectable for only a few hours (see Subheading 12. In general, drugs and their metabolites will be identifiable for longer in urine than in blood. Blood It is good practice to request a sample of blood for drug/alcohol analysis when the incident has occurred in the preceding 4 days. A single sample of 10 mL of venous blood should be placed in a container with an anticoagulant (e. If volatiles are suspected, a portion of blood must be collected into a container with an intrinsic rubber bung to enable the dead space above the blood to be analyzed. Urine It is good practice to request a sample of urine for drug/alcohol analy- sis when the incident has occurred in the preceding 4 days. If the allegation exceeds this time limit, contact the forensic science laboratory for advice on whether a sample is required. Ideally, 20 mL of urine should be placed in a container with a preservative that prevents decomposition and fermentation (e. Complainants should be advised not to dispose of any towels, panty liners, or tampons at this stage. Taylor, members of the toxicology section of the Metropolitan Laboratory of Forensic Science, 2003. Forensic Analysis Forensic science laboratories have the capability of detecting a range of prescribed and illicit substances, but the persistence of different substances or their metabolites in the blood and urine of an individual depends on numerous factors. In some circumstances, the forensic science laboratory may undertake back calculations to estimate the blood alcohol concentration of the individual at the time of the sexual assault (197). Certain information is required to assist the forensic scientist with inter- pretation of the toxicological results. Persistence Data Table 1 provides the approximate detection windows for several pre- scribed/illicit substances. The detection windows depend on a few different factors, including the amount of substance used/administered and the frequency of use. Specialist advice is available for the toxicology section of the forensic laboratory. Medical Treatment The medical facilities should be stocked with the necessary provisions to enable minor injuries to be cleaned and dressed. Practical The examination facilities should incorporate a shower or bath for the complainant to use after the medical is complete, and a change of clothing should be available (preferably the patient’s own garments). Complainants should have access to a telephone so that they can contact friends or relatives and should be encouraged to spend the next few days in the company of some- one that they trust. Whenever any risk is identified, the patient should be counseled regarding the availability of hormonal and intrauterine methods of emergency contracep- tion; the most suitable method will depend on the patient profile and the time since the assault (198). When patients elect for insertion of an intrauterine contraceptive, they should be given prophylactic antibiotics (see Subheading 13. Follow-up appoint- ments should be made at a convenient venue where pregnancy tests are avail- able. Should the patient become pregnant because of the assault, she must be referred for sympathetic counseling. In children who may have been sexually abused, there is a low preva- lence of infections that are definitely sexually transmitted, although other or- ganisms possibly associated with sexual activity may be identified (201). Consequently, it may be more appropriate for the first tests to be deferred until 14 d after the assault. Some centers prescribe antibiotic prophylaxis for all complainants of penile penetrative sexual assaults at the time they present (6,207,208). The use of antibiotic prophylaxis reduces the need for repeated examinations, avoids the anxiety incurred in waiting for the results, and is acceptable to the majority of women to whom it is offered (209). Antibiotic prophylaxis should cover the prevalent, treatable organisms in the local population, and advice should be sought from the local center for disease control regarding an appropriate regimen. In children and young people, a risk/ benefit analysis will inform the decision regarding whether the vaccine should be offered. However, because of the long incubation period an accelerated course of the vaccine (0, 1, and 2 months or 0, 1, and 6 months) may be efficacious if is initiated within 3 weeks of the exposure (202). Psychological Complainants of sexual assault must be offered immediate and ongoing counseling to help them cope with the recognized immediate and long-term psychological sequelae of a sexual assault (214). Routine use of ultraviolet light in medicolegal exami- nations to evaluate stains and skin trauma. The task of the Forensic Science Laboratory in the investigation of sexual offences. Paper presented at the Sixth International Conference in Clinical Forensic Medicine of the World Police Medical Officers, March 17–22, Sydney, Australia, 2002. Deposition of 7-aminoflunitrazepam and flunitrazepam in hair after a single dose of Rohypnol®. The New Hamp- shire sexual assault medical examination protocol project committee sexual assault: review of a national model protocol for forensic and medical evaluation. The significance of transfer of fibres to head hair, their persistence and retrieval. The deposition of cocaine and opiate analytes in hair and fingernails of humans following cocaine and codeine administration. Phenytoin concentration in head hair sections: a method to evaluate the history of drug use. A new means of identification of the human being: the longitudinal striation of the nails. The collection of data from findings in cases of sexual assault and the significance of spermatozoa on vaginal, anal and oral swabs. Spermatozoa in the anal canal and rectum and in the oral cavity of female rape victims. Prevalence, goals and complications of heterosexual anal intercourse in a gynecologic population. Hymenal findings in adolescent women, impact of tampon use and consensual sexual activity. Identification of sperm and non-sperm male cells in cervicovaginal smears using Fluoresecence In Situ Hybrid-isation— applications in alleged sexual assault cases. Identification of male epithelial cells in routine post-coital cervicovaginal smears using Fluoresecence In Situ Hybridisation—application in sexual assault and molestation. Postcoital detection of a male- specific semen protein: application to the investigation of rape. A comparison of the persistence of seminal constituents in the human vagina and cervix. Sperm survival and prostatic acid phosphatase activity in victims of sexual assault. The collection of data from findings in cases of sexual assault and the significance of spermatozoa on vaginal, anal and oral swabs. Variations in vaginal epithelial surface appearance determined by colposcopic inspection in healthy sexually active women.

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