Download Shoulder Dystocia

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DOB: 11/10/YYYY
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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DOB: 11/10/YYYY
DOB: 12/18/YYYY
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 Hospital
12/18/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 Services
05/21/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
08/23/YYY Multiple
Yproviders
10/27/YYY
Y
OCCURRENCE/TREATMENT
* 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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DATE
DOB: 11/10/YYYY
DOB: 12/18/YYYY
PROVIDER
08/21/YYY ABC Hospital
Y
08/22/YYY Not available
Y
OCCURRENCE/TREATMENT
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ABC Hospital
Labs:
Hepatitis B surface antigen (HBsAG): Non reactive
Hepatitis C antibody: Non reactive
HIV: Non reactive
Rubella immunoglobulin: >500 high
554557
Normal: White Blood Cell (WBC) 10.41; Red Blood Cell (RBC) 4.21;
Hemoglobin 12.6; Hematocrit 37.8; Platelet 176
High: Neutrophils 79.6; Absolute neutrophils 8.29
Low: Lymphocytes 15.5, Monocytes 3.1
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
77
Chlamydia/Gonorrhea: Negative
Urine culture: No growth
Rapid Plasmin Reagin (RPR): Non reactive
09/04/YYY Xxxx,
Y
R.D.M.S.
Xxx, M.D.
* Reviewer’s Comment: This information is taken from flow sheets. Detailed
report is not available for review.
Obstetrical ultrasound report:
Pregnancy: Gravida 6, para 5
LMP: 04/10/YYYY
Gestational age by LMP: 21 weeks 0 days
Gestational age by ultrasound: 20 weeks 1 day
EDD: 01/15/YYYY
Previous exam: No previous exam
Indication: Fetal survey
Measurement and fetal age
Measurement
GA
Range
Source
BPD 4.7 cm
20 w 2 d
HC 18 cm
20 w 3 d
18 w 4 d22 w 0 d
19 w 0 d-
3 of 41
Hadlock
Fetal growth evaluation
%
Ratio
GA
31% FL/BPD 0.21
Hadlock
33%
FL/AC
0.22
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DATE
DOB: 11/10/YYYY
DOB: 12/18/YYYY
PROVIDER
OCCURRENCE/TREATMENT
AC 15.2 cm
20 w 3 d
22 w 0 d
18 w 2 d22 w 4 d
Hadlock
38%
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HC/AC
0.18
(1.051.24)
FL 3.3 cm
20 w 3 d 18 w 4 d- Hadlock 36% CI
0.72
22 w 2 d
(0.700.86)
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 isconsistent with normal fetal growth. Fetal heart motion is seen.
10/29/YYY ABC Hospital
Y
10/31/YYY
Y
11/07/YYY ABC Hospital
Y
12/10/YYY Xxxx
Y
12/11/YYY Xxxxx, M.D.
Y
Impression: Satisfactory structural survey. Recommend follow-up for low lying
placenta.
Labs:
Glucose tolerance test:
1 hour glucose: 160 mg/dl (high)
Labs:
Vitamin D – Total 25 hydroxy: 34; Vitamin D-3, 25 hydroxy: 16; Vitamin D-2, 25
hydroxy: 18
Labs:
Glucose tolerance test:
Fasting: 87
1 hour: 171 mg/dl
2 hour: 185 (high)
3 hour: 156 (high)
Telephone encounter:
Reason: Needs ultrasound
Message: Needs follow-up ultrasound for placenta location
Action taken: Called patient to pick up order for ultrasound
Office visit for cough:
Reason for appointment: Cough for 2 days
History 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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DATE
PROVIDER
DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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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
Treatment
Bronchitis: 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.
12/15/YYY Xxxx
Y
08/10/YYY
Y12/02/YYY
Y
Follow-up: 1 week (Reason: OB care.)
Telephone encounter:
Reason: Ultrasound not done
Message: Needs follow-up ultrasound for placenta location
Action 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.
Prenatal record:
Initial physical examination:
Date: 08/10/YYYY
Height: 61; Weight: 188; BP 121/69; Pre OB weight: 184
General: No acute distress
Psychiatric: Mood/affect appropriate to setting
Extremities: No edema
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DATE
DOB: 11/10/YYYY
DOB: 12/18/YYYY
PROVIDER
OCCURRENCE/TREATMENT
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Vagina: Normal
Uterus size: 19 weeks
Adnexa, rectum, pubic arch: Normal
Diagonal conjugate: Reached
Spines: Average
Sacrum: Concave
Gynecoid: Pelvic type gynecoid
Otherwise unremarkable
Last Menstrual Period (LMP): 04/10/YYYY
Initial examination: 09/04/YYYY
Initial Estimated Delivery Date (EDD): 01/15/YYYY
Ultrasound: 09/04/YYYY, Weeks: 21 weeks
EDD: 01/19/YYYY
Date:
YYYY
Weeks
gestation
Fundal
height
Pres.
FHR
Fetal
movement
Preterm
labor signs
Dilation
Effacement
Station
Edema
BP
08/21
08/27
09/04
09/18
10/02
10/08
10/29
11/12
12/02
19 w
0d
19 cm
19 w
6d
20 cm
21 w
0d
27 cm
23 w
0d
23 cm
25 w
0d
25 w
6d
30 cm
28 w
6d
34 cm
30 w
6d
30 cm
33 w
5d
32 cm
162
Yes
Vertex Vertex
145
144
150
Yes
Yes
Yes
No
No
None
121 /
59
188
4
-3
None
116 /
74
188
No
None
118 /
82
187
Vertex Vertex Vertex Vertex
133
154
142
144
Yes
Yes
Yes
Yes
No
No
No
no
None
121 /
76
188
-3
None
123 /
80
191
7
None
114 /
75
191
None
112 /
76
191
7
121 /
65
188
None
108 /
74
189
5
Weight
Total
weight gain
Neg
Neg
Neg
Neg
Neg
Neg
Neg
Neg
Urine
glucose
Neg
Neg
Neg
Neg
Neg
Neg
Neg
Neg
Urine
albumin
2w
2w
2w
4w
3w
2w
2w
2w
Next appt
NY
NY
NY
NY
NY
NY
NY
NY
Initials
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.)
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DATE
PROVIDER
DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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Patient with LMP 04/10/YYYY, EDD 01/15/YYYY. Started prenatal care at another office is
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/YYY ABC Hospital @ 0819 hours: Obstetrical ultrasound report:
Y
Pregnancy: Gravida 7, Para 5, Abortion 1
Xxxxx,
LMP: 04/10/YYYY
R.D.M.S.
Gestational age by LMP: 36 weeks 0 days
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DATE
PROVIDER
Xxxx, M.D.
DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
Gestational age by first study: 36 weeks 0 day
Gestational age by todays ultrasound: 31 weeks 3 days
Gestation age selected: 36 weeks 0 days (LMP)
EDD: 01/15/YYYY
Previous exam: 09/04/YYYY
Indication: Placental location; growth
Measurement and fetal age
Measurement
GA
Range
Source
Fetal growth evaluation
% for
Ratio
36 w 0 d
BPD 8.2 cm 32 w 6 d 29 w 5 d- Hadlock <05 %
FL/BPD 0.75
35 w 6 d
(0.710.87)
HC 29 cm
31 w 6 d 28 w 6 d- Hadlock <05 %
FL/AC
0.23
34 w 6 d
(0.200.24)
AC 26.7 cm
30 w 6 d 27 w 6 d- Hadlock <05 %
HC/AC 1.09
33 w 6 d
(0.921.11)
FL 6.1 cm
31 w 5 d 28 w 5 d- Hadlock <05 %
CI
0.83
34 w 5 d
(0.700.86)
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) Hadlock
Fetal heart rate: 142 bpm
AFI: 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.
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DATE
DOB: 11/10/YYYY
DOB: 12/18/YYYY
PROVIDER
12/18/YYY Xxxxx, M.D.
Y
12/18/YYY Xxxxx, M.D.
Y
OCCURRENCE/TREATMENT
AFI 2.2. Rule out IUGR. Correlate with Non-Stress Test (NST). Dr. Yukoub to be
notified.
Prenatal visit:











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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 Csection. To labor and delivery. Group B Streptococcus (GBS) not done yet will do
one today but given antibiotics while in labor.
Follow-up Obstetrics visit:
Reason for appointment: Obstetrics check
Vital signs: Height 61; Weight 191; BMI 36.089; Heart rate 80, BP 112/77.
84
Assessments: Supervision of normal subsequent pregnancy - (Primary)
Treatment: Supervision of normal subsequent pregnancy. LAB: Culture, vaginal
strep (CULVS)
12/18/YYY Xxx, D.O,
Y
P.G.Y. -1
Xxxxx, M.D.
Procedure: Urinalysis, auto, without scope. Fetal non-stress test.
Follow-up: To labor and delivery (Reason: postpartum check)
@ 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
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DATE
DOB: 11/10/YYYY
DOB: 12/18/YYYY
PROVIDER
OCCURRENCE/TREATMENT
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
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Weight gain: 2.8 Kg
Height: 60 inches; BMI: 37.1
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).
12/18/YYY ABC Hospital
Y
IUGR maternal risk factor for A1GDM
@ 1054 hours: Labs:
High: WBC 12.06; Neutrophils 80.8; Absolute neutrophils 9.74
Low: Hematocrit 35.6; Lymphocytes 15; Monocytes 2.9
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DATE
PROVIDER
12/18/YYY Xxxxx, M.D.
Y
12/18/YYY ABC Hospital
Y
DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
ABO/RH type: A Positive
Antibody screen: Negative
@ 1109 hours: Admission record:
Admission time: @ 1109 hours
Reason for admission : IOL
Other 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.
Labs:
@ 1300 hours:
Toxicology: (Ref. 302)
Positive (high): Opiates
Negative: Cannabinoids, Phencyclidine, Cocaine, Amphetamines,
Benzodiazepines, Barbiturates
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302306
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
12/18/YYY
Y12/19/YYY
Y
12/18/YYY
Y
@ 1502 hours: Glucose 91 (Ref. 302)
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.
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
@ 1851 hours Oxytocin
@ 1852 hours Oxytocin
@ 1854 hours Ancef
@ 1904 hours Oxytocin
Dose and route
30 units IVPB
2 gm IV
10 units
10 units
Procedure: Primary Cesarean section (C-section)
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DATE
DOB: 11/10/YYYY
DOB: 12/18/YYYY
PROVIDER
OCCURRENCE/TREATMENT
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Surgeon: Scott/Moss
Anesthesia start time: 1845 hours
Surgery start time: 1850 hours
Skin incision: 1850 hours
Uterine incision: 1851 hours
Delivery time: 1851 hours
Surgery finish time: 1950 hours
Anesthesia finish time: 2000 hours
Post-operative vitals: BP 118/63; Pulse 92; Respiratory rate 20; Temperature
96.8; SpO2 99%.
12/18/YYY Xxxx, M.D.
Y
Xxx, S.A.C.
Xxxx, P.G.Y.-1
Delivery: Female; birth weight 1481 gm; resuscitation.
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 Xxxx
Complications: None
Intravenous fluids: 600 ml of normal saline
Urinary output: 300 ml clear
Estimated blood loss: 700 ml.
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DATE
PROVIDER
DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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)
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.
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DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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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
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.
12/18/YYY ABC Hospital
Y
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.
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
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DATE
DOB: 11/10/YYYY
DOB: 12/18/YYYY
PROVIDER
12/18/YYY Xxxxx, M.D.
Y
12/18/YYY
Y
12/18/YYY Xxxx, M.D.
Y
OCCURRENCE/TREATMENT
Cord information:
 Number of cord vessels: 3
 Nuchal cord: not applicable
 Infant cord pH arterial: 6.77
Abdomen X-ray reports:
Clinical indication: Sponge count
Comparison: None
Impression: No evidence of radiopaque foreign body.
Neonatal resuscitation data sheet: Illegible notes
Time of birth: 1851 hours
Time of resuscitation: 1851 hours
Reason for resuscitation: STAT C-section NRFHT; severe IUGR _____
Gestation age: 36 weeks
Weight: 1481
APGAR scores:
1 minute: 3
5 minutes: 6
10 minutes: 9
Time
00:30
HR
30
Respiration
Apneic
00:47
1:15
2:25
3:15
4:48
5:30
6:30
100
110
130
140
148
153
1
Apneic
Apneic
Spontaneous
Spontaneous
Spontaneous
Spontaneous
Spontaneous
SpO2
100%
100%
Vent
BM
BM
BM
BM
BM
BM
BM
309
181182
Procedures and comments
1851 delivery, to warmer,
limp, blue, started
compressions, PPV
Intubation attempt, week cry
Intubation attempt, strong cry
spontaneous
6:49
177 47
100% BB
7:30
175 44
10%
BB
8:55
166 52
100% BB
Meconium plug passed
12:00 168 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)
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
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99102
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XXXX
DATE
PROVIDER
DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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:
 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 alert
HEENT: 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 masses
Chest: Clavicles grossly intact, lungs clear to auscultation bilaterally
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DATE
PROVIDER
DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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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 genitalia
Anus: Patent to inspection
Extremities: Moves all 4, no hip clicks
Neurology: Good tone, symmetrical
Skin: 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.
12/18/YYY Xxxxx, M.D.
Y
Neurology: Will continue to monitoring wide sutures. Consider thyroid studies.
@ 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 distress
HEENT: Anterior Fontanelle Open Soft and Flat (AFOSF), large anterior and
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DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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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 pulses
Abdomen: Soft, non tender, non distended
Back: No sacral dimple, spine straight
Musculoskeletal: MAEE, hips stable
Neurologic: Positive suck, positive grasp, positive moro, good tone
Otherwise 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 9.47
Low: 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.
12/19/YYY ABC Hospital
Y
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 monitoring
Cardiac: Continuous hemodynamic monitoring. Monitor murmur. ECHO if
indicated
ID: No risk factors for infection. Follow CBC and 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.
Labs:
CMV-IGG: >10 (high)
HSV-1 IgG: 44.8 (high)
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PROVIDER
DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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HSV-2 IgG: <0.91
Rubella antibody-IgG: 19.20
Toxoplasma IgG: <3
12/21/YYY Xxxxx, M.D.
Y
12/22/YYY Xxxx, M.D.
Y
12/23/YYY Xxxx, M.D.
Y
12/24/YYY Xxx, M.D.
Y
Low: Hemoglobin 9.1; Hematocrit 26.7
Post partum discharge note:
 Discharge method: Wheel chair
 Discharged with: No babies
 Condition: Stable
 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
Ultrasound of neonatal head:
Reason for exam: Newborn with large Fontanelle.
Comparison: No previous
Impression: Negative neonatal brain.
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.
Pathology report:
Specimen: Surgical placenta
Final diagnosis: Mature, third trimester placenta.
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Preoperative diagnosis: Preterm IUP @ 36.1, IOL for oligohydramnios and
severe IUGR, non-reassuring fetal status
Post-operative diagnosis: Same, thin cord
12/19/YYY Multiple
Yproviders
12/30/YYY
Y
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.
* Reviewer’s Comment: Medical records from 12/19/YYYY to 12/31/YYYY are
cumulated department wise and are summarized briefly below.
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 83
Low: pO2 49.7; ABG O2 saturation 85.
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DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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
 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 sepsis
Plan: 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 sepsis
Plan:
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 titers
Otherwise 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 2.440
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DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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.
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
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)
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DOB: 11/10/YYYY
DOB: 12/18/YYYY
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OCCURRENCE/TREATMENT
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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.
12/19/YYY Multiple
Yproviders
12/31/YYY
Y
12/30/YYYY: (Xxxxx, M.D.) (Ref. 124-125)
Patient gained weight overnight. She took increasing amounts of PO. Doing well
in room air. Remains in isolette.
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
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DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
(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.
 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 morning
FEN: 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.
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XXXX
DATE
PROVIDER
DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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)
Apnea; working on feeds.
Assessment and plan:
Respiration: Room air, no spells since morning, had 1 spell 12/22/YYYY,
continue to monitor closely, CPOx
FEN: 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 toxo
FEN: 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/day
Ophthalmology: 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/day
Ophthalmology: 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)
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DATE
PROVIDER
DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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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/day
Remaining plan remains unchanged as on 12/26/YYYY.
12/28/YYYY: (Xxxx, M.D.) (Ref. 146-147)
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 weeks
Plan:
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/YYYY
Remaining plan remains unchanged as on 12/29/YYYY.
01/06/YYY Xxxxx, M.D.
Y
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.
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.
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PROVIDER
DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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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
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.
01/01/YYY Multiple
Yproviders
01/07/YYY
Y
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.
Cumulative Special care nursery progress notes:
01/01/YYYY: (Xxxx, M.D.) (Ref. 154-155)
AOP, working on feeds
Assessment: 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 negative
Other: 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 delivery
Plan:
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PROVIDER
DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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 day
Follow-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 phototherapy
Assessment: 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.
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 iron
FEN: 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
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PROVIDER
DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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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.
01/08/YYY Xxxxx, M.D.
Y
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
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.
Discharge summary: Poorly scanned record
Primary diagnosis: Prematurity
Secondary 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
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DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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
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, vigorous
HEENT: Large and flat anterior fontanelle and posterior fontanelle, moist mucous
membrane, no cleft palate, normal set eyes and ears. Positive respiration bilaterally
Cardiovascular: Regular rate and rhythm, no murmur, femoral pulse 2+ equal
bilaterally
Lungs: Clear to auscultation bilaterally good aeration.
Abdomen: Soft non tender; non distended; no hepatosplenomegaly; normoactive
bowel sounds.
Genitourinary: Normal external genitalia
Extremities: Warm and Well Perfused (WWP), no hip clicks
Neurology: Good tone, symmetric moro reflex, good suck/grasp
Skin: Warm dry, no rash, no jaundice.
Discharge condition: Good
Hepatitis B given: 01/07/YYYY
Hearing: Passed
Newborn screens sent: 12/19/YYYY (normal), 01/01/YYYY, 01/07/YYYY
Congenital heart disease screen: Passed
Car seat trial: Passed
Follow-up Dr. Xxxxx 01/12/YYYY, Dr. Xxxxxxx 1-2 weeks, NICU follow-up
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PROVIDER
05/21/YYY Xxx,
Y
Developmental
Therapist
DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
clinic.
Diet: Neosure 22
Medications: 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.
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.
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
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DATE
DOB: 11/10/YYYY
DOB: 12/18/YYYY
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OCCURRENCE/TREATMENT
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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
levels based on the results of this evaluation.
Domain
Cognitive
Receptive
language
Expressive
language
Gross motor
Fine motor
Socialemotional
Self help
Age
equivalent
3 months
4 months
Percent of
delay
Delay of 25%
No delay
Developmental quotient
3 months
Delay of 25%
75-typical range (low average)
3 months
2 months
4 months
Delay of 25%
Delay of 50%
No delay
75-typical range (low average)
50-mild delay
100-typical range
3 months
Delay of 25%
75-typical range (low average)
75-typical range (low average)
100-typical range
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.
05/21/YYY Xxx M.A.,
Y
C.C.CS.L.P./L.
Pediatric
Speech
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.
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.
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DATE
DOB: 11/10/YYYY
DOB: 12/18/YYYY
PROVIDER
Language
Pathologist,
Early
Intervention
Specialist
OCCURRENCE/TREATMENT
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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:
Development area
Age
Percent
Developmental
equivalent
of delay* quotient
Interaction-attachment
3-6 months
0%
100: Age appropriate
Pragmatics
3-6 months
0%
100: Age appropriate
Language comprehension 3-6 months
0%
100: Age appropriate
Language 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).
05/21/YYY Xxxx, P.T.,
Y
D.P.T.
Recommendations for areas that intervention/monitoring is warranted:
Communication development
Social or emotional development
Adaptive development
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
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DOB: 12/18/YYYY
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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
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 profile
Reflexes
4
3 months
25% delay
Stationary
16
3 months
25% delay
Locomotion
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)/Orthopedic
Patient 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
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DOB: 11/10/YYYY
DOB: 12/18/YYYY
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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:
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
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REF
XXXX
XXXX
DATE
PROVIDER
05/21/YYY Xxxxxx, O.T.
Y
R/L
DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
PDF
REF
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.
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.
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
Grasp
Visual Motor Integration
Raw score
11
5
Age equivalent
2 months
5 months
Delay
50%
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.
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DOB: 11/10/YYYY
DOB: 12/18/YYYY
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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
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
06/10/YYY Xxxx, M.S.,
Y
R.D.N., C.S.P.,
L.D.N.
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.
Nutrition assessment:
Reason for referral: Patient referred to EI due to prematurity.
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DOB: 11/10/YYYY
DOB: 12/18/YYYY
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OCCURRENCE/TREATMENT
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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.
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:
Calories
Protein (g)
Calcium (mg)
Fluid (ml)
Current
intake
320 cal
6.7 g
250 mg
480 ml
Recommended
(per kg)
500 (82/kg IBW)
11.9 g (2.2 g/kg)
200 mg
540 ml
% Recommended
64%
56%
125%
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.
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DATE
PROVIDER
DOB: 11/10/YYYY
DOB: 12/18/YYYY
OCCURRENCE/TREATMENT
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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
06/10/YYY Xxxxxx, M.A.,
Y
L.C.P.C.
Recommendations for areas that intervention may be needed:
 Cognitive development
 Physical development
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
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
Interpersonal relationships
Play and leisure time
Raw score
12
0
Age equivalent
Less than 1 month
Less than 1 month
Percent delay
Not applicable
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
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DOB: 11/10/YYYY
DOB: 12/18/YYYY
PROVIDER
OCCURRENCE/TREATMENT




11/15/YYY Xxxx,
Y
L.C.S.W.
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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.
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
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
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DOB: 12/18/YYYY
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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.
01/14/YYY Xxxx, P.T.,
Y
D.P.T.
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.
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.
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
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DOB: 12/18/YYYY
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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
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.
08/23/YYY Multiple
Yproviders
01/14/YYY
Y
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.
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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