Forensic Examination

Prior to performing the forensic examination, the veterinarian should be briefed on the case by the officer in charge. For the examining veterinarian to fully understand the legal implications and accurately interpret physical examination findings, the briefing should include access to the initial report and photographs.

The forensic examination must be conducted as soon as possible to document the initial physical condition of the victim and expedite the medical treatment. For example, evidence of severe flea

Figure 19.18 This photo, taken 1 month after Figure 19.17, shows the same view, and with a normal body condition score [4/9 on the Purina scale (Laflamme, 1997)]. The body weight was 37.40 pounds.

infestation should be documented and photographed prior to flea treatment. If critical medical care is needed and photographic documentation must be postponed until the patient has been stabilized, the forensic report should include an explanation for any missing items.

Except for photographs, forensic examinations are no different from any other physical examination. Veterinarians are trained to produce a thorough medical exam for every patient, documenting all findings, both normal and abnormal. The enormous workload of most shelter veterinarians often necessitates brief physical examinations and documentation of only the abnormal findings. This is unacceptable for a forensic examination, for this could suggest an incomplete or biased assessment. In addition, the physical exam findings will be used to help the court make important decisions regarding the fate of both the abused animal and alleged abuser.

Having a forensic examination form is a good way to ensure that physical findings are thoroughly documented. If the shelter has an electronic medical record system, then the information may be recorded directly into the system. If the data entry will be performed by someone other than the examining veterinarian, it is recommended that the veterinarian proofread the medical notes to correct misspelled words and inappropriate entries before they are finalized. If examination findings will be written and later entered into an electronic record, a paper exam form should be created that mimics the electronic medical form. This will help to reduce discrepancies and errors in the record and will streamline the data entry process. If possible, all paper documents should be scanned and attached to the electronic medical record. Writing must be legible. All documents will be considered part of the legal case and may be reviewed in the discovery process, so in order to reduce inconsistencies it is ideal to keep the duplication of information to a minimum. To reduce the number of physical pages and loss of documents, pages should be numbered and have the same identifying information at the top of each page (Figures 19.19 and 19.20). To avoid writing redundant information, double-sided pages can be used.

Physical examination should list signalment including species, breed, age, gender with spay/neuter status, weight, colors (primary, secondary, tertiary, special markings), and long or shorthaired if not obvious by the breed listed. All pets should be scanned for a microchip, document whether one was found, and list the microchip number when applicable. Subjective findings that describe the animal’s overall attitude should be listed (e.g., bright, alert, responsive, etc.) Objective findings include all physical exam findings. Vital signs including body temperature (list route, i.e., rectal,

FORENSIC EXAMINATION PAGE 1/4

Signalment

Physical Examination

Objective

(NSF= No significant findings; NE= not examined)

Subjective/Behavior (description)

Notes:

Figure 19.19 Example page 1 of a forensic examination form. This form should include a heading containing the same information as the other pages of the physical exam and include signalment and all physical examination findings. This form follows the subjective, objective, assessment, and plan (SOAP) format commonly taught to veterinarians.

FORENSIC EXAMINATION PAGE 2/4

Assessment/Differential Diagnosis

Plan

Diagnostics

Preventative Care/Treatments

Recommendations/Additional Medical Notes

Figure 19.20 Example page 2 of a forensic examination form. This form should include a heading containing the same information as the other pages of the physical exam form. This page is a continuation of the SOAP format from page 1, and also includes information regarding initial diagnostics, treatments, and recommendations.

otic, etc.), heart and pulse rate, respiratory rate, mucous membrane color, and capillary refill time should be obtained. Body condition score (BCS) should be determined by both visual appearance and palpation (Laflamme, 1997). If palpation is not possible then it should be documented that the BCS is an estimate only. The BCS system used should be referenced and should be predetermined and consistent for all animals involved. All body systems should be evaluated including the eyes, ears, nose, throat, oral cavity, skin, hair, heart, lungs, musculoskeletal, neurological, peripheral lymph nodes, and urogenital. Oral examination should describe all abnormalities and include a dental chart when indicated. If there are testicles present, they should be described. Estrus or possible pregnancy should be noted. Evidence of previous surgery and any tattoos should be described. All lesions including scars, fresh wounds, and tumors should be described and drawn on an anatomical chart. This is particularly important in cases of suspected animal fighting. Any pain detected or suspected should be listed with an explanation and given a score using a referenced pain scale. Following the physical examination is the overall assessment, where findings are concluded and a differential diagnosis is listed. Finally, a plan is documented. This plan should include recommended testing, treatments, and rechecks.

When indicated, a definitive diagnosis should be avoided without supporting documentation. For example, “yeast otitis” should not be a definitive diagnosis without an ear cytology result consistent with yeast overgrowth and supporting clinical signs. If obtaining an ear cytology is not possible, then “yeast otitis” should be listed as a differential diagnosis in the assessment, with the supportive findings such as odor, erythema, stenosis, and so on, placed in the objective findings, and ear cytology should be in the plan section as a recommended diagnostic. If cytology will not be possible, treatment can be initiated based on a presumptive diagnosis based on clinical signs, but this should be explained in the plan section. A similar situation is pain assessment. If you suspect a pet is in pain, for example from dental disease, but there are no overt symptoms to support this suspicion such as a thin body condition, flinching upon oral exam, food avoidance, and so on, then a definite declaration of pain should be used cautiously. In such instances an appropriate description would be "suspect pain due to periodontal disease” with recommendations for pain management, antimicrobials as indicated, and dental care as soon as possible.

It is not uncommon for animal victims to be fearful or aggressive, sometimes to the degree that precludes hands-on examination without sedation. Since sedation can alter vital signs and appearance in photographs, the reason for the sedation and possible effects should be included in the medical record. If an examination is not performed, then the reason should be listed with the best physical description possible.