Medical Chronology
Chronology of Neurological
IME of December 16, 2010 1130AM
For
Prepared for
By
KH , RN, CLNC
Legal Nurse Consultant
December 21, 2010
Chronological summary of events:
|DATE/ |PROVIDER |OBSERVATION/OBJECTIVE DATA |COMMENTS |
|TIME | | | |
|12-16-10 | (PL) |Called patient’s name and led K, her Mother and attorney’s representative to examination room. |Initially, all rooms were full, and PL apologized, as |
|1142AM | | |we offered to return to the waiting room area. Then a |
| | | |room opened and we were taken in there. Did not |
| | | |observe any room “preparation/cleaning” between |
| | | |patients, if there is a protocol for this. |
| | | |Mr. M offered to remain in the waiting area with their|
| | | |baby. This was to offer room, for as often is the |
| | | |case, the examination rooms are rather confined areas.|
| | |PL offered that all may come back to the room as there was plenty of room for everyone. |These examination rooms were rather spacious and |
| | | |allowed for medical equipment use such as: |
| | | |wheelchairs, walkers, canes, crutches, and it this |
| | | |case, the patient’s wheelchair and the baby’s |
| | | |stroller. K H, RN escorted them to the room where the|
| | | |patient and her Mother were. |
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|12-16-10 |PL |History: | |
|1144-1145AM | | | |
| | |Thanked the M’s for driving all the way from Bakersfield for this examination. The ONLY Purpose | |
| | |of this examination is to find out how you’re doing now, about school, the doctors you’re seeing,| |
| | |treatments you may be having. | |
| | | | |
| | |**Cell phone rings. “ Please let me take this call” |PL leaves the room and returns a minute later. |
|12-16-10 |PL |K, “I’m hungry.” Parents discuss going to Denny’s for lunch after the examination. | |
|1145-1146AM | | | |
| | |Took call, returned to the examination room, | |
| | |continued with the history. | |
|1146AM |PL |History continued: | |
| | |Ask questions about medications she’s taking, equipment she has, academics and if she likes | |
| | |school. Then a physical exam that will not be painful uncomfortable or embarrassing and if | |
| | |parent thinks something should not be done, I will not do that. This exam should last about an | |
| | |hour and if she or the baby needs something then things may stop. | |
| | |Offered water before starting | |
| | |According to his notes “Kimberly” is 6 ½ | |
| | |(Mrs. M) “K.” Yes | |
| | |K is left-handed |Called K “Kimberly twice. |
| | |Family lives in Bakersfield in a single story house with a one step entry at all doors. There are| |
| | |four bedrooms, with five people living there: Mother, Father, half-brother and sister. | |
| | |Mrs. M works as a veterinary assistant dealing with small animals. | |
| | |Mr. M. works as a tile setter. | |
| | |Kimberly’s ….K’s health insurance is: Medical. | |
| | |Does not receive SSI and is a client of CCS and goes to McKinley Medical Treatment Unit in | |
| | |Bakersfield. | |
| | |Attends school at Voorhies Elementary in the first grade, regular school. Attended Kindergarten | |
| | |there too. | |
| | |Parents drive her to school in a Nissan Quest Van, without modifications. The school can drive | |
| | |her, but parents prefer to take her. They live about 5-10 minutes from school | |
| | |Program: has a 1:1 aid to assist physically with “cathing” lunch, recess and there from 0800 to | |
| | |2:30 then a second aid for the last 20 minutes of the day. | |
|12-16-10 | |Aid trained by the school district nurse: Lucy Salazar around mid 50’s has worked voluntarily for| |
| | |the district years, her son is the principal and daughter is a teacher. No other background | |
| | |information. Has served in this position for first grade only. Mr. M.: “A real nice lady.” PL| |
| | |states: “Apparently her mind is working well as she learned catheterizations.” | |
| | |Kindergarten Aid was: Jessica C was in her early 20’s, also trained by school nurse to care for | |
| | |K. Mr. M: “She was nice too.” | |
| | |Offered to bring something for K to play with at the table (in the corner of the room) as K was | |
| | |becoming restless and sagging in her W/C | |
| | |K is learning: Reading, writing, adding, subtracting, and normal academic skills. Teacher says | |
| | |she needs to improve math. No particular therapy at home, she has a “coach” who does specialized| |
| | |physical education with K 1x/week, every Wednesday morning for about 1/2hour. They like him. | |
| | |Like “adaptive PE.” Mrs. M, “Yes.” | |
| | |Other Therapy: McKinley Medical Treatment Unit 1x/wk for 1/2hour and right now teaching her how| |
| | |to transfer from a couch or chair to a w/c. and to lift her own body weight, scooting herself, | |
| | |working on propelling herself in the w/c | |
| | |Any other therapy? No. Mr. M. “Just the swimming pool in the summer time!” | |
| | |She is seen by an orthopedic doctor every six months at Valley Children’s Hospital in Madera. | |
| | |She last saw K September 2010 and will see again in the spring | |
| | |McKinley takes care of durable medical equipment decisions as needed. | |
| | |Saw Ortho doctor for fractured femur while with the sitter and has heard that the cause was | |
| | |related to bone density. This occurred in late 07 and into 08. It was casted, and once removed | |
| | |there was a fracture “here” in the tibia and occurred while femur casted. However it had already | |
| | |healed. | |
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|12-16-10 | |No meds or further referral for bone density, and may need to surgically treat left leg length as| |
| | |left leg longer than right | |
| | |Does urinate in diaper along with need to catheterize. Mrs. M states that sometimes K may tell | |
| | |her when she is wet, but does not answer whether or not she can “feel” this. K does not yet | |
| | |catheterize herself. | |
| | |Back seems stable at this time | |
| | |Equipment used: | |
| | |-Wheelchair | |
| | |-Straight-catheters about 4x/day | |
| | |-Back brace not wearing, used for posture. Has a Velcro/elastic (girdle-like) one and a casted | |
| | |type (body jacket), but does not wear the body jacket, rarely, and the girdle type used more and | |
| | |at school than at home. | |
| | |-Diapers : uses 5-6/day |In reference to K’s tibial fracture, Mrs. M pointed to|
| | |-Bath Chair |the anterior proximal area of her tibial area (nearer |
| | |-Memory Foam Mattress due to bed sore history (no bedsores since hospital after MVA) |to the knee) |
| | |No home modifications performed for K’s needs. Uses the w/c and mechanic’s creeper for mobility |No measure of length difference made during Physical |
| | |in the house, otherwise she crawls. |Exam. Seems that a “growth plate” in her long bone |
| | |G-Tube no more, Tracheotomy no more |was affected by the fracture. Usually, resulting in a|
| | |Sleeps in a regular bed in parents’ bedroom because she does not like the dark. |decreased length of the bone. In this case Mrs. M. is|
| | |K does not “feel” sensation in her legs; had femoral and tibial fracture and did not know it. |suggesting that the growth rate is causing an increase|
| | |Has K ever burned herself or had a bad cut on her legs and did not know about it? No. Parents |in length. |
| | |have to “be on her” to remind her to watch her legs. | |
| | |Parents cannot say definitively whether or not K feels any sensation in her legs. Mrs. M, | |
| | |“Sometimes she won’t tell us.” | |
| | |Lately K c/o headaches when being straight cathed to alleviate bladder distention. K does not | |
| | |seem to react as though she feels this procedure. | |
| | |K’s doctors: | |
| | |Pediatrician: Dr. O’Keesy (woman) is the primary doctor since left the hospital and has a | |
| | |physical once/year. | |
| | |Orthopedic: Long name cannot remember at Valley Children’s Hospital | |
|12-16-10 | |Urologist: Dr. Kaji (woman) at Madera sees K 2x/year has x-rays and ultrasound of bladder to | |
| | |assess kidney health and to make sure urine not backing up into them from bladder. | |
| | |GI Clinic: No active problems, but occ. Constipation, eating by mouth, no nausea or vomiting. | |
| | |Why is she still being seen? Mrs. M. “Not sure.” PL: “I guess they like her.” Takes OTC enemas| |
| | |1-2x/week and colace. | |
| | |Dental: Told that had cavities in baby teeth which have since fallen out. Not aware of any | |
| | |active dental problems. | |
| | |Hospitalizations since MVA: | |
| | |Two winters ago for pneumonia no “trach”. | |
| | |Hospitalized three times with pneumonia. | |
| | |Trach and G-tube removed Sept. 06 | |
| | |Medications: | |
| | |-Bactrim 1 teaspoon daily Prevent UTI | |
| | |-Enemas: 1-2/week | |
| | |-Colace: daily | |
| | |Parental assessment of K’s health: | |
| | |-Vision okay |Various dermatomes were not assessed during the |
| | |-Hearing okay |Physical Exam. |
| | |-Speech is okay, learned about “high frequency” word one example “the”. People understand when | |
| | |she talks and she understands when people talk to her. Mrs. M. “Yes.” | |
| | |-Does she Drool? Mrs. M. “No; maybe at night.” | |
| | |-Eating: Okay. Feeds self sometimes, eats table food. Some foods are not manageable and needs | |
| | |assistance if K unable to grasp, like burritos. When sandwich grows small, then unable to | |
| | |manage. Able to manage a hotdog and drinks from a Sippy cup in order to avoid spilling, not | |
| | |because difficulty in swallowing. She uses toddler type eating utensils. Right hand is weaker | |
| | |than left. | |
| | |-Strength: Hands weak? Mrs. M. “I think so, she has trouble lifting her own weight. No movement| |
| | |in her legs | |
| | |-Sleep: In her own bed usually sleeps through the night and repositions self. | |
| | |-With the understanding that you have to do a lot for K, is she an easy, average or difficult | |
|12-16-10 | |child to care for: Pretty easy, today is a “usual” day. Sometimes have tantrums at home, | |
| | |behavior at school, “She knows what side her bread is buttered on, so she shuts down and puts her| |
| | |head down when she wants to and won’t continue with work.” | |
| | |-Socially: Does good with the kids at school. Does tend to socialize with cousins (male) who | |
| | |are her age, not really with children from school. No play dates with children from school | |
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| | |History complete | |
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| | | |Used this information as the basis of his evaluation; |
| | | |did not perform testing of these areas. |
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|12-16-10 | | | |
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|1220PM | | | |
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| | | |History: ~32min 31sec |
|12-26-10 |PL |Left room to obtain some items for Physical exam | |
|1220PM | |K c/o bladder pain | |
|12-16-10 1222PM |PL |Physical Examination: | |
| | | | |
| | |Parents encouraging K to show PL what she is able to do. K moans, and father says, “If you don’t|K was behaving in a tired and hungry manner, and did |
| | |then we can’t go to Denny’s…”Then Mother says, “We can sit here until you show him, the faster |complain of bladder discomfort. Her parents |
| | |you show him the faster we can go to Denny’s.” Then perked up. |encouraged her to complete this portion of the |
| | |Asked who cartoon character was on the ball. |examination quickly so that all may leave and enjoy |
| | |K, “Sponge Bob!” Threw and caught ball with PL x3. “Good, girl. Thank you, honey.” |their lunch and Denny’s. |
| | |PL: “Does she have a tendency to sag forward in chair? | |
| | |Mrs. M: “Yes.” | |
| | |PL: “Can she print her name?” | |
| | |Mrs. M: “Yes.” | |
| | |K performed the following using a sharpie permanent marker: | |
| | |Printed “K” |Initially, using a normal pencil/pen, dexterity was |
| | |Drew a square |difficult. Once offered the Sharpie Marker, she did |
| | |Drew a triangle. PL: “Good.” |much better. |
| | |Picked from two groups of tally marks the greater number and then correctly counted the total | |
| | |number of tally marks. PL: “Wow, good.” | |
| | |Did not understand the meaning of “divide the line in half.” | |
| | |Easier to use the thicker writing tools as opposed to thinner. | |
| | |Measured head circumference without comment. | |
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| | | |Did not measure limb circumferences-Did not note leg |
| | |Viewed eyes with otoscope. PL: “Look better.” |length differences even after Mrs. M told PL about it.|
| | |Looked at teeth. PL: “She looks like she may have some cavities or discoloration up there.” | |
| | |Her previous w/c could tilt back, but this one does not in order to better propel herself. |Darkened areas and uneven edges observed on baby |
| | |Recommendation for chair adjustment though since Pt. seems more comfortable sagging forward. |teeth, in front. |
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|12-16-10 | | | |
| | | |Patient remained fully dressed in her street clothes |
| | |Performed isometric movements with neck. PL: “Okay, good.” |for Physical Examination; he did remove patient’s |
| | | |shoes and socks at one point. |
| | | |PL needed to encourage K to perform these; she was |
| | | |hesitant. PL did not assess for painfulness with this|
| | | |movements as Pt. was reluctant and he reassured her |
| | | |that he was not going to hurt her. Did not perform |
| | | |axial loading. |
| | |Pt. able to shrug shoulders, raise arms out to side then move to front. PL: “Okay, her shoulders| |
| | |are a little weak.” |Right arm sags more than left arm with these |
| | | |movements. |
| | |Performed Isometric movements with the upper extremities assessing flexor and extensor muscle | |
| | |groups bilaterally. PL: “Good, girl.” | |
| | | |Did not perform deep tendon reflexes on her upper |
| | | |extremities. Did not perform dermatome assessment of |
| | |Hand grasps assessed without comment, then wrist extensors L>R. |upper extremities. |
| | |Thumb to finger dexterity for right and left hand. | |
| | | |Difficult to view the performance of these tests. |
| | |Assessed for movement of legs and feet; negative movement. Assessed for sense of touch on feet. |Unable to view from my position |
| | |Negative | |
| | | |Difficult to observe from my vantage point, but Pt. |
| | | |observed shaking head “No” when asked if she can move |
| | | |her legs or if she has feeling in them. However, PL |
| | | |did not use pin prick or soft touch over various |
| | | |dermatomes on the lower extremities |
| | | |Unable to observe reflex response. Clothing remained |
| | |Assessed deep tendon reflexes in lower extremities. PL: “She doesn’t look like she has a lot of |on and pt wore long pants. |
| | |decreased tone.” | |
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|12-16-10 | |Nasal swab and mouth swab + for MRSA. |Spasm observed. |
| | |Looked at spine and back area, no comment. | |
| | |Removed shoes to assess movement, noted “jerk” of left foot. Mrs. M. concurs that this happens | |
| | |at home as well. | |
| | |Viewed shoulders from the front, noted that left lower than right in resting position. Suggests | |
| | |use of the body jacket to prevent a bad curvature of the spine. |K shakes head, “No.” |
| | |Pin prick test on left abdominal area: Negative for pain. |K shakes head, “No.” |
| | |Pin prick test on left upper abdominal area: Negative for pain. | |
| | |Pin prick test just above left nipple line: Pt. cringed and pulled back in her w/c and responded |K nods, “Yes.” And pulls away from the stimulus. |
| | |that it was painful. | |
| | |Asked to propel her w/c towards PL. Able to move 3-4 feet without difficulty. Moaned, and then | |
| | |did move it forward. | |
| | |Request to straighten right arm out to the side once more. | |
| | |PL: I have really enjoyed meeting you and meeting her, you are doing a very good job with her. I|K did an excellent job in performing those tasks asked|
| | |mean it, she is really coming along. You’re really doing it she is really coming along. She is |of her. Her parents too, gave their best efforts in |
| | |very well taken care of and a very nice little girl! |providing accurate information to PL. |
| | |Finished. |Physical Exam: ~30 min. |
| | | |History 32 min 31sec |
| | | |Total Time for Exam: ~63minutes |
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|1237PM | | | |
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