PATIENT: MALENKO, MILADOB: 11/2912006DOS: 1211612009

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C?JCHIEF COMPLAINT: Follow up ER.

SUBJECTIVE: Mila is a 3-year-old girl who was in the emergency room at MaineCoast Memorial Hospital after lacerating her thumb on 12/02/2009. The next day shehad the wound check and was given a tetanus shot. She is in here for a followup. Shehas had no problems with the fingers, not a~le to use scissors at preschool anymore but isdoing quite well. She is an otherwise healthy, "active girl who is at preschool a few days aweek. She attends gymnastics in Ellsworth as well. Mom states she is doing great inpreschool. She is counting to 100 and knows her ABCs. She lives with her mom duringthe week and goes down to Portland where her dad lives. They split custody. Milaknows multiple shapes and colors. I was asking what she does when she is with her dadon the weekends, Mila states that he "poked me in my gina". I said what did he do? Milastated that he, "put his penis next to my gina". Then she stated ~Q,.u can't tell anyone".

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I asked Mila how it makes her feel when he does this and~'makes me sad", "he haswindows in his underwear". I asked what is the window for "to see outside" and I askedMila where do you sleep when you are at your dad's and Mila answered, "in my ownbed". I asked does he wake you up at night to poke you and Mila responded, "No, in themorning". I asked if anyone else was there at the time he was poking her, and she states"no, just my daddy".

OBJECTIVE: Child looks well, sitting comfortably on the exam table. Mom was out ofthe room during that questioning. She is dressed appropriately. Has good eye contact.Weight is 31.8 pounds, and height 3 feet 3 inches tall. I did do a quick visual inspectionof the vagina. There is no swelling, redness or bruising of the vagina or the anus.

ASSESSMENT AND PLAN: Child's disclosure of sexual abuse. I did call SpurwinkClinic in Portland where they have interviewed Mila before and attempted to call DHSwhich was not open at the time of my call. I will contact them in the morning. The childdid leave with the mother. Will try to arranged for evaluation prior to her next visit withher father this upcoming weekend.

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Angela Delvecchio, FNP

DD: Wed Dec 16 17:13:11 2009DT: ThuDec 1710:45:48200920615 118722834

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