. Children's Hospital Los Angeles Patient Name: 4650 Sunset Blvd. MRN: [.03 CA 90027 Ch"dren,S DOB: (323) Hospital Sex: M35 ANGELES Patient Type: We Trenl Kids Better Financial Admit Date: 1 1/26/2012 Discharge Date: 12/3/2012 Physician IP Notes Document Name: History Physical (IP Physician) Signed By: Signed Date/Time: History Phvsical DO NOT USE PROHIBITED ABBREVIATIONS Chief Complaint: Abdominal distension, chronic constipation for 8 months, admitted for manometry/dysmotility evaluation History of Present Illness: a 15 y/o, previously healthy female who has had chronic complaints of abdominal distension and poor stooling/constipation since early April of 2012 which was preceeded by a few days of persistent diarrhea. Patient states her abdomen becomes more distended after eating even very small amounts of food and paradoxically after passing a bowel movement. She continues to have abdominal distension even when stooling seemingly easily with liquid stools at times. Patient is competitive in gymnastics and had repeatedly fallen on her abdomen while trying releases for two days prior to onset of her no other trauma noted. Multiple admissions to CHOC, Loma Linda University and Cedars-Sinai has revealed h/o intermittent bladder distension/retention, minimal improvement from bowel cleanouts, high-risk genotypes for celiac disease, negative IBD labs/biopsy results, and L5 dysraphism/spina biflda occulta without spinal cord involvement. She has adopted a gluten free, low-residue diet only eating boiled chicken most days. Over the past month, her abdmonal distension has continued to worsen to the point of her family stating she "looks like she's 9 months pregnant" today. Admitted today for cleanout/evaluation prior to dysmotility studies/manometry scheduled for Wednesday 11/28. Review of Systems: She complains of significant fatigue since onset of the Had initially lost some weight but over the past month family notes generalized swelling and worsening abdominal distension. She has had to buy larger and even maternity clothing over the past few weeks. No complaints of dysuria. No urinary incontinence but does complain of urgency, having to go immediately when feeling sensation of a full bladder otherwise she may have an accident. Does complain of occasional parasthesias within the "saddle distriubtion" that occur in all positions. Occasional shooting sharp pains in posterior legs down to her calves. Afebrile. No joint pains, no problems walking. Does complain of frequent oral ulcers and cold sores on tongue and roof of mouth. Full ROS otherwise negative. Past Medical History: Previously health h/o ossible EBV infection ~2 years prior. Previous admissions' ce beginning in April 2012. Patient wit at etic car iovascular system, in past HR during sleep has been as low as 37. Did have menses x1 only, none since (last was over 18months ago). Past Surgical History: Has undergone EGD/colonoscopy, and anorectal manometry in the past few months since beginning of Developmental History: Appropriate Nutrition: Gluten free, low-residue diet, eats mostly boiled chicken. Allergies: No known allergies Home Medications: Print Date: 12/ 19/20l2 101-17258 AM Attending Physician: Printed By: -- Service: Inpatient Surgical Service Page 1 of4 Patient Type: Patient Name: Financial MRN: Admit Dt: l/26/2012 DOB: Discharge Dt: 12/3/2012 Sex: Female Physician IP Notes Document Name: History Physical (IP Physician) Signed By: Signed Date/Time: 1 1/26/2012 21:07:15 Magnesium citrate 100--150mL PO constipation Neomycin 250mg PO BID Immunizations: Up to date per report Family History: Father with irritable bowel Maternal aunt with h/o colon cancer that required resection at age 45. Social History: Lives at home with mother and father. Highly competitive gymnast. PHYSICAL EXAMINATION Growth Parameters Weight: 52.3 kg (11/26/12 10:43) Weight Percentile: 45% Height: 158 cm (11/26/12 10:43) Height Percentile: 25% Head Circumference: Circumference Percentile: Vital Signs TMAX: 36.40 (11/26/12 11:58) Temperature Route Oral (11/26/12 12:00) Temperature 36.4 deg (11/26/12 12:00) Heart Rate 57 (11/26/12 12:00) Respiratory Rate 24 Breaths/Min (11/26/12 12:00) Systolic Blood Pressure 98 mm HG (11/26/12 12:00) Diastolic Blood Pressure 63 mm HG (11/26/12 12:00) General Appearance: Awake, alert, pleasant and cooperative, NAD HEENT: PERRL. EOMI grossly. Sclera clear. OP clear. Neck: Supple. No LAD. Chest: Symmetrical excursion. Respiratory: CT AB. No w/r/r. Cardiovascular: Bradycardia at 50, regular No r/m/g. Clear s1, s2. Pulses CR<2seconds. Abdomen: in upper quadrants, none in lower quadrants. Significant distension, tense but not firm. Liver edge auscultated at 4-5cm below costal margin at MCL. No splenomegaly. No CVA tenderness. Diffusely tender to gentle palpation. GU: Normal anal wink, decreased rectal tone, no masses or stool within rectal vault. Extremities: Minimal, non-pitting edema of legs and arms. No cyanosis. WWP. Neurological: CNII-XII grossly intact. MAESS. Normal gait, normal toe-walk, heel-walk, and tandom--gait as well. MS +5/5 bilateral dorsiflexion, plantarflexion, knee extension. DTR's 2+ bilateral patellae and achilles, no clonus noted. Skin: No rashes, no petechiae. Musculoskeletalz No joint swelling, normal ROM throughout. +lumbar Iordosis Labs (last 24 hrs) Print Date: Attending Physician: Printed By: Service: Children's Hospital Los Angeles, 4650 Sunset Blvd., Los Angeles, CA 90027, (323) 660-2450 Stirgical Service Page 2 of 4 Patient Type: Patient Name: Financial MRN Admit Dt: 1 1/26/2012 DOB: Discharge Dt: 12/3/2012 Sex: ema Physician IP Notes Document Name: History Physical (IP Physician) Signed By: Signed Date/Time: 11/26/2012 2 1 Chem Panel (11/26 12:35) 140 I 105 22 /76 Ca_9 5 4.1 I 25 I 0.68 Anion Gap: 10 Bilirubint 0.9 Magnesium Lvl: 2.0 AST: 32 Phosphorus: 4.8 ALT: 33 Protein Total: 7.9 Alk Phos: 93 Albumin: 4.6 Preliminary Micro Positive Micro (Iast36 hrs) Ngative Micro (last 36' hrs) None None None ASSESSMENT: 15 y/o female, previously healthy with now 8 months prolonged abdominal distension, constipation, fatigue, and generalized edema. Additionally, patient with recurrent neurogenic bladder, occasional parasthesias of saddle distribution, and sharp pains through sciatic nerves bilaterally. Prevous imaging showed L5 dysraphism without spinal cord involvement but will evaluate for spinal cord involvement for neurogenic bowel and bladder. Patient with significant gastric/gut dysmotility, admitted for cleanout and evaluation for motility. PLAN: - Primary plan per GI service - KUB obtained on admission: reviewed showing likely full bladder, some stool in rectum and descending colon, non- specific bowel gas pattern. - NGtube to be placed, golytely to be run at 200ml/hr increase by 100ml/hr to goal of 400ml/hr -- IVF at 1x maintenance -- Chem 14, magnesium, phosphorus levels obtained on admission as above -- Red--robbins rectal tube to be placed to assist in clearance - Bladder scan revealed 780mL without sensation to void: will place foley - versed PO for anxiety with foley placement - MRI with contrast of lumbar spine to evaluate spinal cord -- Consider Neurosurgery vs neurology consultation depending on MRI findings - Okay for clear liquid diet today - Scheduled for manometry studies Wednesday 11/28 - IV zofran 7.5mg q8hours around the clock - Hold home neomycin -- consider Thyroid studies and nutrition labs if not previously completed Discussed at length with patient, family, bedside RN and GI service Discharge Criteria: Mannometry completed, cleared by Gi service Print Date: 12/19/2012 10:47:58 AM Attending Physician: Printed By: Service: Inpatient Surgical Service Children's Hospital Los Angeles, 4650 Sunset Blvd., Los Angeles, CA 90027, (323) 660-2450 Page 3 of 4 Patient Type: Patient Name: Financial MRN: Admit Dt: DOB: Discharge Dt: 12/3/2012 Sex: Female 4% A Chemistry Urine Chemistry Date 11/30/2012 12/2/2012 Time 14:25:00 Ref Range Units Tot Vol SO 120 0; Creat -- so 0 34.2": - t2o.o--32o.01 mg/t1L -- 7.7 [33-29.5] meg/24hr Uroporph 5.4 Ilep-COPorpl1yrin See 6.8] meg/24hr HepCarPorph See Comment - 4.6] R3 -- See Comment Rm' 0.9] meg/24hr HexaCarPorph NOT L)li'l'liCTED hvrin - See Comment "ml OR 4.7] meg/24hr . - Pent-aCarPorph See Comment - OR 3.0] R6 -- 64.4 "1 OR 155] meg/24hr Coproporph 45.8 - [1 18-11172] - 72.1 [12-190] meg/24hr Interpretation 24hU See Comment R701 Total Porph 51.2 - [16.4-121.5] Interpretation 11 See Comment - R8 R1: 11/30/2012 (Creat - SO O) Test Performed at: Quest Diagnostics Valencia Nichols 7.7027 Tourney Road Valencia, CA 91355-5386 Peterson MD R2: 12/2/2012 14:25:00 Result is below reportable range for this analyte. R3: 1 1/30/2012 11) Result is below reportable range for this analyte. R4: 14:25:00 Result is below reportable range for this analyte. R5: l4:25:0() Result is below reportable range for this analyte. R6: 11/30/2012 18:00:00 (PentaCarPorph U) Result is below reportable range for this analyte. R7: 12/2/2012 (lnterpretation 24hU) All tested were within the normal range. Print Date: 2 9 7 '43:19 AM Attending Physician: Printed By: Service: Inpatient Surgical Senice Children's Hospital Los Angeles, 4650 Sunset Blvd., Los An gcles, CA 90027, (323) 660-2450 Page 4 of 24 Patient Type: - Patient Name: Financial MRN: Admit Dt: 1 1/26/2012 DOB: Discharge Dt: 12/3/2012 Sex: Chemistry Blood Chemistry Date 1 1/26/2012 Time 12:35:00 Ref Range Units Sodium 140"-' 1135-1451 mEq/l. Potassium 4.1 "3 mEq/I. Chloride 105 "3 ms. 107] co2 Total 25 "3 [2230] Anion Gap [5-151 mF.q/I. BUN 22 [421 mg/dl, Creatinine 0.68 "3 mg/dL Glucose Level 76": [60-l 15] mg/dL I 1.6-2.3] mg/dl Calcium 9.5 "3 I mg/dl, Phosphorus 4.8 "4 mg/dL Protein Total 7.9 "2 g/dL Albumin [32-4.51 g/dL Bilirubin Total 0.9" 10.1-1.3] mg/dl, AST 32 "3 [15-46] ALT 33": [3-35] Alk Phos 93": 130-250] O2: Chem 14 During start please 03: MG During IV start please P04 During IV start please Toxicology Date Ti me Lead Urine Arsenic Mercury Urine I 18:00:00 See Comment See Comment R10 See Comment Ref Range Units Print l)ate: Printed By: 12/19/20! 2 AM Attending Physician: Service: Inpatient Surgical Service Children's Hospital Los Angeles, 4650 Sunset. Los Angeles. CA 90027, (323) 660-2450 Page 6 of 24 Patient Type: Financial Admit I)t: Discharge Patient Name: MRN: DOB: Sex: Dt: 12/3/2012 Toxicology R9: R10: R11: 1 1/30/2012 (Lead Urine) Unable to calculate result since analyte concentration is below detection limit of this method. Nonexposed Adult: I0 meg/g crcatinine 1 1/30/2012 (Arsenic U) Unable to calculate result since analyte concentration is below detection limit of this method. Nonexposcd Adult: or 35 meg/g creatinine Biological Exposure Index (end of shift/work week): or: 50 meg/g crcatinine 1 1/30/2012 l8:00:00 (Mercury Urine) Unable to calculate result since analyte concentration is below detection limit of this method. Nonexposed Adult: or 4 meg/g creatinine Biological Exposure Index (preshilt): or 35 meg/g creatinine Female Print Date: Printed By: 12/19/2012 10:43:19 AM Service: Attending Physician: Inpatient Surgical Service Children's Hospital Los Angelcs. 4650 Sunset Blvd, Los Angeles, CA 90027, (323) Page 7 of 24 Patient Type: Financial Admit Dt: Discharge Dt: 1 1/26/2012 12/3/2012 Time 18:55:00 Date I 1/30/2012 Rel' Range T4 Free 1.17 TSH Patient Name: MRN DOB: Sex: Female End0cL_ri_ne4__% Tests Units ng/dL Print Date: Printed By: 10:43:19 AM Attending Physician: Service: lnpilildlii t\llI'glCH| Children's Hospital Los Angeles, Sunset Blvd., 1.0: Angeles, CA 90027, (323) Page 8 of 24 Patient Type: Patient Name: Financial MRN: Admit Dt: 1 1/26/2012 DOB: Discharge l)t: 12/3/2012 Sex: Female . Bi0ch?mi?a1Gen?tiCS Date 1 1/30/2012 Time 18:55:00 Ref Range Units Vitamin 6.98 [533-18.54] mg/L Vitamin (Beta Gamma) 1.18 [0.26-4.00] mg/I. Print Date: 2 I9 AM Attending Physician: Printed By: Service: npzment . urgiczi Service Children's Hospital Los Angelcs, 4650 Sunset Blvd., Los An CA (323) 660-2450 Page 9 of 24 Children's Hospital Los Angeles Patient Name: 4650 Sunset Blvd. MRN: Los Angelcs, CA [en's DOB: (323) Hospital 1 Sex: 105 ANGELES Patient Type: We Treat Kids Better Financial Admit Date: 1 1/26/2012 Discharge Date: PT -OT --Speech Pathology Audiology Document Name: Note Signed By: - Signed Date/Time: 12:42:38 Physical Therapy Discharge Summary DATE OF DISCHARGE: 12/03/12 REFERRING PRECAUTIONS: Standard EQUIPMENT: CR monitor, Pulse Ox, PIV INITIAL STATUS: Per PT evaluation dated 12/02/12 per -PT "is a 15 y/o, previously healthy female who has had chronic complaints of abdominal distension and poor stooling/Constipation since early April of 2012. Patient is competitive in gymnastics and had repeatedly fallen on her abdomen while trying releases for two days prior to onset of her no other trauma noted. She has adopted a gluten free, low- residue diet only eating boiled chicken most days. She is s/p clean out with golytely for motility sudies on 11/28/12. KUB from admission showed moderate fecal load and no obstruction. Pelvic US shows bladder distension, abdominal US shows minor RLQ fluid; lumbar spine wnl. s/p colonic manometry ll/28, antroduodenal, anorectal manometry 11/29 . Per ortho note: radiographs: accentuation of lumbar lordosis with neg sagittal balance on C7 plumb line no spondylolistliesis appreciated. MRI: no evidence of spinal cord compression or forarninal compression" Possible autonomic neuropathy." SUMMARY OF TREATMENT: Please see treatment note dated 12/04/12 for in-depth detail. Treatment limited 2/2 short inpatient acute stay, pt received modalities (ice, heat), ST to abdomen, and paraspinals, stretching, therex, and ambulation. FAMILY evaluation "T11er ex included: ankle alphabet, heel slides with adduetion t.o stretch lateral hip, and pelvic tilts. Pt. is extremely tight through her low back with minimal movement from excessive lordosis into netural pelvis. Also note tremerous feel to contraction in abdominals and glutes. Pt. provided with ther ex handout" This PT instreted dad in daily STM to paraspinals, dad dcmo'd appropriate self--return. This PT also instructed pt in self massage to abdomen. REASSESSMENT: Remains unchanged 2/2 short inpatient stay, and pt reporting same amount of pain to abdomen. STATUS OF GOALS: Short Term Goals: 2 weeks 1. Patient will participate in 15-20 min ofther ex MET 2. Patient will ambuate without increased pain 250' MET Print Date: 12/ 19/2012 10:41 :29 AM Attending Physician: Printed By: Service: Inpatient Surgical Service Page 1 of2 Patient Type: - Patient Name: Financial MRN: Admit Dt: 1 1/26/2012 DOB: Discharge Dt: 12/3/2012 Sex: liemale PT --OT --Speech Pathology Audiology Document Name: PT Note Signed By: Signed Date/Time: l2/7/2012 12:42:38 3. Patient and her parents will be independent with bed side/home exercise program MET Discharge Goals: at time of 1. Patient. will tolerate 30 minutes of ther ex and high level balance activities in order to participate in age appropriate play. Not Nlet 2. Patient and family will be independent with home exercise program to promote greater independence in mobility and strength. Not Met 3. Patient and family will be familiar with outpatient PT referral for ongoing assessment and treatment of gross motor needs. Not l\'Iet Discharge Goals not met 2/2 short inpatient stay. Pt has been referred to autonomic neuropathy specialist at UCI, and will hold off on outpatient PT referral at this time. REASON FOR DISCHARGE: Pt discharged with plan to be referred to autonomic neuropathy specialist at UCI. PLAN: Pt to follow up with autonomic neuropathy specialist at UCI. Print Date: 12/ 9/2012 :29 AM Attending Physician: Printed By: -- Service: Inpatient Surgical Service Children's Hospital Los Angeles, 4650 Sunset Blvd., Los Angeles, CA 90027, (323) Page 2 ol' '2