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H. EXAM / CONSULTATIONS / FINDINGS & FOLLOW-UP:
PERSONNEL INVOLVED (PRINT) PHONE
History taken by: Q ' Ctf&fhvyrtl fa-zd. 6*^—&r<--*rr-M Physical examination performed by: **a>*fSf m
Psychosocial assessment taken by: M^yU- N/A • Report attached / Interview observed: D Yes jarfvio CONSULT:
TIME CALLED RESPONDED SERVICE DOCTOR
IMPRESSIONS, FINDINGS, AND FOLLOW-UP: Pediatric Examinations Reveals:
• Physical Findings No Physical Findings • Exam consistent with history Q Specific for abuse J3--'Exam consistent with history • Exam inconsistent with history Q Non-specific for abuse Q Exam inconsistent with history IMPRESSION: : Sz^M${ rtd-?<,£*C -~ sdAd fo&•&<&& <^r\ f^»<^7 PATIENT RELEASED TO: z&T
PHYSICAL EXAMINER (print / signature):' -"J /£> <*£L/2 -, /ll.^~)f W' 7/ J "• tOCT'**^-v ^v^/^y / v/ DISPOSITION: • Admit to Q Transfer to ED O-^flome CONDITION AT DISCHARGE: J3"GGood Q Satisfactory • Serious PLANJ-rCTieck if applicable) eassurance regarding health of genitalia. 'Retym to regular family doctor for routine medical care. 56py of medical report to caseworker and/or lawenforcement agency. Other.
AFTERCARE INSTRUCTIONS: ^______ • Follow up appointment ~~ .ja^Counseling: Counseling:. £-"/
^-iXiimts—•— PRINTOR IMPflINT PATIENT INFOHMATION
CookChildren's. 801 Seventh Avenue Fort Worth, Texas 76104-2796
PHYSICAL & SEXUAL ABUSE MEDICAL PROTOCOL 15400 (11/02) (Page 9 of 9) RUN DATE: 10/11/07 Cook Children's HCIS LAB **LIVE** PAGE 1
RUN TIME: 08 2 0 Summary Discharge Report
LOCATION
j? &£{'• Ctfl &/£~o&£c> '* &9*&U/&A Ck**]-7iX*S PATIENT: DEHOYAS,ROSA ACCT #: |V00006053842| LOC: CARE.CMC U #: M002240601 AGE/SX: 14/F ROOM: REG: 06/05/07 REG DR: COFFMAN,JAMYE L MD STATUS: REG CLI BED: DIS:
Test Day Date Time Result Reference Units
HCG SERUM 1 JUN 5 1625 NEGATIVE (NEGATIVE) CHLAMYDIA GENPR 1 JUN 5 1600 NEGATIVE (NEGATIVE) GONORRHEA GENPR 1 JUN 5 1600 NEGATIVE (NEGATIVE) HEP C VIRUS 1 JUN 5 1625 NEGATIVE (NEGATIVE)
Patient: DEHOYAS,ROSA Age/Sex: 14/F Acct#V000 0 6 053 842 Unit#M0 0224 0601 XJU/to £>U>yoj if ifAfzUJ'u+Aa'xT&er'- $
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MAR 27 2015' b*t\b'~o<,/osr/o7 Abel Acosta, Clerk — C) X~ rfJ£ &>*• 7*&r ttsJatjAfc CotaLfef? CA//*?/**/ /^>/>c*/j e>X~7Tx*J
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»*:#« ***** ««yr t^^%T£ ***2~" 1?.*/*~>r.1v« 77S& /f/frf TW'C*/ Mfocr CevvCT ^a>»~>»
H. EXAM / CONSULTATIONS / FINDINGS & FOLLOW-UP:
PERSONNEL INVOLVED (PRINT) PHONE
History taken by: Q ' Ctf&fhvyrtl fa-zd. 6*^—&r<--*rr-M Physical examination performed by: **a>*fSf m
Psychosocial assessment taken by: M^yU- N/A • Report attached / Interview observed: D Yes jarfvio CONSULT:
TIME CALLED RESPONDED SERVICE DOCTOR
IMPRESSIONS, FINDINGS, AND FOLLOW-UP: Pediatric Examinations Reveals:
• Physical Findings No Physical Findings • Exam consistent with history Q Specific for abuse J3--'Exam consistent with history • Exam inconsistent with history Q Non-specific for abuse Q Exam inconsistent with history IMPRESSION: : Sz^M${ rtd-?<,£*C -~ sdAd fo&•&<&& <^r\ f^»<^7 PATIENT RELEASED TO: z&T
PHYSICAL EXAMINER (print / signature):' -"J /£> <*£L/2 -, /ll.^~)f W' 7/ J "• tOCT'**^-v ^v^/^y / v/ DISPOSITION: • Admit to Q Transfer to ED O-^flome CONDITION AT DISCHARGE: J3"GGood Q Satisfactory • Serious PLANJ-rCTieck if applicable) eassurance regarding health of genitalia. 'Retym to regular family doctor for routine medical care. 56py of medical report to caseworker and/or lawenforcement agency. Other.
AFTERCARE INSTRUCTIONS: ^______ • Follow up appointment ~~ .ja^Counseling: Counseling:. £-"/
^-iXiimts—•— PRINTOR IMPflINT PATIENT INFOHMATION
CookChildren's. 801 Seventh Avenue Fort Worth, Texas 76104-2796
PHYSICAL & SEXUAL ABUSE MEDICAL PROTOCOL 15400 (11/02) (Page 9 of 9) RUN DATE: 10/11/07 Cook Children's HCIS LAB **LIVE** PAGE 1
RUN TIME: 08 2 0 Summary Discharge Report
LOCATION
j? &£{'• Ctfl &/£~o&£c> '* &9*&U/&A Ck**]-7iX*S PATIENT: DEHOYAS,ROSA ACCT #: |V00006053842| LOC: CARE.CMC U #: M002240601 AGE/SX: 14/F ROOM: REG: 06/05/07 REG DR: COFFMAN,JAMYE L MD STATUS: REG CLI BED: DIS:
Test Day Date Time Result Reference Units
HCG SERUM 1 JUN 5 1625 NEGATIVE (NEGATIVE) CHLAMYDIA GENPR 1 JUN 5 1600 NEGATIVE (NEGATIVE) GONORRHEA GENPR 1 JUN 5 1600 NEGATIVE (NEGATIVE) HEP C VIRUS 1 JUN 5 1625 NEGATIVE (NEGATIVE)
Patient: DEHOYAS,ROSA Age/Sex: 14/F Acct#V000 0 6 053 842 Unit#M0 0224 0601 XJU/to £>U>yoj if ifAfzUJ'u+Aa'xT&er'- $
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