M.D.

Re: Baby C Consultative Examination The above patient is an approximately twenty six month old infant boy seen in my office today, he was accompanied by his mother Ms B. Ms B provided the medical information. Medical History Ms B stated that C,an ex-preemie, has poor muscle tone , he falls down a lot , he is currently receiving physical and occupational therapy three times a week for this hypotonia. He was reportedly born at thirty three weeks gestation, his mother says that after birth he was kept in the NICU for three weeks before he was discharged home on room air. Apparently as he grew older she noticed that he was lagging behind his developmental milestones when compared to his peers he allegedly rolled over and then sat at nine months, he stood after one year and walked at one and a half years. She is also concerned about his poor appetite and feels that he is underweight, she does not think that he has seen a Neurologist yet. There was no documentation to support any of the history provided. Birth History As mentioned earlier C was born at 32weeks gestation, although this does not correlate with his reported birth weight of 4lbs 8 oz. The pregnancy was said to be unremarkable up until early in the third trimester when the mother went to the hospital with a severe headache, she was found to have ? Pre-eclampsia and fetal distress . C was delivered by emergency C-section the same day,possibly because of the fetal distress. The history was not suggestive of a difficult perinatal course and there were no prolonged episodes of ventilatory support, he was reportedly kept in the NICU for approximately three weeks he did not need the ventilator,although he appears to have used a nasal cannula Ms X denies any history of IVH (Intraventricular hemorrhage) or NEC (Necrotizing enterocolitis), although it is possible that he had a PDA (Patent ductus arteriosus), which appears to have closed spontaneously or after the use of indomethacin, there was no ROP (Retinopathy of prematurity) Development At present C tries to kick a ball forward, he can remove some clothing , he can combine two words and use his own name to refer to

himself,according to Ms , he has a vocabulary of twenty words or more , and in the office when requested he was unable to point to six named body parts. He actually spoke in multi-word sentences, 'Mommy give me that, Mommy I got this All these milestones are achieved by the majority of children by the age of two years. His age corrected for prematurity would approximate to two years Family and Social History Essentially unremarkable according to the mother. Physical Examination C presented as a well nourished, active, well dressed child,he was initially rather shy but he responded to overtures from the examiner during the evaluation, he was anicteric, acyanosed, and afebrile . He was not in any acute respiratory distress. When asked to walk down the corridor he did so without any major difficulty Vital Signs Heart Rate 122/min Resp. Rate 20/min Wt 27lb (<5 %ile) Ht 37'' (<5%ile) (50%ile) [All percentiles corrected for prematurity] HEENT Pharynx Neck Chest Heart Abdomen Genitalia CNS MSS Spine Skin Temp 97.6F Head Circ.20 ''

Dolichocephalic, Pupils equal and reactive to light Normal tympanic membranes , no nasal exudate Normal no obvious hyperemia Supple no obvious thyromegaly No obvious deformities, clear to auscultation S1, S2 no murmurs. Full soft non tender, no sig. palpable organomegaly TSM I male Normal bulk and power in all limbs, no gross deficits Free range of motion in all limbs No obvious scoliosis No obvious neurocutaneous stigmata

Assessment 1)Growing ex-preemie 2)Mild hypotonia Recommendations C is already receiving the appropriate services, if corrected for prematurity his developmental milestones would approximate closer

to normal. He does not appear to have any severe functional impairment at this time. His prognosis looks very promising Yours truly,