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XXXX DOB: 11/10/YYYYXXXX DOB: 12/18/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 prenatal visits, labor and delivery from 08/21/YYYY till the birth of

the child on 12/18/YYYY in detail. Medical records pertaining to the mother from 12/19/YYYY until discharge on 12/21/YYYY are

summarized in brief to know the postpartum condition of the mother Medical records of the child from 12/19/YYYY to 01/14/YYYY are summarized briefly. Records of the child are summarized in blue font Repetitive details are avoided in the chronology If the provider’s name or signature is not decipherable then the snapshot of the same is included

in the chronology If the PDF reference is given within the Occurrence column, we have included the references in

brown color font Important information has been highlighted in yellow

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Brief Summary/Flow of Events

08/23/YYYY-10/27/YYYY: Multiple prenatal visit and office visits for mammogram for prior pregnancies

08/21/YYYY-12/11/YYYY: Multiple prenatal visits

ABC Hospital12/18/YYYY-12/21/YYYY: Ultrasound on 12/18/YYYY revealed oligohydramnios and Intra

Uterine Growth Retardation (IUGR) - Hospitalized for labor and delivery @ 1042 hours - Underwent emergency C-section on for non-reassuring fetal heart tones with fetal bradycardia @

1845 hours - Delivery of child @ 1851 hours - Mother was discharged on 12/21/YYYY

12/18/YYYY-01/08/YYYY: Baby born on 12/18/YYYY at 1851 hours with APGAR scores of 3, 6, 9 - Diagnosed with IUGR and preterm delivery, metabolic acidosis in newborn with risk for infection – Required phototherapy for Hyperbilirubinemia – Discharged on 01/08/YYYY in

stable condition

Illinois Department of Human Services05/21/YYYY-01/14/YYYY: Multiple office visits for retarded growth and development –

Underwent PT/OT and speech therapy

Patient History

Past Medical History: Osteoporosis

Pregnancy History: Total pregnancy 7; Full term 5 Normal Spontaneous Vaginal Delivery; Spontaneous abortion 1; Living 5

Menstrual History: Menarche 12; frequency every 30 days.

Surgical History: Surgery at the age of 13 removed 1 ovary.

Family History: Sister has hypertension and mother died of breast cancer

Social History: No history of smoking, alcohol consumption or illicit drug use

Allergy: No known drug allergy

Detailed Chronology

DATE PROVIDER OCCURRENCE/TREATMENT PDF REF

08/23/YYYY-10/27/YYYY

Multiple providers

* Reviewer’s Comment: Medical records from 08/23/YYYY to 10/27/YYYY are not summarized. Pertinent information has been included in the history section alone.

Medical records: Prenatal record (Ref. 41-52), Mammogram (Ref. 560-561, 569-570, 559), Diagnostic Test (Ref. 571, 568, 567), Labs (Ref. 562-566)

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ABC Hospital08/21/YYYY

ABC Hospital Labs:Hepatitis B surface antigen (HBsAG): Non reactiveHepatitis C antibody: Non reactiveHIV: Non reactiveRubella immunoglobulin: >500 high

Normal: White Blood Cell (WBC) 10.41; Red Blood Cell (RBC) 4.21; Hemoglobin 12.6; Hematocrit 37.8; Platelet 176High: Neutrophils 79.6; Absolute neutrophils 8.29Low: Lymphocytes 15.5, Monocytes 3.1

554-557

08/22/YYYY

Not available Labs: Alpha Feto-Protein (AFP) quad screen:

Risk for NTD: 1 in 3698 Age risk for down syndrome: 1 in 54 Risk for down syndrome: 1 in 652 Risk for Trisomy 18: 1 in 2490 Maternal AFP: 45.1 Maternal AFP MOM: 0.96 Estriol, unconjugated: 1.82 Estriol MOM: 1.06 HCG: 13.24 HCG MOM 0.72 Inhibin A: 141.0 Inhibin A MOM: 0.87

Chlamydia/Gonorrhea: NegativeUrine culture: No growthRapid Plasmin Reagin (RPR): Non reactive

* Reviewer’s Comment: This information is taken from flow sheets. Detailed report is not available for review.

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09/04/YYYY

Xxxx, R.D.M.S.

Xxx, M.D.

Obstetrical ultrasound report:Pregnancy: Gravida 6, para 5LMP: 04/10/YYYYGestational age by LMP: 21 weeks 0 daysGestational age by ultrasound: 20 weeks 1 dayEDD: 01/15/YYYY

Previous exam: No previous examIndication: Fetal survey

Measurement and fetal age Fetal growth evaluationMeasurement GA Range Source %

GARatio

BPD 4.7 cm 20 w 2 d 18 w 4 d-22 w 0 d

Hadlock 31% FL/BPD 0.21

HC 18 cm 20 w 3 d 19 w 0 d- Hadlock 33% FL/AC 0.22

552-553

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22 w 0 dAC 15.2 cm 20 w 3 d 18 w 2 d-

22 w 4 dHadlock 38% HC/AC 0.18

(1.05-1.24)

FL 3.3 cm 20 w 3 d 18 w 4 d-22 w 2 d

Hadlock 36% CI 0.72 (0.70-0.86)

Legend: Bi-Parietal Diameter (BPD), Head Circumference (HC), Abdominal Circumference (AC), Femur Length (FL), Cephalic Index (CI), Weeks (w), Days (d), Gestational Age (GA)

Gestation age for sonogram: 20 w 1 d (18 w 5 d - 21 w 2 d). Fetal weight: 352 gm (301 404) Hadlock Fetal heart rate: 150 bpm

Fetal summary:Cerebellum, lateral ventricles, cistern magna, orbits, nose, mouth, diaphragm, stomach, kidneys, abdomen walls, 4 chamber heart, 3 vessel cord, cord insert, bladder, spine, limbs, hands and feet seen. Placenta anterior low lying.

Summary:There is a single live gestation in breech presentation. The amniotic fluid volume is within normal limits. The placenta is anterior with low lying placenta previa. There is no funneling of the internal orifice. A three vessel umbilical with a normal cord insertion is noted. Estimated total weight is documented above. Fetal growth is-consistent with normal fetal growth. Fetal heart motion is seen.

Impression: Satisfactory structural survey. Recommend follow-up for low lying placenta.

10/29/YYYY

ABC Hospital Labs:Glucose tolerance test:1 hour glucose: 160 mg/dl (high)

550

10/31/YYYY

Labs: Vitamin D – Total 25 hydroxy: 34; Vitamin D-3, 25 hydroxy: 16; Vitamin D-2, 25 hydroxy: 18

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11/07/YYYY

ABC Hospital Labs:Glucose tolerance test:Fasting: 871 hour: 171 mg/dl2 hour: 185 (high)3 hour: 156 (high)

548

12/10/YYYY

Xxxx Telephone encounter:Reason: Needs ultrasoundMessage: Needs follow-up ultrasound for placenta locationAction taken: Called patient to pick up order for ultrasound

87

12/11/YYYY

Xxxxx, M.D. Office visit for cough:Reason for appointment: Cough for 2 daysHistory of present illness: Patient is a G6P5 who presents with cough for 2 days. Sputum is white. She had fever but didn’t take her temperature. Didn’t sleep well

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from the cough. All of her kids are sick also. Decreased appetite. Denies vomiting or diarrhea. She has been coughing so hard that she has some urinary incontinence. She has a history of asthma.

Vital signs: Height 61; Weight 190; Body Mass Index (BMI) 35.90; Temperature 98.7; Heart Rate 132; BP 124/88.

Physical examination:General appearance: Mildly ill, in slight respiratory distress.Head Eyes Ears Nose Throat (HEENT): TMs erythematous without effusion, dark circles around eyes.Neck/thyroid: Bilateral submandibular and anterior cervical adenopathy, tender, supple.Respiratory: Poor aeration of the lungs bilaterally, no crackles or wheezes, improved after the nebulized treatment significant wheezing cough is somewhat improved

Assessments: Bronchitis - (Primary) Asthma

TreatmentBronchitis: Start Prednisone tablet, 20 mg, 1 tablet with food or milk, orally, twice a day, 10 days, 20. Start Robafen AC syrup, 100-10 mg/5 ml, 10 ml as needed, orally, every 6 hours, 5 days, 200 ml. Start Biaxin XL tablet extended release 24 hour, 500 mg, 1 tablet with food, orally, twice a day, 10 days

Asthma: Start Albuterol Sulfate Nebulization solution, (2.5 mg/3 ml) 0.083%, 3 ml as needed, inhalation, every 4 hours, 14 days, 100 ml. Start Symbicort Aerosol, 160-4.5 mcg/act, 1 puffs, inhalation, twice a day, 1 month, 1 can. Start Spacer/Aero-holding chambers device, spacer, as directed, inhalation, daily, 1 year, 1 pack. Start compressor/nebulizer miscellaneous, nebulizer, as directed, inhalation, as needed, 365 days, 1 Pack.

Follow-up: 1 week (Reason: OB care.)12/15/YYYY

Xxxx Telephone encounter:Reason: Ultrasound not doneMessage: Needs follow-up ultrasound for placenta locationAction taken: Patient went to ultrasound department with the wrong order. He had to back home and find the right form. By the time they went back it was too late. They rescheduled their appointment for next Saturday 12/20/YYYY.

93

08/10/YYYY-12/02/YYYY

Prenatal record:Initial physical examination: Date: 08/10/YYYYHeight: 61; Weight: 188; BP 121/69; Pre OB weight: 184 General: No acute distressPsychiatric: Mood/affect appropriate to settingExtremities: No edemaVagina: Normal

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Uterus size: 19 weeksAdnexa, rectum, pubic arch: NormalDiagonal conjugate: ReachedSpines: AverageSacrum: ConcaveGynecoid: Pelvic type gynecoidOtherwise unremarkable

Last Menstrual Period (LMP): 04/10/YYYYInitial examination: 09/04/YYYYInitial Estimated Delivery Date (EDD): 01/15/YYYY

Ultrasound: 09/04/YYYY, Weeks: 21 weeksEDD: 01/19/YYYY

Date: YYYY

08/21 08/27 09/04 09/18 10/02 10/08 10/29 11/12 12/02

Weeks gestation

19 w 0 d

19 w 6 d

21 w 0 d

23 w0 d

25 w 0 d

25 w 6 d

28 w6 d

30 w6 d

33 w5 d

Fundal height

19 cm 20 cm 27 cm 23 cm 30 cm 34 cm 30 cm 32 cm

Pres. Vertex Vertex Vertex Vertex Vertex VertexFHR 162 145 144 150 133 154 142 144Fetal movement

Yes Yes Yes Yes Yes Yes Yes Yes

Preterm labor signs

No No No No No No no

DilationEffacementStation -3 -3Edema None None None None None None None None BP 121 /

59116 / 74

118 / 82

121 / 76

121 / 65

108 / 74

123 / 80

114 / 75

112 / 76

Weight 188 188 187 188 188 189 191 191 191Total weight gain

4 5 7 7

Urine glucose

Neg Neg Neg Neg Neg Neg Neg Neg

Urine albumin

Neg Neg Neg Neg Neg Neg Neg Neg

Next appt 2 w 2 w 2 w 4 w 3 w 2 w 2 w 2 wInitials NY NY NY NY NY NY NY NY

Legend: w: weeks; d: days; Pres.: Presentation; FHR: Fetal Heart Rate; wt: weight; Neg: Negative; appt: appointment; NY: Xxxxx, M.D.

08/21/YYYY: (Xxxxx, M.D.)Patient with LMP 04/10/YYYY, EDD 01/15/YYYY. Started prenatal care at another office is

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transferring here since they do not deliver babies. Patient is not taking prenatal vitamins of vitamin D supplementation, preterm labor precautions given. Start prenatal vitamins and vitamin D supplementation follow up.

Patient reports sporadic headaches which resolve with water and Tylenol, no Urinary Tract Infection (UTI) symptoms. Patient reports one episode of vomiting every 3-4 days, and recent onset constipation, will not have a bowel movement for 2-3days

08/27/YYYY: (Xxxxx, M.D.)No headaches, no UTI symptoms, labs discussed with the patient, complaints of toothache, also had abdominal pain and diarrhea yesterday only today no diarrhea continue folic acids, vitamin D supplementation, follow-up in 4 weeks.

09/04/YYYY: (Xxxxx, M.D.)No headaches, no UTI symptoms, needs Glucola, taking prenatal vitamins and vitamin D supplementation, preterm labor precautions given, follow-up in 3 weeks

09/28/YYYY: Note for September 18, YYYY (Xxxxx, M.D.)No headaches, no UTI symptoms, needs Glucola, taking prenatal vitamins and vitamin D supplementation, preterm labor precautions given, follow-up in 3 weeks

10/02/YYYY: Patient had Cell free genetic testing is here to discuss the results

10/08/YYYY: (Xxxxx, M.D.)No headaches, no UTI symptoms, ultrasound consistent with dates. Needs one -hour Glucola at 26-28 weeks if greater than 130 to 140 may need three-hour glucose tolerance test. Continue prenatal vitamins, vitamin D supplementation, preterm labor precaution

10/29/YYYY: (Xxxxx, M.D.)No headaches, no UTI symptoms, continue prenatal vitamins, vitamin D supplementation, and iron supplementation. Needs 1 hour Glucola. Preterm labor precautions given follow-up in 2 weeks

12/02/YYYY: Note for 11/12/YYYY (Xxxxx, M.D.)No headaches, no UTI symptoms, 3 hour GTT to values abnormal. Patient given referral to diabetic educator and a glucometer to check blood sugar continue prenatal vitamins, vitamin D supplementation, and iron supplementation. Preterm labor precautions given follow-up in 2 weeks

12/02/YYYY: (Xxxxx, M.D.)No headaches, no UTI symptoms, patient did not see the diabetic educator has been busy, did not bring her sugar testing with her reports they are fine no significant weight gain; continue prenatal vitamins, vitamin D supplementation, and iron supplementation. Preterm labor precautions given follow-up in 2 weeks.

* Reviewer’s Comment: Details pertaining to date 12/18/YYYY are summarized below separately. 12/18/YYYY

ABC Hospital

Xxxxx, R.D.M.S.

@ 0819 hours: Obstetrical ultrasound report:Pregnancy: Gravida 7, Para 5, Abortion 1LMP: 04/10/YYYYGestational age by LMP: 36 weeks 0 daysGestational age by first study: 36 weeks 0 day

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Xxxx, M.D. Gestational age by todays ultrasound: 31 weeks 3 daysGestation age selected: 36 weeks 0 days (LMP)EDD: 01/15/YYYY

Previous exam: 09/04/YYYYIndication: Placental location; growth

Measurement and fetal age Fetal growth evaluationMeasurement GA Range Source % for

36 w 0 dRatio

BPD 8.2 cm 32 w 6 d 29 w 5 d-35 w 6 d

Hadlock <05 % FL/BPD 0.75 (0.71-0.87)

HC 29 cm 31 w 6 d 28 w 6 d-34 w 6 d

Hadlock <05 % FL/AC 0.23 (0.20-0.24)

AC 26.7 cm 30 w 6 d 27 w 6 d-33 w 6 d

Hadlock <05 % HC/AC 1.09 (0.92-1.11)

FL 6.1 cm 31 w 5 d 28 w 5 d-34 w 5 d

Hadlock <05 % CI 0.83 (0.70-0.86)

Legend: Bi-Parietal Diameter (BPD), Head Circumference (HC), Abdominal Circumference (AC), Femur Length (FL), Cephalic Index (CI), Weeks (w), Days (d), Gestational Age (GA)

Gestation age for sonogram: 31 w 3 d (29 w 0 d - 33 w 6 d) based on (BPD, AC, FL) HadlockFetal heart rate: 142 bpmAFI: 2.2 cm (5-25)

Fetal weight estimate: Weight: 1751 gm/ 3 lbs., 13 oz. (1496-2007) Hadlock Normal: 2849 gm (2224-3521) Williams Weight %: <10% for 36 week 0 days

Doppler: Umbilical - mid cord: S/D 1.60

Clinical summary:There is a single live gestation in cephalic presentation. The amniotic fluid volume is decreased (oligohydramnios). The placenta is anterior fundal with no evidence of placenta previa. There is no funneling of the internal orifice. Estimated fetal weight is documented above. Fetal growth is consistent with IUGR. Fetal heart motion is seen.

Impression:Anterior/fundal placenta. Single fetus at 36 weeks. Weight below 10th percentile. AFI 2.2. Rule out IUGR. Correlate with Non-Stress Test (NST). Dr. Yukoub to be

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notified.12/18/YYYY

Xxxxx, M.D. Prenatal visit:

Weeks gestation: 36 weeks 0 days Fundal height: 36 cm Presentation: Vertex FHR: 139 Fetal movement: Yes Preterm labor signs: No Edema: No BP: 112/77 Weight: 191; Total weight gain: 8 Urine glucose, urine albumin: Negative Next appointment: To labor and delivery

Visit note: No headaches, no UTI symptoms. Patient had an ultrasound for placental location noted to have Intra Uterine Growth Retardation (IUGR) with Amniotic Fluid Index (AFI) of 2.2, on the NST patient had accelerations irregular contraction sterile vaginal exam closed soft anterior -3 vertex discussed with the OB hospitalist. Patient will be induced today for IUGR. Discuss with husband and patient that she has IUGR will induce if there is fetal intolerance of labor may proceed to C-section. To labor and delivery. Group B Streptococcus (GBS) not done yet will do one today but given antibiotics while in labor.

73-80

12/18/YYYY

Xxxxx, M.D. Follow-up Obstetrics visit:Reason for appointment: Obstetrics checkVital signs: Height 61; Weight 191; BMI 36.089; Heart rate 80, BP 112/77.

Assessments: Supervision of normal subsequent pregnancy - (Primary)

Treatment: Supervision of normal subsequent pregnancy. LAB: Culture, vaginal strep (CULVS)

Procedure: Urinalysis, auto, without scope. Fetal non-stress test.Follow-up: To labor and delivery (Reason: postpartum check)

84

12/18/YYYY

Xxx, D.O, P.G.Y. -1

Xxxxx, M.D.

@ 1042 hours: Admission history and physical record:Obstetrical history: Gestational diabetes, IUGR.

Pregnancy information: Gravida 7 para 5 LMP: 04/10/YYYY Final Estimated Date of Confinement (EDC): 01/15/YYYY Ultrasound reviewed Prenatal complications: IUGR, Oligohydramnios, A1 GDM, GBS

unknown Weight: 190 lbs.; 86.4 Kg Weight gain: 2.8 Kg Height: 60 inches; BMI: 37.1

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Uterine activity: Monitor mode: External Contraction frequency: every 3 minutes Contraction pattern: Normal <= 5 contractions in 10 minutes

Fetal assessment: Monitor mode: External Baseline rate: 140 Baseline changes: No baseline change Variability: Moderate 6-25 bpm Accelerations: 15 x 15 Decelerations: None Category: Category I

Bishop score for induction: Dilatation (cm): Closed Effacement (%): 40-50 effaced Station: Minus 3 Consistency: Soft Position: Anterior Total Bishop’s score: 5 (5-8: small percentage of induction failure)

Prenatal labs: Reviewed

Impression: Patient at 36 weeks 0 days for IOL for IUGR, Oligohydramnios. Contractions intermittent, not more than 1 per hour. No leaking fluid, no vaginal bleeding. Positive fetal movements. No fevers/chills. Positive cough and congestion past 2 weeks, completed course of antibiotic 12/17/YYYY (unknown which antibiotic per patient)

Plan: Patient at 36 weeks 0 days for IOL for IUGR, Oligohydramnios. Patient went for ultrasound, unknown reason per patient. On ultrasound 12/18/YYYY IUGR noted with weight <10% along with Oligohydramnios, AFI 2.2, patient sent for IOL.

IOL exam per Dr. Xxxxx closed/40-50/-3/soft/anterior with Bishop score of 5. Pitocin ordered, low dose for ripening IVF with 0.9 Normal Saline (NS) due to A1 GDM. Continuous Electronic Fetal Monitoring (CEFM).

IUGR maternal risk factor for A1GDM 12/18/YYYY

ABC Hospital @ 1054 hours: Labs:High: WBC 12.06; Neutrophils 80.8; Absolute neutrophils 9.74Low: Hematocrit 35.6; Lymphocytes 15; Monocytes 2.9

ABO/RH type: A PositiveAntibody screen: Negative

304, 306

12/18/ Xxxxx, M.D. @ 1109 hours: Admission record: 540

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YYYY Admission time: @ 1109 hoursReason for admission : IOLOther reason for admission: IUGR* Reviewer’s Comment: Medical record such as nurse notes; physician progress notes, nurse assessments are not available to know the intrapartum monitoring post admission till c section.

12/18/YYYY

ABC Hospital Labs:@ 1300 hours: Toxicology: (Ref. 302)Positive (high): OpiatesNegative: Cannabinoids, Phencyclidine, Cocaine, Amphetamines, Benzodiazepines, Barbiturates

Urinalysis: (Ref. 305)Color yellow, appearance clear, pH 6; urobilinogen 0.2, and specific gravity 1.009. Glucose, bilirubin, protein and nitrite are negative. RBC 1-2 and few epithelial cells.High: Ketones 1+; Blood 3+; Leukocyte esterase 2+. WBC 4-6

@ 1502 hours: Glucose 91 (Ref. 302)

302-306

12/18/YYYY-12/19/YYYY

Fetal monitoring strip:M.D. comments on interpretation of the available fetal monitoring strips:

Decelerations are noted even without uterine contractions in the strips at certain instances but decelerations were not recurrent.

Till 1810 hours on 12/18/YYYY, it is a category 2 trace; post which the traces belong to category 3.

Post 1810 hours decelerations are present with hardly any baseline variability indicating fetal compromise.

238-298

12/18/YYYY

Anesthesia OB record:@ 1845 hours: Comment: Brought emergently to Operative Room (OR) for decreased Fetal heart tone for 15 minutes. Brief history taken and airway evaluated.

Preoperative summary:Vitals: BP 107/56; Weight 190; Height 5 feet

Medication administration:Time Drug Dose and route@ 1851 hours Oxytocin 30 units IVPB@ 1852 hours Oxytocin 2 gm IV@ 1854 hours Ancef 10 units@ 1904 hours Oxytocin 10 units

Procedure: Primary Cesarean section (C-section)Surgeon: Scott/Moss

Anesthesia start time: 1845 hours

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Surgery start time: 1850 hoursSkin incision: 1850 hoursUterine incision: 1851 hoursDelivery time: 1851 hoursSurgery finish time: 1950 hoursAnesthesia finish time: 2000 hours

Post-operative vitals: BP 118/63; Pulse 92; Respiratory rate 20; Temperature 96.8; SpO2 99%.

Delivery: Female; birth weight 1481 gm; resuscitation.12/18/YYYY

Xxxx, M.D.

Xxx, S.A.C.

Xxxx, P.G.Y.-1

Operative report for C section:Dr. Xxxx is covering for Dr. Xxxxx.

Preoperative diagnoses: Intrauterine pregnancy at 36 and 0/7th weeks Non-reassuring fetal heart sounds with fetal bradycardia, remote from

delivery Advanced maternal age Intrauterine growth restriction at less than fifth percentile Oligohydramnios of 2 cm Gestational diabetes type A1 Poor compliance to prenatal care Grand multiparity

Postoperative diagnoses: Intrauterine pregnancy at 36 and 0/7th weeks Non-reassuring fetal heart sounds with fetal bradycardia, remote from

delivery Advanced maternal age Intrauterine growth restriction at less than fifth percentile Oligohydramnios of 2 cm Gestational diabetes type A1 Poor compliance to prenatal care Grand multiparity Uterine atony without postpartum hemorrhage

Procedure performed: Emergency primary low-transverse cesarean delivery.

Anesthesia: General endotracheal intubation by Dr XxxxComplications: NoneIntravenous fluids: 600 ml of normal salineUrinary output: 300 ml clearEstimated blood loss: 700 ml.

Indications: G7, P5-0-1-5 at 36 and 0/7th weeks, gestation induced for the above with initiation of Pitocin. There were 3 consecutive variable decelerations leading to the decision to administer an amnioinfusion with full recovery with the category 1 fetal heart sounds in the presence of the primary _____ (word missing in record)

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care provider, Dr. Xxxxx. Several minutes later, audible deceleration with recovery and then inability to appreciate fetal heart tones after many efforts as documented in the chart.

A sterile vaginal exam was performed with brow presentation, unable to place fetal scalp electrode. An ultrasound revealed inappropriately slow fetal heart motion with cervical exam of 3 cm dilation, 50% effacement, -l station, remote from delivery. Decision was made to proceed emergency cesarean delivery due to fetal bradycardia.

Findings: Viable female infant in cephalic presentation, clear amniotic fluid, very thin cord, 1480 g, APGARS 3, 6, and 9 at 1, 5 and 10 minutes respectively. Pediatrics were present at the delivery due to above. Resuscitative measures included chest compressions and PPV. Initial efforts to intubate were stopped after baby released to cry.

Normal uterus and bilateral ovaries and tubes. Uterine atony without postpartum hemorrhage likely due to grand multiparity status resolved with uterine massage, 30 units of Pitocin and 1 liter of normal saline and 20 units Pitocin administered to the myometrium directly.

We avoided Hemabate due to history of bronchitis and we avoided Methergine brief hypertensive period _____ (word missing in record) at the time of uterine atony. Uterus responded well becoming firm and globular. Please also note that the cord arterial gases were 6.77 with a base excess of 17.

Description of procedure: The patient was taken to the operating room after obtaining verbal consent. The patient was then draped and prepped for a sterile procedure. In an emergent situation, we did a splash of Betadine. General endotracheal intubation was initiated and the scalpel was then used to make a Pfannenstiel incision directly from the skin to the fascia. The fascia was then nicked to the midline and opened in one sweep.

Using the operator’s hand, the fascia was then separated from the rectus muscles. The rectus muscles were then separated digitally and the peritoneum was then entered bluntly with the operator’s hand. The bladder blade was then inserted. The lower uterine segment was then identified. The operator ensured that the bowel and bladder were then clear from the operator site. The scalpel was then used to make a transverse incision in the lower uterine segment.

The operator hands were then used to enter the uterine cavity with the fingers and the uterine incision was then extended in the craniocaudal fashion. The infant’s head was them identified and then delivered. The remainder of the infant s body was then delivered. The cord was then clamped and cut and the infant was handed off to the awaiting pediatric team. Cord gases were then obtained.

The uterus was then exteriorized and the placenta was then delivered manually. The uterine incision was then repaired in a running locking fashion using a 1 Vicryl suture. There was an area of oozing noted in the left one-third lateral area of

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the hysterotomy. A 1 Vicryl suture was placed in a figure of fashion to obtain excellent hemostasis.

The entire incision was then inspected and again excellent hemostasis was obtained. The uterus was then replaced into the uterine cavity. Bilateral gutters were then cleared of clots and debris. Again, the uterine incision was then inspected and found to be hemostasis. The bladder blade was then removed and the inspection of the superior and inferior aspects of the fascia as well as the peritoneum and muscles were then evaluated and there was no evidence of any bleeding.

The fascia was then repaired in a continuous fashion using a 1 Vicryl suture. The subcutaneous layer was then re-approximated in a continuous fashion using a 2-0 plain gut. The skin was then re-approximated in a subcuticular fashion using 4-0 undyed Vicryl. Pressure dressing was then applied. Radiology was then entered into the OR to obtain a plain film due to the inability to perform a sponge count due to the urgent nature of the procedure.

The patient tolerated the procedure well. Again, due to the emergent nature of the procedure 2 g of Ancef were given during the procedure. The patient was then taken to recovery room in a stable and satisfactory condition.

12/18/YYYY

ABC Hospital Maternal delivery record:Date and time of birth: 12/18/YYYY @ 1851 hours

Method of delivery: C-Section C-section primary indication: Non reassuring fetal status Delivery doctor: Scott Labor anesthesia: None Delivery anesthesia: General Maternal complications: None Steroids given: None Shoulder dystocia: No Fetal presentation: Cephalic Cephalic presentation: Brow Breech position: Not applicable

Infant information: Rupture of membrane date and time: 12/18/YYYY @ 1743 hours Length of rupture: 1.13 hours Amniotic fluid color: Bloody Gestational age: 36.1 Gestational status: Preterm Outcome: Live born Birth weight: 1481 gm

Cord information: Number of cord vessels: 3 Nuchal cord: not applicable Infant cord pH arterial: 6.77

542

12/18/ Xxxxx, M.D. Abdomen X-ray reports: 309

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YYYY Clinical indication: Sponge countComparison: NoneImpression: No evidence of radiopaque foreign body.

12/18/YYYY

Neonatal resuscitation data sheet: Illegible notesTime of birth: 1851 hoursTime of resuscitation: 1851 hoursReason for resuscitation: STAT C-section NRFHT; severe IUGR _____Gestation age: 36 weeksWeight: 1481APGAR scores: 1 minute: 35 minutes: 610 minutes: 9

Time HR Respiration SpO2 Vent Procedures and comments00:30 30 Apneic BM 1851 delivery, to warmer,

limp, blue, started compressions, PPV

00:47 100 Apneic BM1:15 110 Apneic BM2:25 130 Spontaneous BM3:15 140 Spontaneous 100% BM4:48 148 Spontaneous BM Intubation attempt, week cry5:30 153 Spontaneous 100% BM6:30 1 Spontaneous Intubation attempt, strong cry

spontaneous6:49 177 47 100% BB7:30 175 44 10% BB8:55 166 52 100% BB Meconium plug passed12:00 168 50 100% Newborn transferred to SCN

** All times are recorded as post-delivery time (as minutes of life) or when resuscitation started.Legend: Heart Rate (HR); Ventilator (Vent.); Bag/Mask PPV (BM; Blow By (BB)

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12/18/YYYY

Xxxx, M.D. Newborn delivery note:Asked to attend by Xxxx, (OB) due to IUGR, Non Reassuring Fetal Heart Tones (NRFHT) / prolonged decelerations.

Maternal information:Mothers age 42; Gravida 7, Para 5. Blood type A positive; antibody negative.

Labs: Negative RPR, Negative HBsAG, negative HIV, negative GC, negative Chlamydia; unknown GBS. Rubella immune.

Mother’s medical history: Induction Of Labor (IOL) for severe IUGR, Estimated Fetal Weight (EFW) 1751; Oligohydramnios.

Labor and delivery:

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Attended delivery: Yes Arrived at (minutes of age): Just prior to delivery Gestational age (weeks):36 weeks Complications: None Anesthesia: General Delivery date: 12/18/YYYY Delivery time: @ 1851 hours Rupture Of Membranes (ROM): 12/18/YYYY @ 1730 hours Amniotic fluid: Clear Type of delivery: C-Section (Crash C-section for NRFHT) Apgar score (1 minute): 3 Apgar score (5 minute):6 Apgar score (10 minute): 9 Oxygen: Free flow, Positive-Pressure Ventilation (PPV) mask Suction: Pharynx

Resuscitation history:Infant limp without respirations at the Ohio table. Initial heart rate was 30, infant was given PPV and chest compressions immediately. Heart rate increased to >100 by 1 minute of life. Infant with irregular, agonal respirations. PPV continued and pulse oxygen as placed with heart rate >140, oxygen saturation at 100%. Infant was pink with good color, poor tone.

Attempted to initially intubate at about 4 minutes of life due to irregular respirations, infant with weak cry. So attempt was aborted. PPV continued for 6 minutes. Infant still with irregular respiration so attempted to re-intubate infant at about 6 minutes of life. Infant always with heart rate >140, oxygen saturation 100%. Infant began to cry with second intubation attempt, so attempt was aborted.

ROM was at 1730, 12/18, clear. Mom was afebrile in labor. IOL for severe IUGR at 36 weeks. Crash C-section due to undetected FHT and in the 50’s in the OR. Mom received PON x 2 doses in labor. Apgar’s were 3, 6, and 9. Infant was transferred to the SCN for further care.

Physical examination of new born:Weight 1480; Height 425; HC 29.General: Awake alertHEENT: Anterior Fontanelle Open Soft (AFOS), no masses, normal set eyes/ears, mucous membranes moist, no cleft palate, suture wide with a large anterior and posterior Fontanelle.Neck: Supple, no massesChest: Clavicles grossly intact, lungs clear to auscultation bilaterally Cardiovascular: RRR 2-3/6 SEM, femoral pulses 2+/=Back: No defects noted Abdomen: Soft, non-tender, non distended, no hepato-splenomegaly masses, 3 vessel cord.Genitourinary: External preterm female genitaliaAnus: Patent to inspectionExtremities: Moves all 4, no hip clicks

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Neurology: Good tone, symmetricalSkin: No rash

Problem list IUGR Preterm delivery Gestational age, 36 weeks

Infant Small for Gestational Age (SGA)

Impression/plan of treatment:36 week SGA infant, IOL for severe IUGR, status-post crash C-section for undetected fetal heart tones/prolonged decelerations status-post neonatal resuscitation with PPV and chest compressions infant does not qualify for cooling based on infants clinical appearance and APGAR scores

Fluid, Electrolytes, and Nutrition (FEN): Infant was made NPO and started on D10W at 80 ml/kg/day. Will leave infant NPO overnight. Continue to monitor strict intake and output and daily weights

Respiration: Stable on room air. Continue CPOX. Cord gas was 6.77/25.1/157.8/22.2/-16.6. ABG was 7.24/32/106.6/14.5/-12.5. Will repeat a CBG in morning.

Cardiovascular: Infant was HDS, initial MAP was 41, BP 54/28. Will continue to monitor.

Infectious Disease (ID): CBC with differential and blood culture was sent due to prematurity. Will hold on antibiotics. Will send urine for CMV x 2 for SGA.

Neurology: Will continue to monitoring wide sutures. Consider thyroid studies.12/18/YYYY

Xxxxx, M.D. @ 2006 hours: Neonatology consultation report:Maternal and delivery history reviewed.Labor complications: NRFHT, prolonged deceleration for 15 minutes with no detectable heart rate.

Physical examinations:Vitals: Heart rate 129; respiratory rate 54; saturation 99% in room air, BP 66/35 (46)General appearance: Alert, active no acute distressHEENT: Anterior Fontanelle Open Soft and Flat (AFOSF), large anterior and posterior Fontanelle, positive Red Reflex (RR) bilaterally, pupils equal round and reactive to light, palate intact, ears normoset.Respiratory: Clear bilaterally, good air movement, no distress.Cardiovascular: Regular rate and rhythm, S1, S2 II/VI murmur, femoral = brachial pulsesAbdomen: Soft, non tender, non distendedBack: No sacral dimple, spine straightMusculoskeletal: MAEE, hips stable

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Neurologic: Positive suck, positive grasp, positive moro, good toneOtherwise unremarkable.

Labs:@ 1856 hours:High: Cord ABG pCO2 157.8 Low: Cord ABG pH 6.77

@ 1920 hours:High: Glucose 101; MCV 133.3; MCH 41.6; RDW 19.1; Lymphocytes 54; absolute neutrophils 9.47Low: Neutrophils 35; MCHC 31.2; RBC 3.42

@ 1922 hours:High: pO2 106.6; Low: pCO2 32; HCO3 13.5; ABG pH 7.24

Assessment: IUGR Preterm delivery Gestational age, 36 weeks

Plan:Patient is a 36 week IUGR female who required resuscitation at delivery. Patient is currently well appearing, in room air with normal neurological exam. She does not qualify for selective cooling.

FEN: NPO for now, D10W at 80 ml/kg/day. Monitor intake/output, daily weight, electrolytes. Repeat gas to follow for resolution acidosis.Respiratory: Continuous respiratory monitoringCardiac: Continuous hemodynamic monitoring. Monitor murmur. ECHO if indicatedID: No risk factors for infection. Follow CBC and blood culture and start antibiotics if indicated. Follow urine CMV and maternal toxo IgG for IUGR statusBilirubin: Monitor jaundice, check bilirubin and provide phototherapy as indicated.Neurology: Monitor exam follow large anterior and posterior Fontanelle.Social: Support and update family.

12/19/YYYY

ABC Hospital Labs:CMV-IGG: >10 (high)HSV-1 IgG: 44.8 (high)HSV-2 IgG: <0.91Rubella antibody-IgG: 19.20Toxoplasma IgG: <3

Low: Hemoglobin 9.1; Hematocrit 26.7

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12/21/YYYY

Xxxxx, M.D. Post partum discharge note: Discharge method: Wheel chair Discharged with: No babies Condition: Stable

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Discharged to: Home Diet: Regular Activity: Normal activity Activity restrictions: No lifting, no driving minimize walking, minimize

stair climbing, no exercise Follow-up: With Dr. Xxxxx in 1 week

12/22/YYYY

Xxxx, M.D. Ultrasound of neonatal head:Reason for exam: Newborn with large Fontanelle.Comparison: No previousImpression: Negative neonatal brain.

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12/23/YYYY

Xxxx, M.D. X-ray report of left Humerus to evaluate for mineralization:Findings: the Humerus showed normal mineralization with no osseous lesions, fracture or dislocation.

Impression: Unremarkable exam as described.

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12/24/YYYY

Xxx, M.D. Pathology report:Specimen: Surgical placentaFinal diagnosis: Mature, third trimester placenta.

Preoperative diagnosis: Preterm IUP @ 36.1, IOL for oligohydramnios and severe IUGR, non-reassuring fetal status

Post-operative diagnosis: Same, thin cord

Microscopic: The umbilical cord shows no vasculitis or funisitis. There is no significant chorioamnionitis or colitis. Chorionic plate vessels show occasional thrombi which are of uncertain significance. No infarction is identified. There is no significant vasculitis. If there is a history of prior miscarriage, maternal coagulation studies may be indicated.

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* Reviewer’s Comment: Medical records from 12/19/YYYY to 12/31/YYYY are cumulated department wise and are summarized briefly below.

12/19/YYYY-12/30/YYYY

Multiple providers

Cumulative Neonatology progress notes: 12/19/YYYY: (Xxxxx, M.D.) (Ref. 103-105)Patient remained NPO overnight. Blood glucose levels were stable. She remains on room air, clinically well appearing.

Labs: High: Glucose 83Low: pO2 49.7; ABG O2 saturation 85.

Assessment: IUGR; Preterm delivery; Gestation age 36 weeks

Plan: Patient is a 36 week IUGR female who required resuscitation at delivery. Patient is currently well appearing, in room air.

FEN: Start feeds at 20 ml /kg/day. D10W at 80 ml/kg/day. Monitor intake and output, daily weights and electrolytes.

Respiratory: Continuous respiratory monitoring

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Cardiac: Continuous hemodynamic monitoring. Monitor murmur. ECHO if indicated

ID: No risk factors for infection. Follow blood culture and start antibiotics if indicated. Follow urine CMV and maternal toxo IgG for IUGR status

Bilirubin: Monitor jaundice, check bilirubin and provide phototherapy as indicated.

Neurology: Monitor exam follow large anterior and posterior Fontanelle. Social: Support and update family.

12/20/YYYY: (Xxxxx, M.D.) (Ref. 106-107)Patient did well overnight, tolerated feeds. Phototherapy started this morning, IV fluids and antibiotics continue. Patient gained weight overnight 1572 gm today.Labs: Bilirubin 5.6 (high); Bedside glucose 74 Assessment: IUGR; Preterm delivery; Gestation age 36 weeks; metabolic acidosis; at risk for sepsisPlan: Patient advancing on feeds. Increase feeds by 20 ml/Kg/day. Continue IV fluids. Monitor intake and output, daily weights, electrolytes.Otherwise plan remains unchanged as on 12/19/YYYY.

12/22/YYYY: (Xxxx, M.D.) (Ref. 108-109)Infant did well overnight. Stable in room air. Taking some feeds PO, remainder NG, tolerating, stooling. Gained 20 g.Labs: Total bilirubin 6.4; direct bilirubin 0.4; indirect bilirubin 6 (high).Assessment: IUGR; Gestation age 36 weeks; at risk for sepsisPlan: FEM: Advance feeds daily to caloric goal. Titrate supplemental IVF. Monitor feeding tolerance closely. Formula feeding per maternal preference. Fortify formula once at 100 ml/kg. Monitor weights, intake output. Encourage PO feeding.Neurology: Obtain head ultrasound given BW and large fontanelle. Thyroid studies due to large fontanelle. Eye exam given BW<1500.IUGR: Follow-up placental pathology. CMV titersOtherwise plan remains unchanged as on 12/20/YYYY.

12/23/YYYY: (Xxxx, M.D.) (Ref. 110-111)Infant did well overnight. Stable in room air without desaturation. Improved PO intake, tolerated advancement of feeds, stooling, gained weight. Head ultrasound normal.Labs: Total bilirubin 5.3; direct bilirubin 0.4; indirect bilirubin 4.9 (high); Free thyroxin 1.64; Thyroid Stimulating Hormone (TSH) third generation 2.440Assessment remains unchanged as on 12/22/YYYY.Plan: FEM: Advance feeds daily to caloric goal. Titrate supplemental IVF. Monitor feeding tolerance closely. Formula feeding per maternal preference. Fortify formula to 22 Kcal transitional once at 100 ml/kg. Monitor weights, intake output. Encourage PO feeding.Otherwise plan remains unchanged as on 12/22/YYYY.

12/24/YYYY: (Xxxx, M.D.) (Ref. 112-113)Infant did well overnight. Had 1 brief desaturation spell to 80’s yesterday. Resolved with stimulation. Tolerating fortified feeds, PO intake continues to

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improve.Assessment remains unchanged as on 12/22/YYYY.Plan: FEM: Advance feeds daily to caloric goal. Titrate supplemental IVF. Monitor feeding tolerance closely. Formula feeding per maternal preference, 22 Kcal. Monitor weights, intake output. Encourage PO feeding.Neurology: Follow HC and exam, consider further workup for large fontanelle if concerns. Eye exam given BW <1500. NICU developmental follow-up clinic after discharge.Otherwise plan remains unchanged as on 12/23/YYYY.

12/25/YYYY: (Xxxx, M.D.) (Ref. 114-115)Infant did well overnight. Taking feeds PO, some supplemental NG, Tolerated increase feeding volume, stooling. Stable in room air no desaturations.Assessment remains unchanged as on 12/22/YYYY.Plan remains unchanged as on 12/24/YYYY.

12/26/YYYY: (Xxxx, M.D.) (Ref. 116-117)Infant continues to do well. Gained excellent weight 1681 gm. Taking most PO. No apnea spells. Voiding and stooling. Placental pathology report unremarkable other than a few small thrombi, weight 600 g.Assessment remains unchanged as on 12/22/YYYY.Plan: Neurology: Follow HC and exam, consider further workup for large fontanelle if concerns. Eye exam given BW <1500, discuss with Lurie ophthalmology as unavailable at Swedish for 3 more weeks. NICU developmental follow-up clinic after discharge.Otherwise plan remains unchanged as on 12/24/YYYY.

12/27/YYYY: (Xxxx, M.D.) (Ref. 118-119)Infant continues to do well. Tolerating feeds, taking most by mouth, no stool since yesterday. No desaturations. I reviewed infant’s case with Dr. Xxx of Lurie ophthalmology on 12/26/YYYY- he stated that infant was low risk for ROP and it was not necessary to transfer her for an eye exam. He said she could been seen as an outpatient upon discharge of when the pediatric ophthalmologist returns to Swedish on 01/12/YYYY – whichever comes first.Assessment remains unchanged as on 12/22/YYYY.Plan remains unchanged as on 12/24/YYYY.

12/28/YYYY: (Xxxx, M.D.) (Ref. 120-121)Infant did well overnight. Improved PO, tolerating feeds, stooled, gained weight. No apnea/desaturation.Assessment remains unchanged as on 12/22/YYYY.Plan remains unchanged as on 12/24/YYYY.

12/29/YYYY: (Xxxxx, M.D.) (Ref. 122-123)Patient gained 3 gm overnight. She remains in room air, tolerating feeds, stable.Assessment and plan remains unchanged as on 12/24/YYYY.

12/30/YYYY: (Xxxxx, M.D.) (Ref. 124-125)

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Patient gained weight overnight. She took increasing amounts of PO. Doing well in room air. Remains in isolette.

12/19/YYYY-12/31/YYYY

Multiple providers

Cumulative Special care nursery progress notes:12/19/YYYY: (Xxxx, M.D.) (Ref. 126-127)36 week IUGR female, status post neonatal resuscitation, rule-out sepsis.

Assessment: IUGR; Preterm delivery; Gestation age 36 weeks; metabolic acidosis; at risk for sepsis

Plan: Respiration: Room air, no spells. Continue to monitor closely, CPOx Cardiovascular: Continue to monitor heart rate and BP Hematology: Will check bilirubin within 24 hour labs CNS: Will do Head Ultrasound (HUS) at 5-7 days of age, will do daily

HC, will also do TFTs to evaluate large AFOS FEN: Total fluids approximately 80 cc/Kg/day. Will start feeds

approximately 20 cc/kg/day BM or preemie 20 kcal/kg/day. Monitor intake and output daily weights. Will do BMP.

Other: Will place in isolette to assist temperature control

12/20/YYYY: (Xxxx, M.D.) (Ref. 128-130)Patient doing well. Tolerating feeds. Voiding and stooling. No new issues.

Assessment: IUGR; Preterm delivery; Gestation age 36 weeks; at risk for sepsis

Plan: Hyperbilirubinemia on phototherapy. Hematology: 24 hour bilirubin elevated at 6, therefore phototherapy

started 12/19/YYYY evening. Will recheck bilirubin level today at 1800 hours.

FEN: Patient tolerated feeds well 12/19/YYYY, therefore feeds increased to 8 ml every 3 hours today 12/20/YYYY. Feeds BM or preemie 20 kcal/kg/day. Feeds plus IVF (D10 0.2 NS) total fluids approximately 110 ml/kg/day. Continue to monitor intake and output, daily weights. 24 hour BMP within normal limits.

Other: Patient is isolette to assist temperature control. Patient Utox positive opiates, mother Utox positive opiates prior to delivery/anesthesia. Will notify SW. Follow-up meconium tox screen.

Neurology: Will continue to follow HC daily due to large open fontanelles (anterior and posterior). Plan for HUS and TFT at 5-6 days of life.

Otherwise plan remains unchanged as on 12/19/YYYY.

12/21/YYYY: (Xxxx, M.D.) (Ref. 131-132)Stable in isolette overnight and tolerating gavage feeds – not interested in PO per nursing.

Assessment: IUGR; Preterm delivery; Gestation age 36 weeks; at risk for sepsis; Hyperbilirubinemia requiring phototherapy.

Plan: Hyperbilirubinemia status post phototherapy.

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Hematology: 24 hour bilirubin elevated at 6, therefore phototherapy started 12/19/YYYY evening and discontinued this morning. Will recheck bilirubin level 12/22/YYYY at 1800 hours.

CNS: Widely spaced cranial sutures but stable HC. Continue daily HC measurements and consider HUS and TFT’s at 5-7 days of age.

FEN: Patient tolerated feeds well via Oro-Gastric (OG) tube. Trial PO as interested and continue t advance as tolerated. Today feeds increased to 120ml every 3 hours and IVF adjusted to keep total fluids 130 ml/kg/day. Continue to monitor intake and output, daily weights.

Other: Patient is isolette to assist temperature control. Patient Utox positive opiates, mother Utox positive opiates prior to delivery/anesthesia but thought to be due to receiving Robitussin with codeine during week prior to delivery. Infants meconium tox negative. SW on consult.

Otherwise plan remains unchanged as on 12/20/YYYY.

12/22/YYYY: (Xxxx, M.D.) (Ref. 133-134)Working on feeds, jaundice status post phototherapy.

Assessment: IUGR; Preterm delivery; Gestation age 36 weeks; at risk for sepsis; Hyperbilirubinemia requiring phototherapy; Metabolic acidosis in new born.

Plan:Hematology: Bilirubin 6.4/0.4, will recheck in morningFEN: TF approximately 140 cc/kg/day. Adequate urine output. Feeds currently 16 c every 3 PO/NG taking some PO. Encourage PO intake.Otherwise plan remains unchanged as on 12/20/YYYY.

12/23/YYYY: (Xxx, M.D.) (Ref. 135-137)Patient doing well, tolerating feeds. Voiding and stooling. One apneic spell yesterday (12/22/YYYY) with desaturation to 80’s.Vitals: Temperature 98.4; pulse 126; BP 89/51; Respiratory rate 46; SpO2 97% room air.

Assessment remains unchanged as on 12/22/YYYY.Plan:Respiration: One spell recorded yesterday (apnea/shallow breathing with desaturation to 80’s). Will continue to monitor closely for spells.Hematology: Bilirubin 5.3/0.4 today, continue to monitor for jaundice clinically, repeat as needed.FEN: TF approximately 140 cc/kg/day adequate urine output. Increased feeds to 20 c every 3 hours PO/NG, today. Patient id taking some partial PO feeds. Continue to follow intake and output and daily weight.CNS: large anterior fontanelle, HUS done 12/22/YYYY negative. Thyroid function tests done and within normal limits, continue to monitor HC closely/daily. Per Dr. Xxxx will order X-ray of Humerus (long bone) to evaluate bone density.Other: Will contact Dr. Xxxxxxx for eye exam.Remaining plan remains unchanged as on 12/22/YYYY.

12/24/YYYY: (Xxxx, M.D.) (Ref. 138-139)

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Apnea; working on feeds.Assessment and plan: Respiration: Room air, no spells since morning, had 1 spell 12/22/YYYY, continue to monitor closely, CPOxFEN: Tolerating feeds, currently taking 24 cc every 3 hours PO/NG. Adequate urine output. Positive stool. TF approximately 140 cc/kg/day.Remaining plan remains unchanged as on 12/23/YYYY.

12/25/YYYY: (Xxxx, M.D.) (Ref. 140-141)Apnea; working on feeds, still in incubator.Assessment remains unchanged as on 12/22/YYYY.Plan:ID: Follow-up urine CMV and monitor toxoFEN: Tolerating feeds, currently taking 28 cc every 3 hours PO/NG. Adequate urine output. Positive stool. TF approximately 140 cc/kg/day. Will plan to increase feeds to goal of 160 ml/kg/dayOphthalmology: Infant will need ROP screen; will follow up with pediatric ophthalmology at Lurie on 12/26/YYYY to timing of exam.Remaining plan remains unchanged as on 12/24/YYYY.

12/26/YYYY: (Xxxx, M.D.) (Ref. 142-143)Patient is tolerating feeds and is mostly taking partial PO feeds well. Infant has not had further spells since then.Assessment remains unchanged as on 12/22/YYYY.Plan:ID: Culture nothing to do; follow-up urine CMV which is still pending and maternal toxo are negative.FEN: Tolerating feeds, currently taking 28 cc every 3 hours PO/NG. IV removed. Adequate urine output. Positive stool. TF approximately 140 cc/kg/day. Will plan to increase feeds to goal of 160 ml/kg/dayOphthalmology: Infant will need ROP screen; Dr. Xxxx spoke with Lurie Pediatric Ophthalmology today and stated that eye exam could be deferred to either as an outpatient or until Dr. Xxxxxxx (Pediatric Ophthalmologist) returned on 01/12/YYYY.Remaining plan remains unchanged as on 12/25/YYYY.

12/27/YYYY: (Xxxxx, M.D.) (Ref. 144-145)Tolerating feeds – took 60% PO in past 24 hours. No bowel movement in past 24 hours but stable abdomen circumference. Assessment remains unchanged as on 12/22/YYYY.Plan:ID: Blood culture negative final and infant did not receive antibiotics. Follow-up urine CMV x 2; maternal toxo are negative.FEN: Tolerating feeds, currently taking 34 cc every 3 hours PO/NG. IV removed. Adequate urine output. Monitor stooling pattern. TF approximately 160 cc/kg/day. Will plan to increase feeds to goal of 160 ml/kg/dayRemaining plan remains unchanged as on 12/26/YYYY.

12/28/YYYY: (Xxxx, M.D.) (Ref. 146-147)

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Tolerating feeds – took a few full feeds overnight. Approximately 60% PO in past 24 hours. Large bowel movement this morning. Continues in isolette.Assessment: IUGR; Preterm delivery; Gestation age 36 weeksPlan:Apnea x 1 six days ago, working on feeds and continues in isolette.FEN: Tolerating feeds, currently taking 34 cc every 3 hours PO/NG. IV removed. Adequate urine output. Stooling normally. At feeding goal of 160 ml/kg/day. Continue to work up on PO feeds. May begin weaning isolette temperature.Remaining plan remains unchanged as on 12/27/YYYY.

12/29/YYYY: (Xxxx, M.D.) (Ref. 148-149)Infant is taking mostly partial PO feeds and tolerating feeds well. No issues overnight.Assessment: IUGR; Preterm delivery; Gestation age 36 weeks; at risk for sepsis; Hyperbilirubinemia requiring phototherapy.Plan remains unchanged as on 12/28/YYYY.

12/30/YYYY: (Xxxxx, M.D.) (Ref. 150-151)Tolerating feeds, taking some feeds all PO. Approximately 68% PO in last 24 hours.Assessment: IUGR; Preterm delivery.Plan:FEN: Tolerating feeds, currently taking 34 cc every 3 hours PO/NG. IV removed. Adequate urine output. Stooling normally. At feeding goal of 150-160 ml/kg/day. Continue to work up on PO feeds. May begin weaning isolette temperature. Will start Multivitamins (MVI) with iron 12/31/YYYYRemaining plan remains unchanged as on 12/29/YYYY.

12/31/YYYY: (Xxx, M.D.) (Ref. 152-153)Patient doing well. Tolerating feeds. Voiding. No stool for 48 hours. Now in isolette.Assessment: IUGR; Preterm delivery; Gestation age 36 weeks.Plan remains unchanged as on 12/30/YYYY.

01/06/YYYY

Xxxxx, M.D. 2 weeks postpartum follow-up visit:Patient status post C-section for fetal wall distress reports that infant is still in the special care nursery. Patient reports no pain, no fever, and no discharge from the wound. Has not been able to pump milk hence infant is formula fed.Assessment:

Postpartum exam Postpartum anemia Asthma

Treatment: Postpartum exam: Refill Vitamin D3 tablet, 2000 unit, 1 tablet, orally,

once a day; refill Vol-Tab Rx, 29-1 mg, 1 tablet, orally, once a day. Asthma: Refill Albuterol Sulfate Nebulization Solution, (2.5 mg/3 ml)

0.083%, 3 ml as needed, inhalation, every 4 hours, 14 days, 100 ml. Continue Symbicort Aerosol, 160-4.5 mcg/act, 1 puffs, inhalation, twice a day

Notes: Discussed with patient the use of Albuterol with a spacer, followed by

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Symbicort 10-15 minutes later to maximize the benefit. Patient need to use the medication until symptomatically improved for one week then use it once a day for another week before discontinuing the medication.

Follow-up: 2 weeks (Reason: Check response to treatment)* Reviewer’s Comment: Medical records from 01/01/YYYY to 01/07/YYYY are cumulated and summarized briefly below.

01/01/YYYY-01/07/YYYY

Multiple providers

Cumulative Special care nursery progress notes:01/01/YYYY: (Xxxx, M.D.) (Ref. 154-155)AOP, working on feedsAssessment: IUGR; Preterm delivery; Gestation age 36 weeks; Hyperbilirubinemia requiring phototherapy.Plan:Status post metabolic acidosis AOP, working on feeds.Hematology: Status post phototherapy. Last bilirubin 5.3 on 12/23/YYYY. Hemoglobin and hematocrit today 13.6/42.1; reticulocyte 0.7%.CNS: HUS negativeOther: Will need eye exam as outpatient, 2nd PKU sent today.Remaining plan remains unchanged as on 12/31/YYYY.

01/02/YYYY: (Xxxxx, M.D.) (Ref. 156-157)NG out yesterday morning and taking full volume feeds 35-42 ml/feed every 3 hours. Voiding and stooling adequately.Assessment: IUGR; Preterm delivery; Gestation age 36 weeks.Plan:FEN: Full feeds on Neosure 22, all PO for 24 hours with weight gain and adequate output. Continue to monitor intake/output, daily weights.Remaining plan remains unchanged as on 01/01/YYYY.

01/03/YYYY: (Xxxx, M.D.) (Ref. 158-159)Infant now 48 hours taking full PO feeds of 35-45 ml/feed every 3 hours. Voiding and stooling appropriately. Weight gain approximately 14 g a day on Neo 22 kcal/oz. parents have not been in to see infant since 12/29/YYYY – social work involved.Assessment: IUGR; Preterm deliveryPlan:FEN: Full feeds on Neosure 22, all PO for 24 hours with weight gain and adequate output. Continue to monitor intake/output, daily weights with goal of 25-30 gm weight gain per dayFollow-up with family and social work parents will need teaching and orientation to infant prior to discharge.Remaining plan remains unchanged as on 01/02/YYYY.

01/04/YYYY: (Xxxx, M.D.) (Ref. 160-161)SGA/IUGR infant working on feeds, status post phototherapyAssessment: IUGR; Gestation age 36 weeks.Plan:FEN: Full feeds PO taking 40-55 cc per feed adequate urine output. Continue to monitor intake/output, daily weights.

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Spoke to father today approximately 1745 hours after several attempts to reach family yesterday and earlier today. Dr. Canfield attempted x 2 on 01/03/YYYY. R.N. attempted x 1 earlier today, Dr. Xxxxx attempted home and father’s cell earlier today. I updated him on his daughter’s condition. Explained she was close to going home. Recommended he bring in her car seat, today or tomorrow for the car seat test. Also recommended either he or his wife come in and spend time caring for her at bedside to get comfortable with her cares.Remaining plan remains unchanged as on 01/03/YYYY.

01/05/YYYY: (Xxxx, M.D.) (Ref. 162-163)Patient doing well, feeding well. Voiding and stooling.Plan:FEN: Full feeds PO taking 40-60 cc per feed adequate urine output. Continue to monitor intake/output, daily weights.

Parents have not been present in SCN, difficult to contact. SW consult ordered, will follow-up on report. Father was contacted yesterday and informed that patient will likely be discharged home this week. Father planning to bring in car seat for car seat trial.Remaining plan remains unchanged as on 01/04/YYYY.

01/06/YYYY: (Xxxx, M.D.) (Ref. 164-165)Patient doing well, feeding well. Voiding and stooling, excellent weight gain in last few days. Primary PCP has assisted in speaking with parents regarding discharge education and planning – and they have provided reassurance that they will be in today or tomorrow for a prolonged period of time.Assessment: IUGR; Preterm delivery; Gestation age 36 weeks.Plan:Hematology: Status post phototherapy. Last bilirubin 5.3 on 12/23/YYYY. Hemoglobin and hematocrit on 01/01/YYYY is 13.6/42.1; reticulocyte 0.7%. on MVI with ironFEN: Full feeds PO taking 40-60 cc per feed adequate urine output. Continue to monitor intake/output, daily weights. Will transition back to Neo 22 when available.SOC: Parents have not been in SCN, difficult to contact. SW consult ordered, will follow-up on report. Mother will plan to come spend 4-8 hours in the unit with the infant for bonding and education with plans for discharge the same say. May give Hep B after parental consent now that infant is > 2 kg.Remaining plan remains unchanged as on 01/05/YYYY.

01/07/YYYY: (Xxxx, M.D.) (Ref. 166-167)Infant continues to take PO feeds well. Assessment: IUGR; Preterm delivery; Gestation age 36 weeks; at risk for sepsis; Hyperbilirubinemia requiring phototherapy; Metabolic acidosis in new born.Plan: Will need eye exam as outpatient, 2nd PKU sent 1/1. Will try to schedule appointment with Dr. Xxxxxxx since the family prefers not to travel down to XYZ Hospital for an outpatient evaluation

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SOC: Parents have not been present in SCN, difficult to contact. SW consult ordered, will follow-up on report. Parents both contacted yesterday and father planning to bring in car seat for car seat trial. Mother will plan to come spend 4-8 hours in the unit with the infant for bonding and education with plans for discharge the same say. Remaining plan remains unchanged as on 01/06/YYYY.

01/08/YYYY

Xxxxx, M.D. Discharge summary: Poorly scanned recordPrimary diagnosis: PrematuritySecondary diagnosis: Very small for gestational age (VSGA)

Problem list: 36 weeks gestation age; IOL for severe IUGR; Crash C-section for no fetal heart tones; Status post neonatal resuscitation; rule out sepsis, labs only; large anterior fontanelle and posterior fontanelle; Hyperbilirubinemia status post phototherapy; Tox screens positive opiates; desaturation spell.

Birth history: Born via crash C-section for no fetal heart tones. Born to 42 year old G7 P5 -6 with PNDA positive Ab negative _____/RPR NR/Hep B negative /GBS unknown. Infant limp and floppy with initial heart rate of 30 so chest compressions given x 30 seconds with PPV continued. Heart rate 140 SpO2 100%. Attempted intubation at about 5 minutes, infant weak cry, so attempt aborted. Continued PPV then retried intubation at 5 min of life and infant with cry, spontaneous respirations. APGAR 3.6.9. To SCN.

Hospital course by system:FEN: Initially infant was made NPO and started on D10W at 80 ml/kg/day. Feeds were started 12/19/YYYY at 4 ml every 3 hours OG for 20 ml /kg/day with SCF 20. Feeds were gradually advanced daily and then fortified to Neosure 22 on 12/23/YYYY. IVF were discontinued on 12/25/YYYY. She was allowed to take PO when interested. Her feeding tube was removed on 01/01/YYYY and she has been taking full oral feeds since that time. At discharge she was taking approximately 60 ml Neo 22 every 3 hours with excellent weight gain noted. She did require rectal stimulation on 2 occasions and glycerin suppository on 1 occasion normal stooling pattern without intervention since 01/01/YYYY.

Respiration: Stable in room air throughout hospitalization except for 1 apneic spell on 12/23/YYYY at 2200 hours associated with desaturation to the 80’s requiring mild stimulation.

Cardiovascular: MAP’s in 40’s, infant in HDS.

Hematology: Phototherapy started evening 12/19/YYYY to 12/21/YYYY morning. 12/31/YYYY started MVI with iron.

ID: CBC with differential and blood culture sent. No antibiotic started. Due to her ASGA status, urine was sent for CMV along with maternal toxo titers and placental pathology. All were normal / negative.\

CNS: Large anterior fontanelle / posterior fontanelle daily HC measurements were within normal. She had long bone film done to evaluate bone density and these

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were normal.

Ophthalmology: Xxxx spoke with Lurie ophthalmology on 12/26/YYYY and per Lurie. Ok to win as outpatient or 1/12 for eye exam. Parents to make an appointment with Dr. Xxxxxxx.

Isolette to open crib 12/30/YYYY at 1700 hours

Other: Mother was taking Robitussin with codeine week prior to delivery per Dr. Xxxxx.Labs reviewed

Physical examination:Vital signs: Temperature 36.7; heart rate 141-153; Respiration 35-57; SpO2 100% on room air.General: Alert, active, vigorousHEENT: Large and flat anterior fontanelle and posterior fontanelle, moist mucous membrane, no cleft palate, normal set eyes and ears. Positive respiration bilaterallyCardiovascular: Regular rate and rhythm, no murmur, femoral pulse 2+ equal bilaterallyLungs: Clear to auscultation bilaterally good aeration.Abdomen: Soft non tender; non distended; no hepatosplenomegaly; normoactive bowel sounds. Genitourinary: Normal external genitaliaExtremities: Warm and Well Perfused (WWP), no hip clicksNeurology: Good tone, symmetric moro reflex, good suck/graspSkin: Warm dry, no rash, no jaundice.

Discharge condition: GoodHepatitis B given: 01/07/YYYYHearing: PassedNewborn screens sent: 12/19/YYYY (normal), 01/01/YYYY, 01/07/YYYYCongenital heart disease screen: PassedCar seat trial: Passed

Follow-up Dr. Xxxxx 01/12/YYYY, Dr. Xxxxxxx 1-2 weeks, NICU follow-up clinic.Diet: Neosure 22Medications: MVI with iron 1 ml PO once daily

State of Illinois Cornerstone Early Intervention Service plan* Reviewer’s Comment: Medical records from 01/09/YYYY to 05/20/YYYY are not available or review to know the condition of patient.

05/21/YYYY

Xxx, Developmental Therapist

Development therapy record:Reason for referral: This referral was made due to concerns with patient’s overall development secondary to prematurity. Patient’s parents were referred to Early Intervention by XYZ Hospital.

Family concerns: Parents expressed concern about patient’s overall development.

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Specific concerns include growth and a preference to rotate her head toward her left shoulder.

Medical history:Mother’s pregnancy with patient was without complication until seven months. She then began to experience significant pain and what felt like contractions. She was told by her doctor that this is common for women who have had multiple pregnancies. An ultrasound at eight months showed low levels of amniotic fluid and a heart rate was not detected.

Patient was then delivered at ABC via emergency cesarean section. She was 36 weeks gestational age and she weighed three pounds, five ounces. She was not breathing upon delivery and her heart rate was 30 BPM. She was resuscitated and intubated. She was admitted to the NICU for 20 days. Initially she was given IV feedings. Feedings were then administered via NG-tube. She was on oral feeds by the time she was discharged. She was treated for jaundice.

Patient passed her newborn hearing screening. Patient did not pass the initial screening for galactosemia. Testing has been repeated two-three more times, with results indicating she has “borderline galactosemia”. Parents were not aware of the results of the final testing or the possible diagnosis. They were strongly encouraged to follow up with Fatima’s pediatrician about this, as there are significant dietary restrictions for people with galactosemia.

Additional concerns related to feeding include a history of constipation, symptoms of reflux, and growth. She weighed approximately seven pounds at three months of age (adjusted). Her parents report that she is a slow eater and that her belly appears swollen after she eats. These concerns should also be raised with patient’s pediatrician.

Fatima is frequently congested. Her parents have used saline drops to address this and they have not seen a difference. She had an appointment at XYZ Hospital. It appears that this was a NICU follow-up clinic. At that time, she was referred to Early Intervention due to concerns about possible torticollis. His vision was assessed and found to be within normal limits.* Reviewer’s Comment: As mentioned above patient had visited XYZ Hospital but medical records pertaining to this hospital are not available for review.

Behavioral observations:This evaluation was done at patient’s home with her mother; father; Xxxx, evaluating occupational therapist; Xxxx, evaluating physical therapist; Xxx, evaluating speech language therapist; Xxxxx, Arabic/English interpreter; and this administrator as test facilitators. Patient is a very attentive baby who demonstrates appropriate eye contact. She enjoys social play and she is easy to engage. She is a beautiful little girl; it was a pleasure to spend time with her.

Tests conducted:The Hawaii Early Learning Profile (HELP Strands) was used during this evaluation. The following is a summary of patient’s current developmental age

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levels based on the results of this evaluation.

Domain Age equivalent

Percent of delay

Developmental quotient

Cognitive 3 months Delay of 25% 75-typical range (low average)Receptive language

4 months No delay 100-typical range

Expressive language

3 months Delay of 25% 75-typical range (low average)

Gross motor 3 months Delay of 25% 75-typical range (low average)Fine motor 2 months Delay of 50% 50-mild delaySocial-emotional

4 months No delay 100-typical range

Self help 3 months Delay of 25% 75-typical range (low average)

Results:Based on Part C EI criteria, patient is eligible for Early Intervention services in Illinois due to a delay of at least 30% in one or more areas of development (E01).

Recommendations for areas that intervention is warranted:Motor and adaptive development.

Recommendations:At patient’s IFSP meeting, ongoing occupational, physical, and speech language/feeding therapy services were recommended. Parents were advised to contact patient’s pediatrician to discuss her possible diagnosis of “borderline galactosemia”, history of constipation, symptoms of reflux, growth rate, lengthy feedings, formula intake, and distended belly after feedings. It is strongly advised that patient’s medical records be translated into Arabic, so that her medical information/history is fully understood by family members.

05/21/YYYY

Xxx M.A., C.C.C-S.L.P./L. Pediatric Speech Language Pathologist, Early Intervention Specialist

Initial Speech Therapy (ST) and feeding evaluation records:Reason for referral: Patient was referred to the Early Intervention program due to prematurity. This evaluation was completed to determine eligibility for the program and establish the family’s goals for patient.

Family concerns: Parents expressed concern regarding their daughter’s overall development.

Behavioral observations: Patient was alert and attentive. Smiling and eye contact were observed.

Tests conducted:The Rossetti Infant-Toddler Language Scale was utilized to assess patient’s expressive and receptive language skills. The assessment consisted of observation, play with the child, and family report. The assessment was conducted with a developmental therapist, physical therapist and occupational therapist. An interpreter was present as well. The results were as follows:

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Development area Age equivalent

Percent of delay*

Developmental quotient

Interaction-attachment 3-6 months 0% 100: Age appropriatePragmatics 3-6 months 0% 100: Age appropriateLanguage comprehension 3-6 months 0% 100: Age appropriateLanguage expression 3 months 25% 75: Low average range

*Note that 0-29% delay is an ineligible level of delay for the Illinois Early Intervention System.

Clinical narrative: Patient would benefit from feeding therapy.

Further assessments recommended:Nutrition and social work assessments were recommended. It was recommended that family follow up with their pediatrician regarding constipation, bloating, reflux and borderline galactosemia diagnosis.

Results/implications:Based on Part C EI criteria, patient is eligible for Early Intervention services in Illinois due to a delay of 30% or greater in one or more areas of development (E01).

Recommendations for areas that intervention/monitoring is warranted:Communication developmentSocial or emotional developmentAdaptive development

05/21/YYYY

Xxxx, P.T., D.P.T.

Physical Therapy (PT) initial evaluation:Reason for referral: Patient was referred to the Early Intervention Program by her parents secondary to being born prematurely.

Concerns expressed by parents in regard to their child’s development: The family is concerned that she is small and likes to look towards the right side. She was also born prematurely and they want to make sure she is developing appropriately.

Medical reports: History reviewed. She went to a NICU follow up checkup at XYZ Hospital in April and they noticed a head tilt. She has her next appointment on August 26. She saw Dr. Xxxxx on January 12 and saw an ophthalmologist one to two weeks after discharge and she does not need to go back until age five. Patient has been healthy since birth, without any major illnesses, hospitalizations, surgeries or ear infections. Patient is not currently medicated, has no known allergies and no other significant health history has been reported. She currently has untreated constipation and reflux symptoms. It is recommended that her parents speak to her pediatrician about this.

Behavioral observation:Patient demonstrated an appropriate attention span and frustration tolerance for a child her age. She transitioned between activities easily and exhibited consistent eye contact while playing and when spoken to. An appropriate activity and arousal

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level were noted, with a calm, alert and organized state for the majority of the evaluation.

Standardized assessments:Patient was assessed with the Peabody Developmental Motor Scales-2 (PDMS-2), gross motor section. Patient’s scores are described below:

Parameter Score Age equivalent Percent profileReflexes 4 3 months 25% delayStationary 16 3 months 25% delayLocomotion 13 3 months 25% delay

*In all areas of development, delays between 0% and 29% are considered within normal limits of typical child development.*

Clinical narrative of developmental domains evaluated:Range Of Motion (ROM)/OrthopedicPatient has full range of motion throughout her upper and lower extremities. She has full cervical rotation and lateral flexion. However, she does have increased redness in her neck on the left side of her neck. She has flatness on the right posterior aspect of her skull. Her right cheek is slightly larger than her left. There are no other facial asymmetries present.Concerns: Patient displays mild asymmetries in her skull and face. Continue to monitor this as she begins to spend more time off of her head and in other positions.

Posture:On her stomach, she will prop on her elbows. Patient will hold her head up for several seconds at a time before putting it down to rest. She will then lift her head up again. On her back, she will bring his hands together. She will randomly kick her legs and move her arms. In supported sitting, she can hold her head off her chest and rotate it side to side. She will put some weight through her legs in supported standing.

Concerns: Patient prefers to look to the right in all positions with her head slightly tilted to the left. She can briefly hold her head in midline. She struggles to hold her head in midline in all positions. Also on her stomach, she does not hold her head up for more than a couple seconds at a time and does not yet attempt to push up onto extended arms.

Muscle tone/primative reflexes:Muscle tone is defined as a muscle’s readiness to fire. Patient displays muscle tone within normal limits. She has no atypical muscle synergies. She has a positive walking reflex. Her asymmetric neck reflex (ATNR) has been integrated. She does not yet have a Landau response. She has a positive Babinski reflex. She has positive plantar and palmar reflexes.Concerns: None at this time.

Strength/gross motor skills:

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Patient will track in all directions on her back. She has a more difficult time with rotation to the left, but can do it. She will bring her hands together. She is also starting to reach for toys. However, it takes her several seconds before reaching on her back. She will randomly kick on her legs. She is not yet grabbing her feet or knees. She will bring her hands together and to her mouth. She is able to roll to her side in both directions.

Patient tolerated being on her stomach. She will prop on her elbows and hold her head up for one to two seconds at a time. She is not yet pushing up onto extended arms or reaching on her stomach. Fatima will sit with maximum support and hold her head up. She is not yet reaching in sitting. In supported standing, she will put some weight through her legs.

Concerns: Patient displays decreased strength based on her gross motor skills. She is starting to hold her head up for brief periods of time and she is not yet pushing up onto extended arms. She is starting to reach on her back but it is delayed.

Further assessments recommended: Nutrition evaluation secondary to concerns with possible allergies and

weight gain. Social work evaluation secondary to the family needing assistance with

medical appointments and needs.

Based on Early Intervention criteria, patient may be eligible for Early Intervention Services in the State of Illinois due to:E01 - Department determined eligible level of delay or greater in one or more areas of development.

Recommendations for areas that intervention may be needed: Cognitive development Physical development Communication development Social or emotional development Adaptive development

Recommendations for goals, outcomes, and strategies for services, with frequency, intensity, and duration will be determined at the IFSP meeting in collaboration with the child’s family based on their identified priorities.

05/21/YYYY

Xxxxxx, O.T. R/L

Occupational Therapy (OT) initial evaluation: Reason for referral: Patient was referred for an OT evaluation through Early Intervention by her parents due to concerns with her development. This OT evaluation is part of a global evaluation with developmental, physical, and ST to determine eligibility for services through Early Intervention.

Medical history:History reviewed. Patient’s general health has been good with no hospitalizations, major illnesses or injuries. Her parents stated that she has always been congested and that they tried saline drops but that it did not make a difference. She has no known allergies and takes no medications. She has had no ear infections to date.

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She is given a bottle 5 times daily with 3 oz. per bottle. Her mother noted that when she has formula her stomach becomes slightly distended and that she is slow to drink a bottle, usually taking 30 minutes to drink 3 oz. She is often constipated. She is small for her age, weighing just over 7 lbs. at her last check-up. She is not meeting the motor milestone of rolling yet.

Behavioral observation:Patient is a sweet baby who is engaged in her surroundings and enjoys social interactions. She tolerated handling well by the therapists. She demonstrates a healthy attachment to her mother and smiled at the therapists occasionally during the evaluation. She shows interest in toys presented but appeared to fatigue fairly quickly in reaching and when placed on her tummy. Her parents report she is not laughing much yet but that she is a good natured baby.

Tests conducted:This evaluation was completed using the Peabody Developmental Motor Scales (PDMS-2), in a non-standardized manner. The PDMS-2 is a formal, standardized assessment tool designed to evaluate motor abilities in children. Of the six subtests, the Grasp and Visual Motor Subtests were used to assess fine motor skills.

Sub test Raw score Age equivalent DelayGrasp 11 2 months 50%Visual Motor Integration 5 5 months 0%

Based on patient’s test scores, she is demonstrating a severe delay in grasping skills for fine motor.

Clinical narrative of developmental domains evaluated:Neuromuscular functioning: Patient demonstrates mild hypotonia and decreased strength. Range of motion in upper extremities is within functional limits. Reflexes are not yet fully integrated.

Fine motor: Patient presents with flatness to the right side of her head but no tightness in her neck. In sitting, she holds her hands to her sides with indwelling thumb on the left hand and right thumb out. When placed on her tummy, she is able to push upward with her hands for a brief period. She is able to bring her hands to midline for exploration and partially extend her arms in reaching for a toy presented to her at midline.

She is able to hold a rattle placed in her hand for greater than 30 seconds and bring it to her mouth. She is able to track a ball in sitting beyond midline and track a ball or rattle to each side well. She is able to finger her hands together and bring them to her mouth. Concerns: Patient is not yet strong enough to straighten her arms to reach for a toy when lying on her back and when given a rattle, is not yet able to move the rattle

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more than 2 to 4 degrees. In sitting, she will reach for a rattle and touch it but is not yet grasping the toy.

Activities of Daily Living (ADL’s): Patient is drinking approximately 15 ounces of milk daily. She demonstrated a weak seal on the bottle nipple though and takes up to 30 minutes or longer to finish a bottle. She is able to sleep through the night from 0100 hours to 0600 hours. She usually wakes then for a feeding and sleeps 3 more hours before waking again. She naps throughout the day. Bath time is enjoyable to patient and she is not resistive to having her diaper changed.

Sensory processing: Patient does not present with difficulties in sensory processing in tactile, vestibular, proprioceptive or auditory at this time. As her strength increases, sensory processing should be monitored.

Implications: Patient’s scores in fine motor grasp are impacted by her reduced strength. Occupational therapy is recommended to help her build strength and begin exploring toys and she surroundings more.

Based on Part C EI criteria, this child may be eligible for Early Intervention Services in the State of Illinois due to: E01 - Department determined eligible level of delay or greater in one or more areas of development.

Recommended for areas that intervention is needed: Physical development, including vision and hearing Language, speech and communication development Social-emotional development

Recommendations for goals, outcomes and strategies for services with frequency, intensity and duration will be determined at the IFSP meeting in collaboration with the child’s family based on their identified priorities.

06/10/YYYY

Xxxx, M.S., R.D.N., C.S.P., L.D.N.

Nutrition assessment:Reason for referral: Patient referred to EI due to prematurity.

Concerns expressed by parents in regard to their child’ s development: Parents concerned about patient size and strength for age. Seems like she is too small, and is weak. Father reports that patient is functioning like a two month infant. Dad reports that newborn screen came back twice positive, once negative. Pediatrician is going to rescreen for galactosemia per dad. Dad did not understand that he needed to call and make appointment. Thought he should be waiting to August follow-up at Lurie. Reportedly going to take her to pediatrician Friday.

History of presenting illness: Patient presents today with decreased PO intake.Reflux: Parents report that patient spits up a lot, and only takes a small amount of formula at a time.Stooling history: Stooling 1-2 times/day, soft

Behavioral observation: Patient interacted with therapist with ease. Not fearful. Easy to weigh/measure. No crying. Made eye contact. Did not smile.

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Clinical observation:Current diet: Enfamil standard formula, feeds on demand. Mom makes 4 oz. bottle x 4 per day. Patient doesn’t take full volume. Mixing 20 cal/oz. verified

Observation eating: Patient observed slowly taking bottle - offered 4 oz., took 1 1/2 oz.

Tests conducted: Height: 24 inches Weight: 5.4 Kg < 5 percentile (Z-score -1.86) 50% for 2 ¼ m Ht/Lt: 61 cm 12 percentile (Z-score -1.17) 50% for 3 ½ m HC: 40 cm 16 percentile (Z-score -0.98) 50% for 3 ½ m Ideal body weight for Ht/Lt (IBW): 6.1 kg

Nutrition assessment: 88.5 % IBW (mild acute malnutrition) 95.9 % expected Ht/Lt for age Weight /length < 10 percentile for age (underweight)

Nutrient: Current intake

Recommended (per kg)

% Recommended

Calories 320 cal 500 (82/kg IBW) 64%Protein (g) 6.7 g 11.9 g (2.2 g/kg) 56%Calcium (mg) 250 mg 200 mg 125%Fluid (ml) 480 ml 540 ml 89%

Clinical narrative of developmental domains evaluated:Areas of concern: Current volume of feeds is below goal for age. Patient growth (weight) is below goal for age. Patient not showing normal interest in eating typical volume of formula for age. Current formula intake may be inappropriate pending results of newborn screening test.

Further assessments recommended: Yes: Nutrition services recommended. Frequency 2 times per month.Other recommendations and educational materials provided: Needs to begin soy formula and discontinue regular cow’s milk formula immediately.

Implications:Based on EI criteria, this child may be eligible for Early Intervention Services in the State of Illinois due to: E02 - Diagnosis of qualifying medical condition/listed

Recommendations for areas that intervention may be needed: Cognitive development Physical development

06/10/YYYY

Xxxxxx, M.A., L.C.P.C.

Initial psychological assessment:Reason for referral: Fatima was referred to the Illinois Early Intervention by Lurie’s Children’s hospital due to her prematurity and her overall development and

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medical concerns.

Concerns expressed by parent: Mom and dad expressed several concerns. They are concerned about their daughter’s size, medical condition, eating challenges and overall development. They also stated that she does not cry or fuss very often. They are concerned that she is weak and not growing.

Test conducted:This assessment was conducted at her home, “Vineland Social- Emotional Early Childhood Scale” was administered by this therapist along with an informal parent interview. Mom, dad, nutritionist and this therapist were present.

Vineland Social- Emotional Early Childhood Scale:Interpersonal relationships:Patient was alert and attentive. She smiled and eye contact was observed. She did not cry or fuss during the evaluation.

Play and leisure time:Patient was content laying on a blanket on the floor. When presented with an object to grab she did not respond. She did turn her head towards noise and was very alert and looking around throughout the evaluation.

Parameter Raw score Age equivalent Percent delayInterpersonal relationships 12 Less than 1 month Not applicablePlay and leisure time 0 Less than 1 month Not applicable

Implications:E01 - Department determined eligible level of delay or greater in one or more areas of development.

Recommendations for areas that intervention is needed: Cognitive development Physical development Language, speech and communication development Social emotional development Adaptive self help skills

Recommendations for goals, outcomes and strategies for services, with frequency, intensity, and duration to be determined at the TFSP meeting in collaboration with the child’s family based on their identified priorities.

11/15/YYYY

Xxxx, L.C.S.W.

6 month follow-up psychological assessment:Service Coordinator Faith Schwartz requested this six month review as part of Patient’s IFSP. Originally, patient was referred to the Early Intervention Program by Lurie’s Children’s Hospital due to prematurity, overall development and medical concerns. Her parents were initially concerned about her eating challenges and her rate of growth.

At the time of social work referral, the family was hoping patient would qualify for

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SSI benefits. Although benefits have not been applied for, it is unlikely that Fatima would qualify given no medical diagnosis. The family is awaiting receipt of medical summaries to ensure they have the support from her medical team before formally applying for SSI.

Patient had been off of milk products since mid-July and was only given soy based formula. Although galactosemia was initially suspected, blood work does not support the diagnosis. Per parent report, her reflux and constipation have since resolved. Frequent diarrhea was reported 2-3 months ago but has since resolved as well. Milk products have been recently introduced into her diet. She has also been introduced to a variety of baby foods and cereals and she seems to be tolerating them well.

Patient is an alert and happy infant. She can follow one simple command without physical prompts. She is able to find a small toy after it is completely hidden under a blanket or cloth. She has recently been able to hold her bottle to feed herself with both hands. She knows what “no” means and reacts. She moves to rhythms and imitates several new gestures.

She engages in simple relational play. When an adult holds out a hand and asks her for a toy, she will offer it to the adult although she may or may not let go of it. She shows like/dislike for certain people, objects and places. She recognizes several people in addition to her immediate family.

Patient has enjoyed good health aside from a few common colds. Her parents voice concern about frequent congestion and have been advised to bring their concerns to the attention of her pediatrician. She has had several doctor appointments since birth and mother has followed through on most recommended medical appointments.

Patient is to follow up with neonatal services in February YYYY. She is likely to be discharged from neonatal services based on her progress. She is seen by her pediatrician, Dr. Xxxxx, for well child checks.* Reviewer’s Comment: Medical records of Dr. Xxxxx are not available for review to show the condition to the patient.

I have seen patient bimonthly since July. Mother has welcomed this therapist into her home and has been very gracious, open and forthright. She has followed through with medical recommendations. Patient is very well cared for by her family and it is evident that she is quite attached to her mother. This family has been a pleasure to work with and I hope to continue services until patient exits the early intervention program.

01/14/YYYY

Xxxx, P.T., D.P.T.

Physical therapy discharge summary:Reason for referral: Patient was referred to the Early Intervention Program by her parents secondary to being born prematurely. This evaluation was done as her discharge from physical therapy.

Concerns expressed by parents in regard to their child’s development:The family does not have any concerns with her gross motor skills.

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Medical reports:History reviewed. She went to a NICU follow-up checkup at XYZ Hospital in August. She saw Dr. Xxxxx on January 12, YYYY and saw an ophthalmologist one to two weeks after discharge and she does not need to go back until age five. Patient has been healthy since birth, without any major illnesses, hospitalizations, surgeries or ear infections. She is not currently medicated, has no known allergies and no other significant health history has been reported. She learned to walk right around her birthday.* Reviewer’s Comment: It is stated that patient has visited Dr. Xxxxx on 01/12/YYYY and saw an ophthalmologist one to two weeks after discharge (01/08/YYYY); however these records are not available for review to show the condition to the patient.

Behavioral observation:This evaluation was completed with a physical therapist, patient’s mother, and older sisters present. Patient was easily engaged in play activities and participated in both adult-directed and self-directed play tasks. She demonstrated an appropriate attention span and frustration tolerance for a child her age. She transitioned between activities easily and exhibited consistent eye contact while playing and when spoken to. An appropriate activity and arousal level were noted, with a calm, alert and organized state for the majority of the evaluation.

Clinical narrative of developmental domains evaluated:ROM/Orthopedic: Patient has full range of motion throughout her upper and lower extremities. She has full cervical rotation and lateral flexion. She no longer has any tightness or asymmetries in her skull.Concerns: None at this time.

Posture: Patient can sit in a variety of positions to best suit her needs. She can ring, long, and side sit. She has an erect spine and slight posterior pelvic tilt. She can reach within and out of base of support. She can stand independently with a moderate base of support and low guard. Her feet are flat with mild calcaneal valgus and pronation. She has a slight anterior pelvic tilt. She can stand for greater than one minute.Concerns: None at this time.

Muscle tone/primative reflexes: Muscle tone is defined as a muscle’s readiness to fire. She displays muscle tone within normal limits. She has no atypical muscle synergies.Concerns: None at this time.

Strength/gross motor skills: Patient displays age appropriate strength. She uses walking as her primary means of locomotion. She will walk across the room. She has a moderate guard and base of support. She lands flat on her feet and does not yet have a heel strike. She continues to use her arms for balance and does not have an arm swing.

Patient can stand up from the middle of the floor via plant/grade position. She will

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crawl on her hands and knees when things are close together. She easily transitions between positions. Concerns: None at this time.

Further assessments recommended: None at this time.

Based on Early Intervention criteria, patient may be eligible for Early Intervention Services in the State of Illinois due to: This child has not met the eligibility criteria for Early Intervention Services in Illinois.

Recommendations for areas that intervention may be needed: Cognitive development Physical development Communication development Social or emotional development Adaptive development

Recommendations for goals, outcomes, and strategies for services, with frequency, intensity, and duration will be determined at the IFSP meeting in collaboration with the child’s family based on their identified priorities.

08/23/YYYY-01/14/YYYY

Multiple providers

Other related records:Assessment (Ref. 183-187, 1-9), Consent (Ref. 526-527, 188), Discharge Records (Ref. 420, 352-355, 341-342, 331-340, 189-190, 191, 193-194, 171-173, 328-330, 442-444), Flow Sheet (Ref. 490-523), Orders (Ref. 450-478, 201-222), Others (Ref. 192, 479, 487, 524-525, 447-449, 343, 174-180, 88-90, 10-16, 488), Labs (Ref. 223-234), Patient's Information (Ref. 97-98, 310-311), Telephone conversation (Ref: 94, 95),

*Reviewer's comment: The above records have been reviewed and important details have already been included in the chronology. Hence not elaborated. We can summarize if needed on request.

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Wiliam Sepulvado - Trivent Legal | Medical Summaries ... · Web viewThe placenta is anterior...

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