1. /--".-.~
PATIENT: MALENKO, MILA
DOB:
DOS:
11/2912006
1211612009
C?J
CHIEF COMPLAINT: Follow up ER.
SUBJECTIVE: Mila is a 3-year-old girl who was in the emergency room at Maine
Coast Memorial Hospital after lacerating her thumb on 12/02/2009. The next day she
had the wound check and was given a tetanus shot. She is in here for a followup. She
has had no problems with the fingers, not a~le to use scissors at preschool anymore but is
doing quite well. She is an otherwise healthy, "active girl who is at preschool a few days a
week. She attends gymnastics in Ellsworth as well. Mom states she is doing great in
preschool. She is counting to 100 and knows her ABCs. She lives with her mom during
the week and goes down to Portland where her dad lives. They split custody. Mila
knows multiple shapes and colors. I was asking what she does when she is with her dad
on the weekends, Mila states that he "poked me in my gina". I said what did he do? Mila
stated that he, "put his penis next to my gina". Then she stated ~Q,.u can't tell anyone".
s-i-t- ttiJ(~
s
I asked Mila how it makes her feel when he does this and~'makes me sad", "he has
windows in his underwear". I asked what is the window for "to see outside" and I asked
Mila where do you sleep when you are at your dad's and Mila answered, "in my own
bed". I asked does he wake you up at night to poke you and Mila responded, "No, in the
morning". 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 of
the 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 inspection
of 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 Spurwink
Clinic in Portland where they have interviewed Mila before and attempted to call DHS
which was not open at the time of my call. I will contact them in the morning. The child
did leave with the mother. Will try to arranged for evaluation prior to her next visit with
her father this upcoming weekend.
;:;;'-1«,-0'7 SpoU, 10 />v f(;CCI' ;:;
-I IrA: Sf v •• 1rJt~ e. CI/I ~~/ c. j ft...e ; 14/ Ii /~
r-e:f cv I -- hJJ aclu /'6-t J C ttf-t /:J
Angela Delvecchio, FNP j) rI ;? I "'BOG' oF- tV'd Shtk), M-
Pc v j J c:w tis fIA- a -11"1-1>'- .
CC: Il -/(~ ci'l
- C tt /1 (J b HS -- N' fc-v+ec!
t 1) C/; c{Le~. -----. ~/
DD: Wed Dec 16 17:13:11 2009
DT: ThuDec 1710:45:482009
20615 118722834
~
