T-495 P0001/0007 F-414 07-23-M8 10:48 FROM- TCH IbasCMdmt Ro^ttal' Fax Public Health Pediatricd Child Abuse Pediatrics 6621 PanniD,Suite A 275 Houston,TX 77030 [Pick the date] PAGES:..,.7 COMMENTS? - ^h>i^ If you have any questions, please feelfree to contact me at the above,number. Thanks in advance, □URGENT Q FOR REVIEW Q PLEASE COMMENT PGR YOUR RECORDS Disclaimer: This facsimile contains privileged and confidential information only for the use of the specified individual or entity named. If you or your employer are not the intended recipient of this facsimile or any employee or agent responsible for delivering it to intended recipient, you are to hereby notified that any unauthorized dissemination or copying of this facsiinUe or the information indicated in it is strictly prohibited. If you have received this facsimile in error, please immediately notify the pei'son named above by telephone and return the original facsimile to use at the abm'e address by mail. PACE t/7'RCVDAT 7/29/20171lQlS^lSir(^£)iEti0£i^1sflQ37sS^QMll* CStO^' OuOilOiA3t62 07-23-'18 10:48 FROM- TCH T«»rchad.«.', Patient's Name + T-495 P0002/0007 F-414 REGARDING INJURY TO A CHILD ■ . 00»» XNMlf u C8N1W1814360 IIIUllllllfjmHillllllll nal-A _ Date of Birth .Admit Date 1. History Given of tnJury/Cohdltion by Parent, Guardian or Accompanying Adult: \i\Y<\6e\^ a-Pf of a. fbWAV\(g Uwn 2. Detailed Description of Child's Medical Condition - Diagnosis: 6^vi l Cpfii^rie^tofwnM L\a\eecUn^ Cbiee^Utn'j i» hoHy (fy\ COin^^efc , ryiodfifocAj of- hwyi), of bofh / 3. Physician's Impressions Relating to the Condition of the Child and Prognosis: pypkjnoGl^ ffp \pr^y\ irt/lfh me)sp]^v\ees( jyywW^^ iy\ \^\cM f^ot i^f Injvuo^ . If non-moMe. re^medl /nh> -the Satm 6r>\/iyOinrti^int ,-+Vidre iQ yi<>k ft/ fvilUn^/ Could permanent physical damage or death result from failure to obtain Immediate medical treatment? JO.Yes No If no, why? 5. In your professional opinion Is the child's condition consistent with the family explanation? _Ye5 6. Is IX. No If no, why? wrtni -e +Vie r0po/t^ pager # Attending Physician's Subscribed and sworn to before me, the undersigned notary public, on this Printed Name Phone # day of -_20 IL .....1 «>>*!»««>*■ tliil GAWIUROStiiiSXiRUSGt LI Notary Public In and For Harris County) S\ NOTARY PU8LA: IDViaOSSMOS Slate Of TdXSB OonmecpkOS^MCpO rj"- M*t 2N/3oia CS«' 891614360 PACE in * RCVD AT 7/23/2916 Cm* llllllilfllil] f ill{ I«^SiJGK3entiJBiR£9£)!j>^:3AX^1^4/tJS!E:276l8* ceori-' £U3[£)3i6l>3>l8 07-23-'18 10:49 FROM- TCH T-495 P0003/0007 F-414 6RiQMt;idASbN'b^"*' oofr vnm a u V C6N:891614360 Age itm w Date Occurred Sex TSonasssssr Diitfjiiniiiiiiiiiiiiiiiii Witness Date Observed Case Name Vvev^owV^^^ Photographs Taken; □ Yes □ No \\1 left: occ:if\X(X'\ Please indicate In RED ink on this diagram the area . and type of damage and bruias color (i.e.. E1). Check off all observed injuries indicated by witness below. A. BONES □ I. Simple fiacturc □ 2. Open fracture □ 3. Multiple fracture □ 4. Dislocation □ S.Olhcr E. BRUISES & WOUNDS □ I. Welts □ 2. Faded Bruise □ 3. Obvious Britlse Q 4. Scratches a 5. Cuts □ 6. Open Wound B. BURNS □ 1. Cigarette □ 2. Scalding □ 3. Chemkai O 4. Flame □ 5. Electrical 6. Branding □ □ 7. Immersion □ 8. Other 1. BRUISES & WOUNDS Bruise Colon □ 0-2 days > swollen^tender * □ 0-5 - red,blue,purple □ 5«7 days - green □ 7-10 days • yellow □ 10-14 days-brown □ 7. Gunshot Wound □ 8. Inflicted by: □ Hand HASINJURYRESULTEDIN Q Foot □ Pennanent Damage? Q Instrument □ Death of the Child? PACE OT • RCVD AT TOSCOIB1l:]^EI^grBl C. SEXUALABUSE D. INTERNALINJURV □ 1. FondJing □ 2. Anat Bnoy □ 3. Vaginal Entry □ 1. Imemal Bleeding □ 2. Organ Damage □ □ 3. Intestinal Damage □ 4. Muscle Damage 4. Coltua □ S. Oral Stimulatsn □ 6. Other Organ □ 5. Other F. HEAD INJURY G. INJURIES □ 1. Brain Damage Q I. Dlsmembeiment □ 2. Concussion . Skull FractuR □ 2. Exposure □ 4. Dental Damage □ 4. Poisoning □ 5. Sprains □ 5. Broken Bone a 6. Split Up □ 7. Black Eye , L R 8. Subdural Heiratoma 0 3. Malnutrition □ 6. SufTocation □ 7. Hemorrhage □ 8. Other (specify) □ 9. Other • ®3?6V(ic6I0:T' OUlQhO T-495 P0004/0007 F-414 07-23-'18 10:49 FROM- BRIGHT.MASON DEAN TEXAS CHILDREN'S HOSPITAL 6621 Fannin St DOB; 2/4/2010, Sex: M Houston TX 77030 AdtD! 7/18/2018, D/C: MRN 3002233446 Tfexas ChUdmi's Hospital' Mason Dean Bright 'mrN:3002233446 Description: Male DOB: 2/4/2018 Depenmen] Wt Surgeiy Care MD Progress Note by Shanghvi, Dhvani R, MD at 07/21/18 1257 Author Shanghvi, DhvanI R, Service: Public Health MD Pediatrics Filed 07/21/10 1444 DflieofService 07/21/10 1257 Editor; Shanghvi, DhvanI R, MD(FELLOW) Author Type; FELLOW Status: Allfisted Addendum CDsiflner; Bachim. Angela N, MD at 07/21/18 1503 Attestation signed by Bachim, Angela N, MD at 07/21/18 1503 I have examined the patient. I have reviewed, discussed and agree with history, exam assessment and plan as documented by CAP fellow Dr. Shanghvi. I have reviewed the clinical labs, radiological and other medical tests, and discussed results with appropriate personnel. Discussed hematology work up plans with parents, Including that those tests will take time to result. Discussed ophthalmology findings with parents. Specifically discussed that the the diffuse (yet not fully out to the periphery) RH in the L eye are out of proportion to what would be expected with a simpfe short fall. Discussed that this Is in context of RH healing every day since event that caused Injury. Discussed that there are still 2 skull fractures that would have needed 2 separate impacts to occur, and only a 1-impact explanation thus far In a non-mobile Infant. : Discussed that the Intracranlal hemorrhage/fluid collBctionB are slill more extensive than would be expected from a short fall. Parents had any concerns and question both over what to expect with CPS and regarding what to expect for Mason's prognosis. Impression; Concerning for Inflicted Injury In addition to Dr. Shangvi's plan, Mason's sibling wit! also be evaluated in CRN clinic. Please do not diacharge until CPS has given dispo. Angela Bachim, MD Child Protection Team Attending Pager 2290 Child Protective Health Progress Note Subjective Rriahf PAce^rr'RCVDAT rrzwoiB T-495 P0005/0007 F-414 07-23-'18 10:49 FROM- TCH Mason is a previously healthy 5 month old male who presented after a reported fall from a lawn chair onto a concrete driveway and was subsequently found to have a left parietal and occipital skull fraoturee as well as bilateral subdural hemorrhages. Per parents. C-spine was cleared this AM and Mason has been slightly more comfortable since C-collar was removed. He continues to have emesis with feeding and underwent a repeat CT today. They have been unable to recall any further instances of significant trauma or accidental Injuries to Mason's head. jCurrent Medicattohs Active Scheduled Medications: l*Physlcal Exam Weight: 9.1 kg(20 lb 1 oz) Height:69 cm (2' 3.17") Head Gin 46 cm (18.11") 89 %ile(2= 1.25) based on WHO(Boys, 0-2 years) weight-fbr-recumbent length Normalized weight-for-stature data available only for age 2 to 5 years. 93 %ile(Z-1.51)based on WHO(Boys. 0-2 years)weight-for-age data using vitals data using vftals from 7/19/2018. from 7/19/2018. >99 %ile (Z::^ 2.52) based on WHO(Boys, 0-2 years) head circumference-for-age data using vitals from 7/19/2018. Temp:98 T (38.7 ^C) Pulse; 85 BP: fJ) 121/84 Resp: 24 General: alert, no acute distress, but fusses with examination HEENT: Head: normocephalic, anterior fontanelie full Eyes: Pupils equal, round, reactive to light. Sdera white, no subconjunctivai hemorrhages Ears: normal, no lesions or deformities, pinna are uninjured Throat: Moist mucous membranes, no injuries to the labial or lingual frenulum. Chest/Respiratory: No respiratory distress, symmetric and clear to auscultation bilaterally, No palpable abnormalities to the clavicle or rib cage Cardiovascular Regular rhythm with quiet precordium. normal SI and 82. and no murmur, rub, gallop, or dick. Abdomen: soft, non-tender, non-distended, no masses, bowel sounds normal, no hepatomegaly Muscidoskeletai/Extreinities: No palpabie bony nodules In the arms and legs, moves all extremities vrell, no gross deformities Skin: no rashes, petechiae. lesions or ulcerations Neurologic: alert, age appropriate, moving all extremities ^Results 7/18 Head CT: Minimally displaced linear left parietal and frontal bone fractures traversing the coronal suture with overlying scalp hematoma. Mlnhnally displaced left occlpftai bone fracture with overlying scalp swelling. Right subdural hematoma. Rriaht PAOES/T"RCVD AT r/23/20« II SI 18* II ejoQL'ceiirf'Di at 7/2. 07-23-'18 10:50 FROM- TCH + T-495 POOOe/0007 F-414 7/18 CT C-spine; Mild asymnietfy of the diBtance between the occipital condyies and the C1 lateral masses. No Itgamentous injury. 7/19 MRI Brain/C*spine: Muitlfocal subdural hemorrhages along bilateral cerebral hemispheres, bilateral tentorium, and anterior aspect of the foramen magnum and upper cervical spinal canal. Small subdural hematoma along the anterior aspect of the foramen magnum and upper cervical spinal canal. Approximately 3 punctate foci of reduced diffusion in the left frontal and parietal cortex consistent with small areas of ischemia. 7/19 Skeletal Survey: No additional fractures noted. 7/20 Ophtho exam: Bilateral retinal hemorrhages. Right eye: flat, small hemes along inferior arcade. Left eye: small preretinal hemorrhage, diffuse small retinal hemorrhages surrounding the macula, but not extending all the way out to the periphery(refer to visual depiction In Opthalmology consult note). 7/21 Head CT: Evidence of increased ICR with widening of the fracture lines In the left frontal, parietal, and occipital calvarium. Partial resorption of hyperdense component of right subdural hemorrhage, but Interval enlargement of bilateral hypodense subdural fluid collections. No midllne shift. New subdural hemorrhage In the supra and Infiralentorial compartments. *lmpre8Slons Conceming for abusive head trauma Findings: 1. Left parietal and frontal bone fracture 2. Left occipital bone fracture 3. Multifocal subdural hemorrhages along bilateral cerebral hemispheres and txlateral tentorium 4. Subdural hematoma along foramen magnum and upper cervical spinal canal 5. Punctate foci of reduced diffusion In the left frontal and parietal cortex 6. Few small retinal hemorrhages contained to the posterior pole in the right eye 7. Diffuse smaif retinal hemorrhages and one small preretinal hemorrhage In the left eye, not fully extending to the periphery PAnalysis/Pfan Mason Is a previously healthy 5 month old male who presented after a reported fall from a lawn chair onto a concrete driveway and was subsequently found to have a left parietal and occipital skull fractures as weH as bilateral subdural hemorrhages and bilateral retinal hemorrhages. Above findings were reviewed with both parents today. The single short-fat! event described by Mason^s parents could feasibly account for his parietal fracture: however, no explanation Is provided for his occipital fracture. In addition, tNs degree of extensive Intracranla! bleeding and bilaferBl retinal hemorrhages would not be expected to occur secondary to a simple fall. These unexplained findings raise concern for possible Inflicted Injury. 1. Appreciate Hematology recommendations re: further bleeding workup. Will follow-up results. 2. Patient will need a referral to Child Protective Health clinic CPHC(832-824-6522)for follow up examination and repeat skeletal survey In 2 weeks'time. 3. Please do NOT discharge Mason Dean Bright until Child Protective Services(CPS) provides a disposition. Dhvani Shanghvi, MD Child Protection Team Fellow PGY-4 07-23-'18 10:50 FROM- TCH + T-495 P0007/0007 F-4U - -to- • — • Pgr; 14472 Revision Hjst£ry y Palienjt Informa^^^^^ Bright. Mason Dean [3002233446] lOilSBU^CKBtRCH.LN TOMBALl/tX'77375 " Chart Review Routing Histoiy No Routing History on FRe DOB ""Home Phone iAforkPtone 02/04/2018 404-391-3019 ' Mate DFPS PRODUCTION PT.l - 000369