wiliam sepulvado - triventlegal.com · web viewmedical chronology - instructions to follow....

XXXX XXXX DOB: 01/05/YYYYXXXX XXXX DOB: 04/29/YYYY

MEDICAL CHRONOLOGY - INSTRUCTIONS TO FOLLOW

General Instructions:Brief Summary/Flow of Events: In the beginning of the chronology, a Brief Summary/Flow of Events outlining the significant medical events is provided which will give a general picture of the focus points in the case

Patient History: Details related to the patient’s past history (medical, surgical, social and family history) present in the medical records

Detailed Medical Chronology: Information captured “as it is” in the medical records without alteration of the meaning. Type of information capture (all details/zoom-out model and relevant details/zoom-in model) is as per the demands of the case which will be elaborated under the ‘Specific Instructions’

Reviewer’s Comments:Comments on contradicting information and misinterpretations in the medical records, illegible handwritten notes, missing records, clarifications needed etc. are given in italics and red font color and will appear as * Reviewer’s Comment

Illegible Dates: Illegible and missing dates are presented as “00/00/0000”(mm/dd/yyyy format)

Illegible Notes: Illegible handwritten notes are left as a blank space “_____” with a note as “Illegible Notes” in the heading of the particular consultation/report.

Specific Instructions:The chronology focuses on the Labor and Delivery notes with subsequent complication of developmental delay as given below:

09/19/YYYY-04/23/YYYY: These records of the prenatal visits till the time of delivery has been summarized in detail including the lab reports and ultrasound imaging to assess for any maternal complications

04/28/YYYY-05/02/YYYY: These records have been summarized in detail including the admission for active labor, all progress notes until delivery, labor and delivery note, its associated complications and NICU notes

05/07/YYYY-10/31/YYYY: These records of the multiple pediatric visits of X year time have been reviewed and only those pertaining to developmental delay has been summarized in brief to assess the infant’s status alone

The reference is given brown font when captured in the Occurrence columnThe mother details are presented in blue font color for ease of reference

Critical/Non-Critical Missing records:What records/medical bills are needed

Hospital/Medical provider

Date/ Time period

Why we need the records/bills?

Is record missing confirmatory/ probable?

All the Prenatal ultrasounds

Unknown 09/19/YYYY-04/28/YYYY

To assess if Cephalopelvic Disproportion (CPD) could have been assessed earlier

Confirmatory

Labor and delivery sheet

XXXXX County Hospital

04/28/YYYY

To assess the complications of the infant during delivery

Confirmatory

1 of 23


including respiratory distress

Brief Summary/Flow of Events

09/19/YYYY – 04/23/YYYY: Prenatal visits09/19/YYYY-09/21/YYYY: Mother had multiple prenatal visits for ultrasound screening, vaginal

bleeding and vaginal discharge (spotting) – Managed conservatively

04/04/YYYY - Ultrasound revealed cephalic presentation, with measurements of BPD 8.9, HC 31.8, AC 31.2, FL 7 3, EFW 2721, OFD 11.4, FHR 130 and AFI within normal limits

04/28/YYYY – 05/02/YYYY: Admitted for term pregnancy – Attempted vacuum extraction - Delivered by cesarean section – Discharged home

04/28/YYYY:@ 1935 hrs: Presented for irregular contractions – Vaginal exam revealed Dilation 3, effacement

70, Station -1, Presenting part: vertex@ 2317 hrs and 2326 hrs: Vacuum applied multiple times per Dr. XXXXX

Assessed with Cephalopelvic Disproportion (CPD) and failure to descend – Taken for c-section

* Reviewer’s Comment: The patient went for C section owing to cephalopelvic disproportion. The Labor and Delivery note/ Procedure report including the vacuum extraction details are not

available for review.

04/29/YYYY: @ 0024 hrs Male infant delivered by primary cesarean section secondary to failure to progress, cephalopelvic disproportion with meconium stained fluid – Assessed with

decreased Apgars of 4, 6 and 9; questionable pneumothorax on the left - Infant admitted in NICU for respiratory distress

05/01/YYYY-05/03/YYYY: Infant managed in NICU – Discharged home

05/03/YYYY-10/09/YYYY: Multiple Pediatric visits for developmental delay and multiple other conditions

09/01/YYYY: Assessed with speech fluency stuttering, delayed developmental milestones speech – Recommended speech therapy

09/30/YYYY-04/30/YYYY: Assessed with mild to moderate receptive language delay, mild expressive language delay; articulation, language and fluency disorders, mild to moderate

sensorineural hearing loss – Managed with speech therapy and hearing aids

06/11/YYYY: Psychological Evaluation revealed Below Average Intelligence, Below Average Academic Achievement, Rule out Intellectual Disability, Phonological Disorder, Bilateral

Hearing Aids, Symptoms of inattention are most likely secondary to significant learning problems

2 of 23


Patient History

Past Medical History: No relevant history

Surgical History: No relevant history

Family History: Significant for hearing loss, hypertension, and headache

Social History: No relevant history

Allergy: No known drug allergies

Detailed Chronology

DATE PROVIDER OCCURRENCE/TREATMENT PDF REF09/19/YYYY

Hospital/ Provider Name

Emergency Room (ER) visit for Threatened Abortion (AB):

Her Last Menstrual Period (LMP) was 07/28/YYYY roughly, Estimated Date of Confinement (EDC) 05/04/YYYY. This puts her about 7 weeks. She had a positive pregnancy test last week. No further spotting. She is not bleeding. Her cervix is closed. Weight 156. I have scheduled her for an ultrasound Friday for threatened AB.

82, 133

09/21/YYYY


Pre- Natal Flow record: Illegible notes Patient’s Blood type and Rh: O positive, Antibody negative, serology not recorded, rubella titer 60, pap test Within Normal Limits (WNL), blood sugar 89, negative for cervical culture, sickle cell test, Human Immuno Deficiency Virus (HIV), Hepatitis B and Chlamydia. No prior contraception. Vaginal discharge and bleeding (spotting) present since LMP.EDC: 04/30/YYYY, weight 154, Blood Pressure (BP) 121/79, pulse 89

Pregnant History:Gravida 2, Term 1, Preterm 0, Abort 0, Live 1.In 2006, a male child weighing 5#7 was delivered via vaginal delivery at 39th gestational week at XXXXX County Hospital- Emergency Department (ED).

85, 83- 84

09/21/YYYY


Obstetrical (OB) Ultrasound:Fetal number- Single, Fetal cardiac activity and movement- Normal.Placenta location: Anterior, yolk sac 7 cmExpected Date of Delivery (EDD): 04/30/YYYY, Mental age (MA): 8w 2dCrown Rump Length (CRL) 1.7cm, Fetal Heart Rate (FHR) 155, Amniotic Fluid Index (AFI) within normal limits

122

09/22/YYYY


Labs: Screening test negative for HBsAg, Rubella antibodies, IgG, Antibody screen, RPR and HIV.

113-114

3 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFCBC, Platelet count and Differential count: No abnormalities detected.

09/27/YYYY


Labs:Tests ordered: Pap Ig, rfx HPV all pathology

Diagnosis: Negative for intraepithelial lesion and malignancy

118

10/19/YYYY


OB visit: Illegible notes Weight 156, BP 122/74, Gestational Age (GA) 11 weeks 3 days. Positive fetal heart rate. No edema. _______ cramping. Decreased appetite. Prenatal vitamins changed per patient request. 4 weeks

82

11/16/YYYY


OB visit: Illegible notes Weight 163, BP 120/62, GA 16 weeks. Positive fetal heart rate. No edema._______

82

11/20/YYYY


Labs:GA 16 weeks, maternal age at EDD 19.3, weight 163.

Screening test negative for fetal Open Spina Bifida (OSB), Down syndrome and Trisomy 18.

111-112

12/07/YYYY


OB visit: Illegible notes Weight 166, BP 121/76, GA 19 weeks, Fundal height 19, and no edema.

82

12/07/YYYY


OB Ultrasound:MA 18 weeks 6 days, EDD 5/3/YYYYPresentation: Transverse head to maternal left, Placenta location: Anterior, Bi Parietal Diameter (BPD) 4.5, Head circumference (HC) 15.9, Abdominal circumference (AC) 13.7, Femur length (FL) 3.2, Estimated Fetal Weight (EFW) 296, Occipital Frontal Diameter (OFD) 5.4, FHR 148, AFI within normal limits.

121

01/09/YYYY – 03/21/YYYY


Prenatal Flow Record:*Reviewer’s comment: The only available prenatal details from flow sheets are summarized below in a tabulation format for ease of review

Weight BP GA Fundal height

Fetal heart rate

01/09/YYYY

170 126/71 23 weeks 5 days

25

02/01/YYYY

172 140/78 26 weeks 5 days

25

03/07/YYYY

173 124/56 31 weeks 6 days

30 160

80

4 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REF03/21/YYYY

175 138/78 33 weeks 6 days

35

03/24/YYYY


Labs:Negative for Streptococci Group B culture

81

04/04/YYYY


OB Ultrasound:MA 35w 5d, EDD 5/4/YYYY, Presentation: Cephalic, Placenta location: Anterior fundalBPD 8.9, HC 31.8, AC 31.2, FL 7, EFW 2721, OFD 11.4, FHR 130, AFI within normal limits.Positive for fetal cardiac activity, fetal movement, three vessel cord, 4 chamber heart, fetal stomach, bladder, kidneys, spine and cord insert.

120

04/28/YYYY


OB visit for irregular contractions:Contractions are irregular and started at 0800 hrs.Last solids and drank liquids @ 1500 hrs.

Arrival @ 1935 hrs: (XXXXX, RN)Vitals: BP 104/64, temperature 98.8, pulse 72, respiration 18Dilation 3, effacement 70, Station -1, presenting part: vertexFHT 140, reactive variability and negative Group B streptococcus.Previous OB complications: Hyper emesisRepair sutures and medications: 2.0 Vicryl

@ 2126 hrs: (XXXXX, RN)Pain 10/10, Dilation 5-6, Effacement 90%, Station +1, FHT 150, FHM external, Variability: Reactive.Negative deceleration. Intra Venous (IV) fluid Lactated Ringers (LR)Contraction: Moderate strength, 1-2 min frequencyVertex position

@ 2146 hrs: (XXXXX, RN)1 mg Stadol, Intra Venous Push (IVP), LR right hand 125 mg Intra Venous Fluid (IVF), 18 g Cathlon to right hand X 2 attempts blood specimen collected and sent to lab.

@ 2248 hrs: (XXXXX, RN) Strength: Strong, every 1 min, duration 1 min, FHT 120, FHM external. Vertex position.

@ 2250 hrs: (XXXXX, RN)Patient off monitor. Transferred to delivery room via cart in stable condition.

Artificial Rupture Of Membrane (AROM) at 1 hour 10 min before delivery

@ 2256-2300 hours Fetal monitoring strip: (Ref: 725)

598-599, 605, 725, 727

5 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REF

MD comments: Fetal strip showing minimal beat to beat variability and absence of accelerations.

@ 2317 hrs: Vacuum applied x 4 per Dr. XXXXX

@ 2320 hours Fetal monitoring strip: (Ref: 727)

MD comments: Fetal strip showing persistent prolonged decelerations.

@ 2326 hrs: Vacuum applied x 4 per Dr. XXXXX

* Reviewer’s Comment: The patient went for c-section owing to cephalopelvic disproportion. The Labor and Delivery note/ Procedure report including the vacuum extraction details are not available for review.

04/29/YYYY


History and Physical:Chief Complaint: Onset of labor, failure to descend and cephalopelvic disproportion.

History of Present Illness: The patient was taken to the delivery room at 10 cm dilatations and 100 effacement. She failed to descend beyond a plus one station on numerous attempts position wise, including flexing the hips. She was even placed in the hands and knees position and in the kneeling position with failed vacuum extraction with episiotomy. She is now going to have cesarean section.

Review Of System: Unremarkable, except for history of present illness.

Examination:Vitals: BP 115/72, respiration 20, temperature 98.6, pulse 90.She is a well-developed gravida Afro-American female in mild distress.

126-127

6 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFHead: Atraumatic and normocephalic. Pupils are equally round and reactive to light accommodation. Extraocular movements are intact. Cranial nerves 2 through 12 are grossly intact. Tympanic membranes (TM) clear. Nose is clear. Oropharynx is clear.Neck: SuppleLungs: Clear to auscultation bilaterallyHeart: Regular rate and rhythm without gallops, rubs or murmurAbdomen: Soft and non-tender. Fundal height is 39 cm and fetal heart tones are in the 130s.Genitourinary (GU), Rectal, Skin: NormalGenitalia: Episiotomy repair and midline in place. Cervix is 10 cm. 100% effaced plus one stationExtremities: No cyanosis or edemaNeuro: Intact

Impression: Cephalopelvic disproportion (CPD) and failure to descend.

Plan: Admit and perform cesarean section04/29/YYYY


@ 0000 hours Fetal monitoring strip:

MD comments: Fetal strip showing absence of beat to beat variability and absence of accelerations.

732

04/29/YYYY


Operative Report for primary cesarean section:Pre-operative diagnosis: CPD, failure to progressPost-operative diagnosis: Same, meconium stained fluidAnesthesia: General

Procedure: After the patient had an unsuccessful vaginal delivery with vacuum assistance it was obvious there was CPD and she was brought to the OR where general anesthesia was obtained. A Pfannenstiel incision was made and carried sharply through the fascia. The fascia was opened sharply. The rectus reflected off the rectus muscle and the rectus divided along the midline.

The peritoneum was sharply entered. Bladder flap was constructed and a low transverse incision was made. Meconium stained fluid was observed. The infant was male in the occiput posterior position with the head molded into the pelvis. The infant was delivered and tended by myself while Dr. XXXXX closed.

The placenta was manually extracted and the uterus exteriorized, curetted with a towel and irrigation with antibiotic solution was performed. The lower transverse segment was closed with running locking #1 Vicryl. The anterior and posterior gutters were irrigated free of clots. Good hemostasis was noted. Tubes and ovaries were normal. The uterus was returned to the abdominal cavity by Dr.

132

7 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFXXXXX.

The rectus was approximated and the fascia was closed with running #I Vicryl, subcutaneous 2-0 Vicryl, skin with auto suture. The patient was stable and to the Recovery Room (RR).

04/29/YYYY


Nurse Notes:At 0024hrs a male infant was delivered.

APGAR score:1 min: 4, 5 min: 6, 10 min: 9

Weight 7 lbs. 8 oz.

No physical abnormalities noted. No intake taken.

Output: Urine, meconium

599

04/29/YYYY


Newborn Transitional Record: Illegible notes @ 0040 hrs: (Ref 546) Vitals: Respiration 98, temperature 95.4, pulse 156, oxygen saturation 93%

@ 0045 hrs: (Ref 546, 561) Received to nursery from OR. Weighed and placed on radiant warmer with warm, humidified O2 at 100% per Oxyhood. Dr. XXXXX arrives. Chest X- ray ordered. Infant grunting loudly. No nasal flaring. No retractions.Tone: floppy, skin color blue, head: large caput, lungs wet sound, good breath sounds and harsh sounding cry.

@ 0055 hrs: (Ref 546) Chest X- ray done. Infant active and crying. IV established. Blood culture drawn. IV dislodged with active infant’s ______. 24 gauge Cathlon inserted in right forearm and taped securely. Dextrose 5 ½ Saline started at 10cc/hr ________

@ 0100: Current Medications: Erythromycin eye ointment both eyes, Vitamin K Intra Muscular (IM) right thigh, Hepatitis B vaccine IM left thigh, HBIG vaccine IM and triple dye applied via cord.

@ 0115 hrs: Ampicillin, then Claforan doses given IVP slowly. Tolerated well.

@ 0140 hrs: Vitals Respiration 80, temperature 98.5, pulse 141, oxygen saturation 98%

@ 0200 hrs: Active and crying. Irritable. Cries and kicks without any stimulus

546, 561

8 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REF@ 0215 hrs: Asleep and quiet for first time since admission. Tachypnea with respiration 90. Now resting on abdomen under radiant warmer and 100% oxygen.

@ 0245 hrs: Quiet only a few minutes. Then crying again. Vital signs stable.


@ 0340 hrs: Vitals: Respiration 172, temperature 98.6, pulse 172, oxygen saturation 100%


@ 0500 hrs: Vital signs stable. Excessive crying. Remains on radiant warmer. Tachypnea. Under 100% O2 per Oxyhood

@ 0510 hrs: 2 hour glucose: 5404/29/YYYY


New born Assessment on discharge: Illegible notes

Complications of Antepartum and delivery: Primary C-section, CPD/FTP. Vacuum and ____ x 4 per Dr. XXXXX. Probable meconium aspiration.

On Admission @ 0100 hrs: Weight 7 lbs. 8 oz; 3406 grams, Head circumference: 14, Length 20.

On Discharge @ 0800 hrs: Blood type: B positive, blood sugar 54, hematocrit 37.3, hemoglobin electrophoresis 12.1 and negative for Coombs and Hepatitis B.

Complications in Nursery: Low oxygen when out of Oxyhood. Meconium aspiration.

Feeding: Nil per oral

Discharge Diagnosis: _______, Meconium aspiration

Newborn Discharge Assessment: ID bands verified between mother and baby. Foot prints complete and mother offered a copy. Newborn transferred to MCU at UMCNewborn will not reside with the mother.

Skin condition and ability to void/ stool: Good

543-544

9 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFMedications on discharge: Dextrose ¼ NS at 10 ml/ hour, Ampicillin 200 mg IV, Claforan 200 mg.

Unresolved issues: Transfer to MCU at UMCAssessment of newborn: Oxygen saturation 100% Oxyhood. Report to MCU. IV site right arm with 24g intact. IV fluid, infusing well. Active muscle tone, color pink. Respiratory tachypnea. Cord clamp intact. ______

Discharged to UMC04/29/YYYY


Discharge Summary:Diagnosis: Probable meconium aspiration syndrome

History: The patient had an uncomplicated pregnancy. Attempts have been made by Dr. XXXXX at vaginal delivery when she became complete. Vacuum extractor had been placed several times without success and the decision was made to go to cesarean. At the cesarean delivery there was fairly moderate to thick meconium stained fluid noted. The infant initially had been suctioned aggressively on the operating field but had decreased Apgars of 4, 6 and 9.

Bag valve mask resuscitation had to be performed. I did visualize the cords but not after the baby had taken the first breath. The initial X-rays showed some bilateral perihilar infiltrates consistent with probably aspiration. The child has been under the Oxy-Hood all night and has been crying incessantly.

This morning the child is alert and active. Oxygen saturations are nearly 100% under the Oxy-Hood but when taken out from the Oxy-Hood they drop fairly quickly but he has been able to maintain oxygen saturations for a while in the 90 percentile but when he starts crying he does become cyanotic and his oxygen saturation drop.

Chest X-ray shows improvement of the infiltrates. There is a questionable pneumothorax on the left and we are waiting the radiologist’s interpretation. My impression, however, is that the child has meconium aspiration syndrome. My other concern is the possibility of a subdural or epidural hematoma.

The caput that was present at birth has pretty much resolved; however, due to the infant’s incessant crying I am concerned about the possibility of a subdural. Ampicillin and Claforan were given after appropriate cultures. The mother did receive Ampicillin in labor. I have contacted Dr. XXXXX at UMC, Neonatal ICU, and they will arrive as soon as possible to transport the baby to UMC.

Transfer record: (Ref 558)The patient is transferred in an unstable condition to the NICU via

138, 599, 624, 558

10 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFambulance with the diagnosis of meconium aspiration for special care.

04/29/YYYY


NICU Report: Illegible notes Birth:(Ref 624) Time 0024 hrs, Weight 3.406, Length 50.5 cm, HC 35.5 cm, GA 39 weeks 6 days, Growth: adequate for gestational age. Amniotic fluid: Meconium stained.

Admission Laboratory studies: (Ref 625) WBC 19.3, Hemoglobin 12.1, hematocrit 37.3, platelets 403. Blood culture pending

Physical Examination:Vitals: BP 66/39, respiration 36, temperature 97.7, pulse 144Bed: Radiant warmerHead, Eyes, Ears, Nose, Throat (HEENT): Normocephalic, moderate molding with caput succedaneum, anterior fontanelle soft and open, eyes clear, no discharge, ears normoset, no tags, no pits and palate intact, gums pink, no teethRespiratory: Bilateral breath sounds equal and clear and easy work of breathing, occasional tachypneaCardiac: Regular Rate and Rhythm (RRR), no obvious murmur, femoral and brachial pulses 2+ and equal and cap refill <3 secondsAbdomen: Soft, nondistended, normoactive bowel sounds, cord clamped, no organomegaly and no masses palpatedGU: Normal term male features, testes palpable bilaterally and anus presentNeurologic: Tone intact, symmetric, semi- flexed and responsive to light touchSpine: Full range of motion of neck and spine straight, no obvious mass, dimpling or hair tuftExtremities: Moves all extremities, all digits present and intact and no hip clickSkin: Pink, intact, breast tissue appropriate for age, sacral mongolian spot and small nevus lower left back and upper back

Radiology studies: XXXXX, MD (Ref 550) @ 0052 hrs: Borderline cardiomegaly with diffuse bilateral pulmonary interstitial and alveolar infiltrates from edema and/or pneumonia.

@ 0719 hrs: Borderline size heart otherwise, normal chest.

Respiratory Support:(Ref 625) Hood O2, FiO2 0.35 and oxygen saturation 98.

Current problems and Diagnosis:

624-627, 628, 550, 609

11 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFTerm Birth Living Child: Status- Active.Comments:Infant active on exam with no distress noted. Able to quickly wean from supplemental oxygen. Maternal labs and history reviewed. Mother reports she received post natal care. Updated mother regarding infant’s current clinical status and plan of care over telephone today.

Plans: Follow clinically, support as indicated.

Nutritional Support: Status- ActiveComments:Infant NPO upon admission due to respiratory distress. ICFs currently infusing. Infant quickly weaned to room air upon admission to UMC NICU with easy work of breathing. PO feeding given. Infant tolerated well with no problems.

Plans: Continue IVFs at 80ml/ kg, offer PO as desired (ad lib) feeds, wean IVFs depending on PO intake, strict input and output and follow renal panel.

Transient Tachypnea: Status: Active, Procedures: OxyhoodComments:Infant delivered via C section after failed attempts at vacuum extraction. Amniotic fluid was meconium stained. Infant required Positive Pressure Ventilation (PPV) in the delivery room and was subsequently placed under Oxyhood with 100% FiO2 at OSH. Unable to wean from supplemental oxygen at OSH.

Infant transported to UMC for future care and management. Infant quickly weaned from 35% FiO2 to room air after admission to UMC. Easy work of breathing on exam. Chest X-ray shows mild interstitial streakiness.

Plans: Monitor clinically, support as indicated

Possible Sepsis: Status: Active. Antibiotics started.Comments:Infant with respiratory distress after birth requiring supplemental oxygen. Blood culture drawn at OSH and antibiotics started. Ampicillin 170mg IV every 8 hours x 3days started on 04/29/YYYY; Gentamicin 8.5mg IV every 12 hours x3 days started on 04/29/YYYY

Plans: Continue antibiotics overnight, monitor clinically, follow C Reactive Protein (CRP) and CBC with diff, follow blood culture results from OSH.

Fluid Intake: Peripheral Intra Venous (PIV): D10 + ¼ Normal

12 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFSaline (NS) and Calcium 0.7.Feeds: Similac 20/ Fe 20 kcal/ oz. Per Oral (PO) as desiredTotal Fluids Ordered: 80ml/ kg/ dayTotal Calories Ordered: 27kcal/ kg. day

Attending note: (XXXXX, MD) (Ref 628)Baby seen and examined and history reviewed with resident or Neonatal Nurse Practitioner (NNP). Baby transferred in from Indianola, Dr. XXXXX referring physician. Baby started having more respiratory distress following delivery in meconium.

Transport team picked the baby up. Was able to start reducing oxygen and still keep saturations above 95. Upon admission baby under an Oxyhood. Head: fontanelle is soft and not abnormally sized, scalp no lesions. Eyes no lesions. Ears normal shape.

Nose patent with no malformations. Mouth no lesions. Neck no masses or sinuses and not abnormally shaped. Lungs: mild tachypnea and retractions. Respiratory distress is not severe. Abdomen soft, has bowel sounds, not distended, no organomegaly and no masses. Genitalia normal male.

Extremities no malformations or other lesions. Skin no lesions noted. Neuro: baby has appropriate tone and reflexes for gestational age. Is appropriately alert for gestational age. We will start on careful fluid management. Maintain antibiotics. Check the blood culture. Monitor fluid balance. Monitor respiratory status.

04/29/YYYY


Labs of Cord Blood:High: WBC 19.3, Mid Cell Fraction (MID) 1.7, granulocytes 12.9

Normal: Lymphocytes 4.7, lymphocytes % 24.6, mid % 8.6, granulocytes % 66.8, RBC 3.84, hemoglobin 12.1, hematocrit 37.3, Mean Corpuscular Value(MCV): 97, Mean Corpuscular Hemoglobin (MCH) 31.6, Mean Corpuscular Hemoglobin Concentration (MCHC) 32.4, platelets 403, Mean Platelet Volume (MPV) 7.6

Accucheck 20: 54. Negative for Direct Coombs test.

548-549

04/29/YYYY


Chest X-Ray:Clinical History: Persistent tachypnea

Impression: No significant abnormality noted

553


* Reviewer’s Comment: The infant was managed conservatively with no change in examination. Hence the daily progress notes till discharge on 05/03/YYYY are summarized briefly to assess for any change in clinical status alone

04/30/YYYY


Progress Notes:Physical Exam:Bed: Crib

630-632, 618

13 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFVitals: BP 68/41, respiration 31, temperature 97.3, pulse 135Urine output 138 ml and stool 4

Physical Examination:Respiratory: Bilateral breath sounds equal and clear and easy work of breathing on room air.

Laboratory studies:WBC 27.7, hemoglobin 13.3, hematocrit 39, platelets 421, Segmental% 86, Lymphocytes% 14, Total bilirubin 2.2, Direct bilirubin 0, C reactive protein 0.80

Respiratory Support: Room air, oxygen saturation 100%

Current Problems and Diagnoses:Term Birth Living Child: Infant remains well perfused and active on exam, no distress noted, anticipate discharge home in the next day or two. Follow clinically

Nutritional Support: As desired feeds started after weaning from supplemental oxygen yesterday, improving intake noted overnight, stable voiding and stooling patterns, remains on supplemental IVF’s. Continue ad lib feeds, monitor intake, discontinue IVF’s, and follow input and output.

Transient Tachypnea: Resolved. Infant weaned from supplemental oxygen upon arrival to UMC yesterday, remains clinically stable on room air with no distress noted.

Possible Sepsis: Resolved. Infant worked up for possible sepsis due to respiratory distress following delivery. Infant has received 24 hours of antibiotic therapy. Blood culture remains negative. Infant remains clinically stable on room air with no signs of sepsis.

Current Fluid Intake: PIV: D10 +1/4 NS. Calcium 0.7. Feeds: Similac 20/ Fe 20 Kcal/ oz. PO ad libPO ad lib feeding with improving effort. IVF decreased to 40ml/ kg overnight with improvement in PO intake.

05/01/YYYY


Attending Note:Baby seen and examined and history reviewed with resident and NNP. In newborn nursery, on full feedings, having stools and good urine output.

Impression/ Plan: Maintain full nutrition. Ready for discharge.

633-635

05/02/YYYY


Discharge Summary:Diagnoses: Term pregnancy delivered by primary cesarean section secondary to failure to progress, cephalopelvic disproportion with meconium stained fluid.

125

14 of 23



Hospital course: The patient presented at term in active labor. She had a progression of labor and was taken to the delivery room by Dr. XXXXX. She failed to descend adequately and vacuum extraction assistance was applied but he was unable to deliver her. We proceeded therefore with primary cesarean section.

There was thick meconium stained fluid and the infant had 4/6/9 Apgars and had to be resuscitated. The infant was later transferred to UMC with meconium aspiration syndrome and reportedly is doing well and is ready for discharge at the time of the mother's discharge. Postoperatively she has done well. She had a fairly smooth postoperative course.

She is afebrile. Her blood pressures are normal. Hemoglobin and hematocrit is 9 and 28. She is Rh positive. Rapid Plasma Reagin (RPR) nonreactive. HIV, hepatitis negative. She is discharged home at this time on Motrin 800 t.i.d., Ferrous Sulfate 325 t.i.d., Tylenol #3 (20) one every 6 as needed severe pain. She will follow-up in the office on Wednesday for staple removal.


Reviewer’s Comment: The NICU reports for 05/02/YYYY are not available for review.

05/03/YYYY


Discharge Summary:Resolved Diagnosis:Transient Tachypnea: Status: Resolved, Procedures: OxyhoodComments:Infant delivered via C section after failed attempts at vacuum extraction. Amniotic fluid was meconium stained. Infant required PPV in the delivery room and was subsequently placed under Oxyhood with 100% FiO2 at OSH.

Infant transported to UMC for future care and management. Infant quickly weaned from 35% FiO2 to room air after admission to UMC. Infant remains clinically stable on room air with no signs os sepsis.

Possible Sepsis: Status: Resolved.Comments:Infant worked up for possible sepsis due to respiratory distress following delivery. Infant has received 24 hours of antibiotic therapy. Blood culture remains negative. CRP 0.8 mg/dl this morning. Infant remains clinically stable on room air with no signs of sepsis.

Active Diagnosis:Term Birth Living Child: Status- Active.Comments:Infant was transported from XXXXX County Hospital due to respiratory distress. He weaned quickly to room air. Remains pink on

254-258

15 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFroom air with no clinical signs of distress. No murmur. Stable axillary temperatures in open crib. Discussed discharge follow up with local MD in 1-2 weeks with mother.

Plans: Discharge home with mother today and follow with local MD at 1-2 weeks of age.

Nutritional Support:Comments: PO intake appropriate for age with as desired feedings, normal pattern of voiding and stooling and abdominal exam benign.

Plan: Continue as desired feeds.

Diagnosis during this hospitalization: 4 day old 39 week appropriate for gestational age male newborn, term birth living child, nutritional support, transient tachypnea and possible sepsis ruled out.

Discharge Type: Home05/06/YYYY


ED Triage Notes: Illegible notes Category: UrgentPresenting complaints: Complains of spitting up yellow stuff (1 time tonight). Full term. C section. 1 week old.Similac with ___ 4oz every 4 hours. Bowel movement today.Doesn’t use ___ suction.

Emergency Medical Treatment and Labor Act (EMTALA) screening: No abnormalities detected

Vitals: Respiration 44, temperature 97.5, pulse 163, oxygen saturation 99, pain level 0/10 and weight 82

Plan: Instructions given for feedings.

* Reviewer’s Comment: Only the triage notes available for this visit.

569


XXXXX Medical Group


* Reviewer’s Comment: The multiple pediatric visits for time period of 6 years from 05/07/YYYY to 10/09/YYYY for various conditions (like Contact dermatitis, Phimosis, Acute upper respiratory Infection) has been reviewed and only the details pertinent to developmental delay has been summarized below

07/03/YYYY -07/30/YYYY


Cumulative Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) visits:Hearing: Responds to sounds, smiles and laughs. Newborn hearing screen: Normal. Developmental screen: Normal

04/30/YYYY: XXXXX, CFNP (Ref 312):

322, 320, 318, 314, 312, 311

16 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFHearing/ Speech: Hears well. Says 2-4 wordsVision: Notices small objectsDevelopmental screen: Normal

07/30/YYYY: XXXXX, CFNP (Ref 311):Hearing/ Speech: Hears well. Says 3-6 wordsVision: Notices small objectsDevelopmental screen: Normal

05/21/YYYY


Pediatric and Adolescent Assessment:Neuro, ENT, Developmental, Cardiopulmonary, Gastrointestinal and Genitourinary, Musculoskeletal- Functional, Integumentary - WNL

591-592

04/30/YYYY


EPSDT 2 Year Visit:Problems/ Concerns: Pulling at right ear a lotHearing: Hears well and uses two-three word sentences. Vision: sees distant objects well.Developmental Screen: Uses a spoon, puts three words together, points to body parts, follows directions and walks up and down stairs and runs well. Developmental screen was normal.

Impression: No growth development, elimination, feeding and sleep concerns. No medical problems. Anticipatory guidance addressed as per the history of present illness section

300-302

09/01/YYYY


Pediatric Follow-up Visit: General appearance, posture/ gait, head, skin, eyes, ears, nose, mouth, pharynx, teeth, heart, lungs, abdomen, genitalia, bones, joints, muscles, neurological, glands and muscular coordination – Normal for ageSpeech: Stutters. Cannot pronounce S, T, F. Delayed developmental milestones speech.

Assessment: Speech fluency stuttering, delayed developmental milestones speech and skin: rash.

Plan:Apply Hydrocortisone 2.5% external cream to affected area twice daily as directedRefer to Speech Therapy (ST) outpatient Greenwood Leflore Rehab.

298-299, 535- 537

09/30/YYYY


ST Records:Medical Diagnosis: Delayed developmental milestones and speech fluency stuttering.Therapy Diagnosis: Mild expressive language delay and mild to moderate receptive language delay.

Date of Onset: Patient’s mother reported patient’s grandmother began noticing the patient “stutters” approximately 1 year of age.

Level of function: Speech language skills reportedly mildly decreased across developmental time spans.

248-251

17 of 23



Impression:Patient presents with a mild receptive language disorder. Patient is functioning in the average range for expressive language among peers his age. Evaluation this date did not indicate “Fluency disorder” or “articulation disorder”. But more a lack of language stimulation on daily basis to promote increased language and speech skills. Therefore it is recommended by this Speech Language Pathology (SLP) that patient be enrolled in a daycare or mother’s morning out to promote language stimulation from peers his age. Speech/ language treatment not indicated at this time. Results of the evaluation and recommendations were discussed with patient’s mother who voiced good understanding, however patient’s mother reported didn’t want him in a daycare because those kids cuss and bite and scratch and stuff. He likes to watch TV at home and I work with him on his ABC’s and stuff.

05/06/YYYY


EPSDT 3 Year Screening: (XXXXX, NP)

No growth, development, elimination and feeding concerns.

293-296

05/03/YYYY


EPSDT 4 Year Screening: (XXXXX, NP)Assessment: Health maintenance, atopic dermatitis, speech fluency stuttering, furuncle and delayed developmental milestones speech.

Plan: Refer to ST outpatient evaluation and treatment.

287-291

07/13/YYYY


Speech Therapy Records: Impression: Test results indicated articulation, language and fluency disorders. Medical history was significant for meconium aspiration.

Discharge Plan: Patient will be discharged when articulation, language and fluency are within normal limits.

239-244

02/25/YYYY


Audiological Evaluation Summary:Summary:Normal hearing sensitivity 500 - 1500 Hz before sloping to a mild to moderate sensorineural hearing loss 2000 - 6000 Hz, bilaterally. This hearing loss is considered sufficient to interfere with the ability to hear and understand soft speech, specifically high frequency speech sounds such as /sh/, /t/ and /s/.

Hearing aids are recommended to ameliorate the deleterious effects this hearing loss will have on the patient’s speech and language development, education and socialization. Binaural amplification is necessary to provide consistent and comfortable access to speech stimuli across the broadest range of frequencies in a variety of listening settings.

Recommended Amplification System:Oticon Safari 300 13P behind-the-ear (BTE) hearing aids. The patient’s grandmother chose a steel grey casing to be coupled to grey

214-215

18 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFand white standard ear molds. Ear mold impressions were obtained without incident and will be sent to Emtech for make.

Recommendations:1. Medical/ otologic evaluation with ENT for sensorineural hearing loss with consideration of medical clearance for amplification. This is currently scheduled for 4/30/YYYY with Dr. XXXXX.2. Return for hearing aid fitting following medical clearance for amplification.3. Return for hearing aid check/follow-up in 4 - 6 weeks after fitting. Aided testing will be completed at that time.

04/29/YYYY


EPSDT 5 Year Visit:Examination:Hearing/ Speech: Problems with speechAudiometric hearing screen: PassVision: PassDevelopmental Screen: Repeats sentences with 10 syllables and catches bounced ball, but does not count 10 objects and does not ask about meaning of words. Developmental screen was normal. Skips and heel to toe walk.

Impression:No growth, elimination, feeding, skin and sleep concerns. Developmental concerns include delayed language skills and speech much improved. No medical problems. Anticipatory guidance addressed as per the history of present illness section. No vaccines needed. Information discussed with Grandmother.

282-286

04/30/YYYY


Progress Notes:Audiometry Summary:Normal hearing sensitivity 500 - 1500 Hz before sloping to a mild to moderate sensorineural hearing loss 2000 - 8000 Hz, bilaterally.

Assessment: Sensorineural hearing loss

Plan:Recommend proceeding with hearing aids. He has an appointment with Dr. XXXXX tomorrow for hearing aid check with aided testing. We also recommend a baseline vision exam and a referral was placed to pediatric ophthalmology.

The risks and benefits of my recommendations, as well as other treatment options were discussed with the grandmother today.We will plan to see the patient back in the clinic as needed or with any changes in his condition.

674-676

05/01/YYYY


Progress Notes:Amplification System:Make and model: Oticon Safari 300 13P BTE

678-679

19 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFElectroacoustic Analysis: Did not test.

Validation: Informal testing in the binaural aided condition, using conversational un-monitored live voice, yielded identification of LING 6 sounds /a/, /i/, /u/, /m/, /s/, and /sh/ and pointed to body parts.Results suggest: Need for further assessment in quiet and in noise following consistent use of amplification.

Comment: The patient’s grandmother was counseled about the use and maintenance of the hearing aids. She was advised to call our office with any concerns or questions.

Recommendations:1. Consistent use of amplification in the binaural condition during all waking hours.2. Return for a hearing aid check in 4-6 weeks.

07/24/YYYY


Follow-up Visit:Assessment:1. Delayed Developmental Milestones Speech 2. Acute Upper Respiratory Infection

PlanDelayed Developmental Milestones Speech: Refer to Speech Therapy Outpatient Evaluation and Treatment.

463-466

05/16/YYYY


EPSDT 6 to 10 Year Screening:

Problems: Going to try and get him in school on 06/11/YYYY, when he goes to child development UMC.

Audiometric Hearing Screen: Right ear: 500 Hz at hearing impaired and wears hearing aids in both ears decibel, but hearing screen fail.

School Age Development Screen: Heel to toe walk backward, copies and draws stickman, but adolescent counselling not done. Developmental screen was normal.

Child Development Assessment:Gross Motor Function: Skips, walks on heels and toes, tandem (one foot directly in front of another) face forward and hops in place.

Visual Perceptual Fine Motor Function: Copies a square with a circle inside and copies two lines that cross.

Cognitive development: Identifies primary color and grade failure of hasn’t started school grade. But does not count to 10, does not know whether it was morning or afternoon and does not identify ABCs.

Assessment

276-281

20 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REF1. Health Maintenance 2. Hearing Loss 3. Delayed Developmental Milestones Speech 4. Developmental Learning Difficulties 5. Speech Fluency Stuttering

Plan: Had 2 failures and refer to Child Development. Budesonide 0.5 MG/2ML Inhalation Suspension; use 1 unit dose via nebulizer daily. Hemoglobin- Done. Urinalysis- Complete

06/11/YYYY


Psychological Evaluation:Educational History:The patient attended speech therapy in City for a short period of time. However, this was not effective due to hearing problems. Subsequently, the speech pathologist discontinued services. He was signed up for school at Ida Green Bementary School; however, mother reported the school had no one to teach him and he was not enrolled.

The patient has not attended school to date. He can count to at least ten, label colors and shapes, dress himself and tell his mother about experiences in simple sentences. However, his articulation is poor, he does not yet write his name, does not yet label letters or numbers. He can dress himself, use utensils, and help with simple chores including mopping and sweeping, and brushes teeth independently. He does not yet consistently put shoes on the correct feet, is working on fastening buttons. Bathes with assistance and sometimes wets the bed.

He plays frequently with his brother and other relatives, plays imaginative/ pretend type activities. He may engage in tantrums when told "no."

Motor: The patient can pedal a bicycle with training wheels and enjoys playing baseball, football, and tag. He can cut with scissors and tries to draw shapes but has not mastered these skills.

Examination Behaviour:The patient was accompanied by his mother. He was polite and friendly. He wore his hearing aids and appeared to hear the examiner during testing. Rapport was easily established and maintained throughout the test session. During testing, he made adequate eye contact, demonstrated understanding of instructions, and attempted all tasks presented.

Effort was consistent as the items became more difficult. Therefore, the following test results are considered to be a valid Index of current psychological/ intellectual functioning.

Kaufman Brief Intelligence Test- Second edition: (KBIT-2)

190-195

21 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFSubtest Standard

scoreConfidence Interval

Percentile

Verbal IQ 71 65-81 3Non- verbal IQ

69 62-80 2

Composite IQ 66 60-74 1

Wechsler Individual Achievement Test – 3rd edition (WIATT-III)Subtest Standard score PercentileEarly reading skills 69 2Math problem solving

68 2

Numerical operations

72 3

Results of the present psychological evaluation in the Child Development Clinic suggest the following diagnostic impressions:1 .Below Average Intelligence2. Below Average Academic Achievement3. Rule Out Intellectual Disability4. Phonological Disorder5. Bilateral Hearing Aids6. Symptoms of inattention are most likely secondary to significant learning problems

Recommendations:1. Further evaluation through the patient's school district to determine eligibility for services including special education services due to well below average IQ and Academic Achievement Scores on standardized testing. It is unlikely that the patient will be successful in school if he does not receive special education assistance to include an Individual Education Plan (IEP).2. Mother and Grandmother should contact Mississippi Disability Rights for assistance with the IEP process.3. Continuation of speech therapy is recommended.4. Medical follow up with XXXXX.5. Psychological followup

09/14/YYYY – 12/05/YYYY


Other related medical records: Labs, Orders, , Diagnostic test – others, Consent, , Medication sheet, Hearing aid checks, Pediatric Visits for contact dermatitis, phimosis, acute respiratory infection, staphylococcal infection, acute otitis media, Pneumonia, cervical lymphadenopathy, allergic conjunctivitis, hypoglycemia, tachycardia, acute sinusitis, acute viral pharyngitis(Ref 1-67, 69-81, 86-110,115-117, 119, 123-124, 128-131, 134-137, 139-149, 150-155, 158-189, 196-213, 215-238, 245-247, 252-253, 259-267, 268-275, 292, 297, 303-310, 313, 315-317, 319, 321, 323-369, 372-392- 398-462, 467-503, 505-534, 538-542, 545, 547,551- 552, 556- 557, 559-560, 562-568, 570-590, 593-597, 600-604, 606-

22 of 23


DATE PROVIDER OCCURRENCE/TREATMENT PDF REF617, 619-623, 629, 633-634, 636- 662, 664- 673, 676-677, 680-703)

* Reviewer’s Comment: The above records are reviewed. All the significant details

have already been included in the chronology, hence not elaborated here.

No further medical records are available to know the status of the patient

23 of 23

wiliam sepulvado - triventlegal.com · web viewmedical chronology - instructions to follow....

Documents