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H. EXAM / CONSULTATIONS / FINDINGS & FOLLOW-UP: PERSONNEL INVOLVED (PRINT) PHONE Q ' Ctf&fhvyrtl fa-zd. History taken by: <J~, <?<?, W 6*^—&r<--*rr-M Physical examination performed by: Specimens labels and sealed by: Assistant: Psychosocial assessment taken by:

N/A • Report attached / Interview observed: D Yes jarfvio CONSULT: TIME CALLED UL *fii&T—rM^yURESPONDED

IMPRESSIONS, FINDINGS, AND FOLLOW-UP: Pediatric Examinations Reveals: • Physical Findings • Exam consistent with history • Exam inconsistent with history Q Specific for abuse Q Non-specific for abuse Mg? *i>**a>*fSf m<A?

SERVICE

No Physical Findings J3--'Exam consistent with history Q Exam inconsistent with history DOCTOR

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/ O-^flome DISPOSITION: • Admit to CONDITION AT DISCHARGE: J3"G PLANJ-rCTieck ifapplicable) Good Q Satisfactory
eassurance regarding health of genitalia. 'Retym to regular family doctor for routine medical care.

56py ofmedical report to caseworker and/or lawenforcement agency. Other. AFTERCARE INSTRUCTIONS: ^______ • Follow up appointment ~~ .ja^Counseling: £-"/<C '/""^ Counseling:. Followup lab: Q Transfer to ED
• Serious

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Q^fKnliapaXary guidance

15400 (11/02) CookChildren's. 801 Seventh Avenue Fort Worth, Texas 76104-2796 PHYSICAL & SEXUAL ABUSE MEDICAL PROTOCOL (Page 9 of 9) • Physician list
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PRINTOR IMPflINT PATIENT INFOHMATIONRUN DATE: 10/11/07 RUN TIME: 08 2 0 Cook Children's HCIS LAB **LIVE** Summary Discharge Report
LOCATION PAGE 1 j? &£{'• Ctfl &/£~o&£c> '* &9*&U/&A Ck**]-7iX*S

PATIENT: DEHOYAS,ROSA
REG DR: COFFMAN,JAMYE L MD

Test Day Date
HCG SERUM CHLAMYDIA GENPR GONORRHEA GENPR HEP C VIRUS 1 JUN 5 1 JUN 5 1 JUN 5 1 JUN 5

Patient: DEHOYAS,ROSA ACCT #: |V00006053842| LOC: AGE/SX: 14/F ROOM: STATUS: REG CLI BED:

Time Result 1625 NEGATIVE 1600 NEGATIVE 1600 NEGATIVE 1625 NEGATIVE Reference (NEGATIVE) (NEGATIVE) (NEGATIVE) (NEGATIVE) CARE.CMC

Units U #: M002240601 REG: 06/05/07 DIS:

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