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Access clinical reference cards built for attorneys handling forensic cases.
1
Key Questions in a Strangulation Case
2
Sexual Assault Exam Findings: What to Know
3
Child Abuse vs. Bone Disease: Fractures
4
Toxicology Facts for Attorneys
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Reference Cards
Key Questions in a Strangulation Case
›
Sexual Assault Exam Findings: What to Know
›
Child Abuse vs. Bone Disease: Fractures
›
Toxicology Facts for Attorneys
›
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Strangulation Case
Clinical & Investigative Checklist
1
Was petechiae documented?
Conjunctival, facial, and scleral petechiae are clinically significant. Location, distribution, and timing of documentation should all be recorded.
2
What are the examiner's qualifications?
Forensic nurses (SANE/FNE) receive specialized strangulation training. Credentials are relevant to the weight given to clinical findings.
3
Was neck imaging performed?
Strangulation can cause soft tissue and vascular injury not visible externally. CT imaging of the neck is the standard of care when strangulation is reported.
4
Were symptoms assessed and documented?
Voice changes, difficulty swallowing, loss of consciousness, and urinary incontinence should be documented whether present or absent.
5
Was a standardized assessment tool used?
Validated strangulation instruments provide consistent, reproducible documentation. The tool used — or its absence — is relevant to exam completeness.
6
Were differential causes considered?
Petechiae, bruising, and redness have multiple etiologies including coughing, Valsalva maneuver, skin conditions, and prior injury.
7
Was the timeline of injury documented?
The interval between the event and examination — and between exam and photography — is relevant to accurately interpreting findings.
8
Were findings separated from opinion?
Clinical documentation should distinguish observed findings from clinical interpretation. Conflating the two can compromise reliability of testimony.
For attorney reference only · Godoy Medical Forensics, Inc. · GodoyMedical.net
Sexual Assault Exam Findings
Key Clinical Points
Critical FactA normal exam does NOT mean assault did not occur. Research consistently shows the majority of sexual assault exams reveal no visible injury — this is clinically expected and well-documented in the literature.
Injury Heals Rapidly
Genital mucosal tissue heals within 24–72 hours. The interval between the event and examination is a key variable in interpreting findings.
Anatomical Location Matters
Posterior fourchette, fossa navicularis, and hymenal margin are primary injury sites. Precise anatomical documentation is essential to accurate clinical interpretation.
Examiner Training Affects Documentation Quality
SANE-certified examiners are trained in colposcopy and standardized evidence collection protocols. Examiner qualifications are relevant to the reliability of documented findings.
Non-Genital Injuries Are Common
Bruising, bite marks, and defensive injuries are frequently documented. A thorough exam includes full-body assessment, not only the anogenital region.
Hymenal Findings Require Expertise
Notches, clefts, and anatomical variations are frequently within normal range. Accurate interpretation requires comparison against established normative standards and peer review.
Drug-Facilitated Cases Require Toxicology
When substances are a factor, timing of toxicology collection is critical. Screens vary in what substances they detect — the specific panel used should be reviewed.
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Child Abuse vs. Bone Disease
Fracture Differential Diagnosis
Clinical ConsiderationUnexplained fractures in infants warrant careful evaluation — infants typically do not sustain fractures from normal daily activities or minor accidents.
37wk
Mean age at first presentation in misdiagnosed OI cases
40%
Of misdiagnosed cases had positive family history
Key Factors in Differential Diagnosis
Consistency of history with injury pattern · Evidence of prior unexplained injuries · Age and developmental stage of the child.
Classic Features of Osteogenesis Imperfecta (OI)
Multiple fractures after minor trauma at early age, blue sclera, osteopenia, wormian bones, dentinogenesis imperfecta, family history of bone disease or "easy" fractures.
Misdiagnosis Rates
25.5% rate of Silent Type IV OI mistaken for CAN; 13.1% for other OI types. Classic findings are not always present in all patients.
Expert Review Recommended
Evaluation requires comprehensive medical history, incident history, physical examination, and radiographic imaging by qualified medical experts.
| Factor | Suspected Abuse | Osteogenesis Imperfecta |
|---|---|---|
| History | Often inconsistent or suspicious | Family history of bone disease |
| Physical Signs | Evidence of prior injuries | Blue sclera, dental issues |
| Fracture Pattern | Ribs, skull, specific locations | Multiple from minor trauma |
| Age Factor | Especially concerning under 18 months | Fractures starting at early age |
Glossary
CAN — Child Abuse and Neglect
The umbrella term for physical abuse, neglect, emotional abuse, and sexual abuse of a minor. In forensic contexts, often used specifically to refer to suspected physical abuse cases involving injury patterns.
OI — Osteogenesis Imperfecta
A genetic connective tissue disorder causing abnormally fragile bones that fracture easily, sometimes with little or no apparent cause. Also called "brittle bone disease." Caused by defects in the gene that produces type I collagen. There are multiple types (I–IV and beyond), with varying severity.
Dentinogenesis Imperfecta
A genetic disorder of tooth development associated with OI. Affects the dentin (the layer beneath tooth enamel), causing teeth to appear translucent, blue-gray, or amber-colored. Teeth are weaker than normal and prone to wear and breakage. Its presence can support an OI diagnosis.
Wormian Bones
Small, irregular extra bones that form within the sutures (joints) of the skull. Named after Danish anatomist Ole Worm. Their presence — particularly when more than 10 are found — is associated with OI and other connective tissue disorders. Identified on skull X-rays or CT imaging.
Blue Sclera
A bluish tint to the whites of the eyes, caused by abnormally thin scleral tissue that allows the underlying choroid layer to show through. A classic — though not universal — sign of OI. More pronounced in infants and may fade with age.
Osteopenia
Lower-than-normal bone mineral density, making bones weaker and more prone to fracture. In OI, osteopenia results from defective collagen production. Identified on bone density scans (DEXA) or visible on standard X-rays as abnormally "light" bone appearance.
Differential Diagnosis
The process of distinguishing between two or more conditions that share similar signs or symptoms. In fracture cases, a proper differential diagnosis rules out medical causes (such as OI, rickets, or metabolic bone disease) before attributing injuries to abuse.
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Toxicology Facts
Essential Information for Attorneys
Critical FactA positive drug test does NOT prove impairment at the time of incident. Expert interpretation is required to establish causation between substances and behavior.
Detection Windows
| Sample Type | Detection Window |
|---|---|
| Blood | 12–24 hours (gold standard for impairment) |
| Urine | 1–3 days most drugs; up to 30 days for THC |
| Saliva | 12–48 hours most drugs |
| Hair | Up to 90 days most substances |
| Nails | Up to 6 months |
| Vitreous humor | Similar to blood, longer stability |
| Gastric contents | Hours to days depending on ingestion |
Sample Collection Priorities
Collect samples as soon as possible · Chain of custody documentation is critical · Proper storage and transport essential · Consider postmortem redistribution effects · Document time of collection relative to incident.
Common Substances
Alcohol
Legal limit 0.08% in most states.
Cannabis
THC levels do NOT correlate with impairment.
Cocaine
Rapid metabolism, short detection window.
Opioids
Include prescription and illicit varieties.
Amphetamines
Include methamphetamine and ADHD medications.
Benzodiazepines
Therapeutic vs. toxic levels vary significantly.
Interpretation Challenges
Presence doesn't always equal impairment · Tolerance affects individual response · Drug interactions can alter effects · Postmortem changes affect concentrations · Individual metabolism rates vary significantly · Consider therapeutic vs. recreational use.
Legal Considerations
Chain of custody must be unbroken · Laboratory accreditation and methods matter · Distinguish between screening and confirmation tests · Expert testimony often required for interpretation · Understand limitations of each test type · Document all circumstances of sample collection.
For attorney reference only · Godoy Medical Forensics · Info@GodoyMedical.net · GodoyMedical.net
