CASE EXAMPLES - CEREBRAL PALSY CASE

Melissa Wingerd is a five-year-old Caucasian female seen for evaluation in my office in Oviedo, Florida accompanied by her father Tony and her mother Nora. Melissa was referred for a rehabilitation evaluation by her attorney, Gregory Mose. The purpose of this evaluation is to assess the extent to which handicapping conditions impede her ability to live independently, handle all activities of daily living, and to assess the disability's impact on her vocational development status.

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Demographic Information:

Client Name: Melissa Wingerd; Social Security#: 378-42-9845; Address: 1306 Winding Waters Circle, Coral Springs, FL 33071; County: Broward; Closest Metro Area: Ft. Lauderdale; Phone: 954-224-1702; Birthdate: 3/23/99; Age: 5; Sex: Female; Race: Caucasian; Marital Status: Single; Birthplace: Deerfield Beach; Citizen: Yes; Elementary/Secondary Education: Maplewood Elementary (was in Pre-K) Starts Kindergarten in Fall; Employer at time of injury: Starts Kindergarten in Fall; Position/Grade: Transdisciplinary Program; Bilingual: No; Glasses: No; Dominant Hand: Right; Height: 41 1/2”; Weight (present): 40 pounds; Date of Onset: 9/3/98.

History: Melissa was born with Tetralogy of Fallot, hydrocephalus and cleft palate. She has a VP shunt in place and is developmentally delayed. She was conceived by invitro fertilization and implantation procedures. She was born by C-section delivery as one of a set of quadruplets. Her estimated gestational age was 31+ weeks. Records indicate that her Apgars were 7 and 8 at one and five minutes respectively.

Loss of Consciousness or Altered State of Consciousness: No.
Length of Unconsciousness or of Altered State: Not applicable.
Independent Recall: Not applicable.

Rehabilitation Program(s) [In/Outpatient Since Injury]: She was initially transferred from North Broward Medical Center to Broward General Hospital on March 24, 1999. She remained in Broward General until the end of April, when she went back to North Broward Medical Center where she remained for approximately one week. She was then transferred to Chris Evert Children’s Hospital where she stayed from 5/18/99 – 8/17/99. She began some OT and PT while in All Children’s. Discharge summary noted the following:

She was discharged with 12 hours per day of home nursing paid for by private health insurance for seven days after which Medicaid covered the costs. She began OT within a couple of months of returning home. OT came two times per week for thirty minute intervals. The home therapy stopped at age three when she entered the school program.

She began therapy at school under IDEA receiving OT three times per week, which continues currently for thirty minutes each session. She began receiving ST two times per week at one year of age for thirty minute intervals. It also ended at age three when school began. PT also began approximately the same time as OT, twice a week for thirty minutes each session. All therapies converted at age three to IDEA with the school program. PT and ST were also given at three times per week for thirty minutes each time. This also continues at this time.

Shunt surgery at five weeks of age. Revision done one week later. She had a shunt infection in November of 1999 with a revision and she had a shunt malfunction in May of 2000 with a revision. She has been clear since that time.

Cleft palate surgery done February of 2000. She has had follow-up Flap surgery done in relation to the cleft palate in February of 2004. She had hypernasality where air was passing out the nasal passage instead of across the vocal cords and it was hard for her to enunciate certain words. The doctor created a flap to prevent this from happening. Her tonsils had to be removed before the flap surgery could be done.

She had one heart surgery to correct the Tetralogy of Fallot. This was successful.

She has had repetitive ear infections and could not pass hearing exams, so in December of 2003 she had tubes placed in her ears.

She had eye muscle surgery done in December of 2003. This was to correct crossed eyes.

Prior Medical History: Not applicable. Birth onset.

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Chief Complaint(s)

Current Disability

Disabling Problems: (By client/family history and report. No physical examination occurred).

Nora: “My understanding with the hydrocephalus is she will have the shunt for the rest of her life. As a result, when she has a headache or a fever I watch a little closer because I never know if it is shunt related or not. As for the developmental delays, no one has been able to tell us what that will really mean and only time will tell. I know they are there because I have three others to compare her to. Her analytical skills, her reasoning skills, even the way she plays are just not like the other children. Melissa is consistently six plus months behind where the other children are in play activities even when she has the other children to mimic. I see a lot of discrepancies with her fine motor skills. Her sisters and brothers can write their names, while Melissa can spell her name, but she can’t even trace her name. Her siblings can color in the lines, but Melissa simply can’t. With some of her gross motor skills, she shows a problem with her balance. In hopping on one foot, riding a bike, using the trampoline, she has balance problems. In other skills, she is emerging but very much behind her siblings. She has constant problems with her asthma, especially with weather changes or if she develops a cold. She is being monitored on an annual basis for her heart, but right now everything seems to be going well. When she is a teenager, we may have to do stress tests. She tends to tire much more easily than the other children. She can’t keep up with the other children physically without a nap or without tiring. She interacts with adults better because of all her hospital stays and doctor visits. She does not do as well with peer group play.”

Observations: Melissa is very active and difficult to keep on task. She is on the edge of hyperactivity, but her parents note that she is no more active than the rest of her siblings and in fact tends to tire more easily than her siblings. She tends to be somewhat stubborn and defiant with her parents and is inconsistent with inhibit on command. She is resistant to parents instructions during the evaluation and overall is seen as a very active, five year old that is under limited control of parents. Her behaviors are likely to worsen as the gap between herself and age related peers continues to grow over time. Behavioral intervention strategies are recommended, with instruction to the parents strongly recommended, along with appropriate intervention strategies for Melissa.

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Developmental Delay

Seizure Disorder

Type: None.

Surgeries

Performed: Shunt and shunt revisions, tonsillectomy, tubes in ears, gastrostomy when she was a baby, strabismus surgery and cleft palate surgery.

Anticipated: Possible shunt revisions if malfunctions. 50% of strabismus surgeries have to be repeated.

Therapy/Education

Therapuetic/Educational Programs Since Onset: See rehabilitation section of this report.

Present Therapy Schedule: School program offers OT, PT and ST 3 X / week each, for 30 minute sessions.

School Program: Upcoming school year she will be in a multidisciplinary program at Maplewood Elementary. It is like a second year of preschool. They actually are in Coral Springs Elementary School district, but all four kids are going to return to Maplewood at least for one more year, so they can be at same school.

Summer School Schedule: Goes to daycare.

After School Care: Goes to daycare after school.

Transportation To/From School: Mom will take them to school and daycare will pick them up.

Daily Care

Current Attendant and/or Nursing Care: Parental care and daycare.

Bowel/Bladder Program: Potty trained. She will wear a pull-up at night.

Self-stimulating Behaviors: None.

Motor Skills

Bring Hands to Midline: Yes.

Grasp (Left/Right): Intact.

Grasp with thumb & forefinger: Yes.

Voluntary purposeful movements (upper & lower extremities): Yes.

Sit unassisted: Yes.

Hold head erect: Yes.

Roll front to back: Yes.

Roll back to front: Yes.

Pull self upright: Yes.

Drink from cup: Yes.

Drink from bottle: No.

Tube feeding schedule: No.

Ambulate: Wide based gait with some balance deficits.

Assist in dressing: Yes.

Perform household chores: No, not even at an age related level. It is difficult for her to follow multi-step instructions.

Perform personal hygiene: She can bathe herself with assistance.

Crawl: Yes.

Ascend/descend stairs: With hand-holding assistance.

Social Skills

Smile: Yes.

Laugh out loud: Yes.

Dintinguish family from strangers: Yes.

Demand personal attention: Yes.

Cognitive Skills

Imitate sounds: Yes.

Talk in 1 or 2 word sentences: Yes.

Follow simple 1 or 2 step instructions: She does best with one step instructions. With serial instructions, she will need things repeated.

Avoid hazards: She has no sense of hazards. She will run out into the parking lot.

Communicate wants and/or needs: Yes.

Attention to task: She has a short attention span.

Long-Term Care Options

Facility/Home Care: Home care.

Anticipated Treatments : Nothing scheduled as far as treatment interventions. She has her regular physician visits scheduled and those will continue.

Psychosocial Issues

Patient: See developmental assessment and testing. Mother indicates she gets along with peers in school. She feels she is social and has friends in school and daycare. She has a strong curiosity about what the other children are doing. She has some difficulty with siblings such as when they are coloring and she can’t stay within the lines and they don’t want her to color with them. She is resistant to trying new things in therapy. She finds them difficult and is resistant to things that are difficult for her to accomplish.

Family, Emotional Impact on Spouse/Children: Mother describes the parents as overwhelmed at times. She notes that Tony and she are divorced at this time and she shoulders the primary responsibility. Nora feels that having the four children with one significantly ill was a contributing factor to the divorce. “I worked a full-time job and then came home to my real job.”

Tony notes, “It is certainly getting better now, but it was very tough in the beginning. I don’t worry as much about Melissa now. It is a little easier now.”

Physical Limitations

Loss of Tactile Sensation: Tactile sensation is intact. She is very sensitive on bottoms of her feet.

Reach: Normal reaching ability with full range of motion.

Lift: She does not have the muscle strength to lift at a peer related ability. She can lift, but weight amount is limited.

Prehensile/Grip: Normal grip strength.

Sitting: Normal ability to sit. She does have difficulty sitting still for long periods of time.

Standing: She can stand at a age appropriate level.

Walking/Gait: She does walk with a somewhat wide based gait. She has some balance deficits. Gait is not smooth. Running is more difficult. She does fall frequently.

Bend/Twist: Bending and twisting at the waist is an emerging skill, but at this time she will primarily bend at the knees and stoop to pick something up.

Kneel: She can do this at age appropriate level.

Stoop/Squat: She can do this at age appropriate level.

Climb: She can climb stairs, but she needs standby assistance and usually hand holding. Descending stairs is much more precarious than ascending.

Balance: Balance deficits. Balance is fair, but improving.

Breathing: She has Asthma. Bronchial Pulmonary Dysplasia. When she gets a cold it compromises her breathing. Seasonal allergies. Nebulizer used during colds and seasonal allergies only. Mom estimates episodes requiring Nebulizer treatments about six times per year.

Headaches: She has recently complained of headaches. This was the first time she had ever complained of a headache. They went to ER and the shunt was checked and it was functioning well.

Vision: She has had eye muscle surgery for strabismus in both eyes. She does not wear glasses, vision tested and they feel she is near sighted but not bad enough to require corrective lenses at this time. Monitoring every 6 months.

Hearing: She has PE tubes in both ears. She has a mild hearing loss in both ears. Not sure what level. No need for correction at this time.

Driving: Possible candidate in the future. Will need handicapped evaluation.

Physical Stamina (average daily need for rest or reclining): She tires much more easily than her siblings. She has to have a nap.

Environmental Influences

Problems on exposure to:

Air Conditioning: No.
Heat: Yes, sweats profusely.
Cold: No.
Wet/Humid: Yes, Asthma.
Sudden Changes: Yes, Asthma.
Fumes: Yes, Asthma.
Noise: Yes, very short attention span in noisy environments.
Stress: No, very social child.
Other: She has more difficulty interacting with peers than she does with adults.

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Present Medical Treatment

Coral Springs, FL

Ft. Lauderdale, FL

Coral Springs, FL

Ft. Lauderdale, FL

Margate, FL

Over-the-Counter Medication(s): None.

Drugstore and Phone Number: Publix (954) 321-1095, Walgreen’s (954) 242-0432.

Assistive Devices: Equipment: Nebulizer, purchased 11/99, is in poor condition

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Medical Summary

Date of Medical Summary: 6/2/04

Melissa Wingerd is a 5-year-old Caucasian female who was born with Tetralogy of Fallot, hydrocephalus and a cleft palate. She was one of quadruplets conceived through invitro fertilization. She has a VP shunt in place and is developmentally delayed.

VERY LIMITED MEDICAL RECORDS. SEE CASE NOTES AND LETTERS IN CORRESPONDENCE SECTION OF FILE.

CHRIS EVERT CHILDREN’S HOSPITAL: 5/18/99 – 8/17/99; 1/6/01 – 1/7/01; 2/23/01; 3/18/01; 3/19/01 – 3/24/01; 8/8/01 – 8/13/01; 8/18/01: 8/23/01; 2/27/03; 9/15/03; 12/12/03; 2/11/04; 2/20/04 - 2/21/04

Chris Evert Children’s Hospital: 5/18/99 – 8/17/99
Transferred from Broward General Medical Center. History indicates Melissa was born via C-section delivery for quadruplets. Apgars were 7 and 8 at one and five minutes respectively. Estimated gestational age was 31+ weeks. Significant maternal history included maternal blood type A and Group B Strep positive. Pregnancy was significant for invitro fertilization with multiple gestation and a prenatal ultrasound that revealed hydrocephalus in quadruplet B. Delivery room resuscitation included intubation.

Melissa was transferred to Broward General Medical Center at 1-2 days of age with VP shunt in place. Her course was complicated by apnea of prematurity, which was treated with Theophylline. Melissa had a cleft palate and history of poor nippling with minimal gastroesophageal reflux. She had Stage I-II retinopathy of prematurity and Tetralogy of Fallot with pulmonary stenosis. She was transferred to Chris Evert Children’s Hospital for further management of Tetralogy of Fallot and evaluation of possible TET (?) spells vs. apnea vs. reflux. Hospital course was as follows:

RESPIRATORY/APNEA: Melissa was admitted on nasal cannula oxygen at 1/4 liter flow and weaned to room air shortly after admission. She was free of respiratory distress. Her initial chest x-ray revealed a boot-shaped heart consistent with Tetralogy of Fallot.

Caffeine was started for apnea of prematurity at 56 days of age and discontinued at 77 days of age, based on results of a sleep study. She had follow up sleep studies performed, which had findings consistent with GE reflux. Medical management for GE reflux was optimized and she was free of episodes of apnea. She persisted with infrequent, self-correcting bradycardia episodes.

Melissa was returned to NICU following her Tetralogy of Fallot repair, which was performed on 7/31/99 at 112 days of age. She had a persistent elevated left diaphragm noted on chest x-ray. Fluoroscopy was performed and showed no movement of the left hemidiaphragm. She was asymptomatic on unassisted room air with oxygen saturations in the mid to high 90’s. She had occasional tachypnea but had remained free of distress and the tachypnea was well tolerated. There was improvement with BID (twice daily) Lasix. Pulmonary service recommended outpatient follow up with no current need to plicate the paralyzed hemidiaphragm.

CARDIOVASCULAR: Melissa had Tetralogy of Fallot with pulmonic stenosis. On echocardiogram, she had Tetralogy of Fallot with right ventricle/OT (outflow tract) gradient of 70 mmHg (mainly valvular), no patent ductus arteriosus (PDA) and a small left pulmonary artery. Follow up echocardiogram showed a RVOT (right ventricle outflow tract) gradient of 93-100.

Cardiac catheterization was performed at 99 days and showed Tetralogy of Fallot with single mal-aligned ventricular septal defect, good branch pulmonary arteries, a patent foramen ovale (PFO), and normal coronaries. She had repair of Tetralogy of Fallot with infundibular patch, pulmonary valvotomy and subtotal closure of atrial septal defect. She had an uncomplicated post-operative recovery. She was extubated to nasal cannula oxygen on her second post-op day and weaned off pressors. She continued on Lasix and would require cardiology follow up after discharge. She also required subacute bacterial endocarditis prophylaxis.

RENAL: A neonatal post-Lasix renal ultrasound was performed and showed nephrocalcinosis. Nephrology was consulted and she was started on Diuril. Nephrology follow up was required in 3-4 weeks after discharge for a renal ultrasound.

METABOLIC: Melissa developed hypochloremic metabolic alkalosis secondary to chronic diuretic losses. She continued on potassium chloride and ammonium chloride supplements and would need electrolytes checked one week after discharge.

INFECTIONS: Melissa developed a fever at 102 days of age. Septic work-up was conducted and cultures were positive for Enterococcus Faecalis. A ten- day course of Ampicillin and Gentamicin was administered.

HEMATOLOGY: Due to anemia and congenital heart disease, Melissa required several transfusions with packed red blood cells. She continued on Poly-Vi-Sol with iron.

NUTRITION AND GI SYSTEM: Full feeding of 24 calorie breast milk with rice cereal was resumed at 56 days of age. Zantac and Reglan were continued for reports of minimal GE (gastroesophageal) reflux. A pH probe at 57 days showed moderate GE reflux. Upper GI and small bowel follow through was done at 70 days of age and showed slow gastric emptying but no obstruction. An OPMS (Oral pharyngeal motility study) was performed at 70 days of age and showed NP (nasopharyngeal) reflux and laryngeal penetration but no transglottic aspiration. Medical management of GE reflux was optimized with use of wedge pillow, thickened feedings, Cisapride, Reglan and Zantac. Follow up probe revealed no GE reflux on that management. Melissa was unable to nipple feed secondary to cleft palate and NP reflux. A PEG tube was inserted at 128 days of age.

CENTRAL NERVOUS SYSTEM: Melissa had history of congenital hydrocephalus of unknown etiology that was diagnosed by prenatal ultrasound at 15 weeks. She was S/P placement of VP shunt during her first week at Broward General.

A CT done at 57 days to rule out shunt malfunction showed slight improvement in her ventricle size. Follow up CT at 84 days showed decreased size of dysplastic shunted hydrocephalic ventricles and an increase in biparietal/vertex extra-axial fluid. Follow up CT at 133 days showed even size compared with 6/29/99 CT scan and probable absence of the septum pellucidum.

GENETIC: Genetic consult was obtained and it was felt that Melissa had isolated defect. Family follow-up with Genetics recommended.

Melissa was discharged to home on an apnea monitor with arrangements for 12 hour home nursing. Discharge diagnoses:

Chris Evert Children’s Hospital: 1/6/01 - 1/7/01
Presented to ER with complaint of increased work of breathing over last two days, requiring Albuterol every two hours. She was started on Prelone by the Pulmonology team; however, mother reported no improvement. Chest x-ray revealed no infiltrates. She was admitted and administered Albuterol every four hours and was clear to auscultation with no stridor. She was discharged home on Vanceril and Albuterol for underlying asthma.

Chris Evert Children’s Hospital: 2/23/01
CT of the brain revealed: (1) No change from 11/11/00, (2) Small ventricles, (3) Good evidence of shunt malfunction not seen.

Shunt Series revealed (1) Intact shunt system, (2) Question of right lower lobe atelectasis or pneumonia.

Shunt series revealed intact shunt tubing and parenchymal opacity at the right base, which was present, at least in part, on 2/23/01.

Melissa’s gross motor skills were at 11 month-old level. She could not walk. She was on regular diet and did not use G-tube for feed.

Upon admission, oxygen was required to keep saturations above 93%. She developed purulent nasal discharge and required frequent suctioning. She remained on oxygen until 3/23/01. She gradually began to have better intake and IV fluids were discontinued. Albuterol was changed to every 4-6 hours and Melissa did well with the schedule until discharge. She remained on IV Zinacef until day of discharge when it was changed to Ceftin. Vanceril was changed to Flovent. At discharge, Melissa was noted to be back at baseline. Discharge diagnosis:

CT of the head and shunt series were performed secondary to increased lethargy and were unremarkable. Urine culture was positive for Streptococcus Viridans. Over the next several days, the oxygen was weaned to room air without consequence. Medications were adjusted as necessary and Melissa showed marked signs of improvement. On 8/13/01, she was considered back at baseline and was discharged to home. Discharge diagnoses:

Abdominal x-ray was revealed normal bowel gas pattern and no pneumonia.

Chris Evert Children’s Hospital: 8/23/01 (H & P and Radiology Only)
Admitted for fever and cough. CT of the head and shunt series were performed and were negative. Partially treated pneumonia vs. otitis media vs. sinusitis was suspected.

Chris Evert Children’s Hospital: 2/27/03
Shunt series revealed intact shunt tubing.

Chris Evert Children’s Hospital: 9/15/03
Audiogram revealed moderate to mild loss with suspected conductive component supported by Type B tympanogram bilaterally and normal SRT (speech reception threshold) via bone conduction.

Chris Evert Children’s Hospital: 12/12/03 (OR Reports Only)
Admitted for surgery. Underwent medial rectus recession 4mm, both eyes, with one third superior transposition, both eyes to improve binocular visual functioning.

Also underwent bilateral myringotomy with tubes under binocular microscopy, tonsillectomy, nasopharynx examination under anesthesia.

Chris Evert Children’s Hospital: 2/11/04
Audiogram revealed normal hearing in both ears; however, tympanometric and otoscopic results were consistent with a blocked PE tube in the right ear.

Chris Evert Children’s Hospital: 2/20/04 – 2/21/04 (Consultation, Radiology & OR Report Only)
Admitted to undergo pharyngeal flap for cleft palate with velopharyngeal insufficiency. She tolerated the procedure well. On 2/21/04, pulmonary consultation was obtained for decreased oxygen saturations. Chest x-ray revealed (1) Dense opacity of the left lower lobe which was probably left lower lobe atelectasis or pneumonia (2) Less likely cause would be pleural fluid. She was started on Albuterol and Atrovent. Plan was to continue oxygen for time being and begin to wean as tolerated.

Martins, Clyde M.D.: 9/9/99
Neurosurgical follow up. Melissa had good evidence of shunt function. Follow up CT in 3 months recommended.

Martins, Clyde M.D.: 1/3/00
Melissa had shunt infection in 11/99. Shunt was removed and replaced. She has had no difficulty since then.
Martins, Clyde M.D.: 4/20/00

Melissa was making excellent developmental strides. Follow up CT showed good decompression of the ventricles.

Martins, Clyde M.D.: 5/31/00
Melissa underwent shunt revision one week earlier. She was now much more awake, alert and interactive. Sutures were removed.

Martins, Clyde M.D.: 2/23/01
Melissa recently had URI. Otherwise, she was fine. Head circumference was in 25 th percentile for age. She was awake, alert and her gaze was conjugate. Extraocular movements were full. CT of the brain was unchanged. Follow up in one year recommended.

Follow up genetic consultation. Original consultation was performed during first hospital admission.

Melissa showed mild delays in development for her corrected age of four months and 12 days and continued to be at risk for further delays in development. She was evaluated by the Early Intervention Program in Broward County and OT and ST were recommended. She smiled socially, laughed aloud, tracked visually, and made good eye contact. She had not rolled over. Reflux appeared to be resolving. A swallow study performed one week earlier had good results. Plan was to start Melissa on bottle feeding during the day and continue gastrostomy feedings at night. Melissa passed her most recent hearing test. Retinitis of prematurity had resolved.

Melissa’s mother reported she was doing well from a cardiac standpoint. She had a 10% residual from her initial surgical repair but remained stable. She was followed by pediatric pulmonology due to paralysis of the left side of her diaphragm. She continued on an apnea monitor.

On examination, weight was in the 85 th percentile and head circumference was in the 30 th percentile. There was plagiocephaly with ridging of the sutures on the right side and her head tapering in back. There were down-turned corners to the mouth and evidence of a cleft palate.

Chromosome analysis and FISH analysis showed normal results with no microdeletion. Melissa continued to make progress. She had not shown any new problems. She was scheduled to begin oral feeding soon.

Melissa appeared as a nondymorphic baby, with hydrocephalus likely to be the result of an in utero event and Tetralogy of Fallot and cleft plate of unknown etiology. It would be difficult to predict the risk for recurrence in the family. At this point, Melissa appeared to be receiving appropriate attention.

KALAVITIS, NICK M.D.: 12/15/99 - 7/20/00

Kalavitis, Nick M.D.: 12/15/99

Neurology follow up S/P hospitalization. Melissa was nine months old. She was one of quadruplets born at 31 weeks gestation and birth weight was 2 pounds, 15 ounces. She had congenital hydrocephalus and was shunted shortly after birth. He saw her at two months old because of suspected seizures that he did not believe were documented clinically, or by EEG. She did not require antiepileptic drug treatment. Subsequent to discharge, there had been no recurrence of seizures or seizure like activity. She experienced shunt malfunction in November and following revision, had done well.

From a developmental standpoint, Melissa was improving at a fairly steady pace. She was described as alert and visually attentive. She smiled responsively and cooed. She had been reaching with either hand and transferring from hand to hand for at least one month. She rolled onto her side from her back and on one occasion, rolled over completely, but not easily. She did not sit independently.

On examination, she weighed 18 pounds, 8 ounces. Head circumference was in the 5 th percentile. She was alert, attentive and smiled responsively. She reached with either hand and transferred. She had good head control. Impression:

Since last visit, there was significant developmental improvement. Melissa was crawling on her abdomen usually leading with her LUE. She was described as alert and beginning to babble. She had shunt malfunction in May but was doing well since revision.

Examination revealed Melissa was alert and visually attentive. She smiled responsively and made some babbling sounds. She had mildly reduced axial tone. Tone was normal in all limbs. She had good head control. She reached with either hand and transferred. When crawling, she seemed to lead with her LUE, with the right arm tucked in, but from time to time she did extend her right arm. She had good movement of both legs. Impression:

Continuation in developmental program recommended.

Melissa was attending a varying exceptionality Class at Maplewood Elementary school. She was classified as Other Health Impaired. She received OT, PT and Speech Language therapy services. She received direct specialized instruction daily, speech therapy 120 minutes per week, language therapy 60 minutes per week, OT 90 minutes per week and PT 60 minutes per week.

Multi-Disciplinary Team Report indicates Melissa was evaluated on 2/6/02 and 2/14/02 by personnel at the Early Intervention Program. She was transitioning from Part C (Early Intervention) to Part B (School Board). Evaluation processes included review of file, interview with parent, record review and administration of Vineland Adaptive Behavior Scales; Interview Edition, Survey Form and Differential Ability Scales.

On the Vineland Adaptive Behavior Scales; Interview Edition, Melissa scored as follows:

Melissa’s Adaptive Behavior composite score of 63 on the Vineland placed her overall adaptive functioning in the Low category and represented a fifteen month delay from her chronological age.

She demonstrated average cognitive abilities related to reasoning. She was continuing to exhibit delays in both language and motor skills, which inhibited her performance on academic tasks unless they were tailored to her individual needs. For example, she was able to point to objects but was not able to copy block designs or to draw objects. Her articulation difficulties inhibited comprehension of her message; but she was able to point to pictures, point to objects, and use sentences as long as the listener was aware of the context and could “fill in the blanks.” She tended to omit the /s/ and last portion of words.

Based on findings, she met the eligibility criteria for ESE services on the basis of health concerns.

Most recent Speech/Language Therapy Evaluation dated 4/16/02 indicates Melissa received ST 2X weekly at ABC Day Care Center. The Preschool Language Scale-3 (PLS-3) was administered to assess receptive and expressive language abilities. Melissa had just turned three and her scores were significantly lower than had she been tested two weeks prior. Results:

The Goldman-Fristoe 2 Test of Articulation was used to evaluate her articulation skills at the single word level. Her performance on the Sound-in-Words subtest (37 errors) earned her a percentile rank of 29 and a test age of 2 years, 3 months.

Melissa continued to present with moderate receptive and mild expressive language delays, as well as hypernasal vocal quality, resulting in decreased intelligibility. She communicated in phrases and sentences with an average length of three to four words. Continued therapy was recommended 2X/weekly for 30 minute sessions.

According to conference held on 12/2/03, Melissa had many emerging pre-readiness skills. She was motivated to learn new skills. She was curious and asked many questions. Her communication skills were blossoming recently. Team’s major concern was her fine motor skill and delays with balance. She was very social with adults and needed to increase socialization with peers.

Pre-K Student Progress Report dated 3/15/04 indicates Melissa was independent with eating (though messy), dressing, toileting skills. She washed her hands, opened milk cartons, used silverware appropriately and used bathroom independently. Fine motor skill wise, she could draw a circle, trace letters in her name, color inside the lines of basic shapes with fair accuracy. She could do interlocking puzzle if encouraged. She needed more fine motor practice. She preferred socializing instead of sitting down to complete fine motor activity. Her gross motor strength had improved and she could use pedal tricycle, swing on monkey bars, hop and climb. She need continued PT to build strength and coordination.

Melissa’s mother. College senior at University of Miami (Pg. 6). She was scheduled to graduate in December. She majors in accounting. She currently has accounting position and would like to go further and become a CPA (Pg. 7). Employed by HCM & Associates, a management company for a real estate development company. She is an accountant (Pg. 8). She works part-time. She averages 32 hours week (Pg. 10).

Melissa’s neurosurgeon is Dr. Clyde Martins (Pg. 146). She is also seen at Coral Springs Clinic (Pg. 147) for primary pediatric care (Pg. 149). Dr. Hyram Kleinman is pediatric ophthalmologist (Pg. 149). She saw him lately due to eyes crossing. Surgery was scheduled for 12/12/03 (Pg. 150). Melissa was evaluated by a Dr. Smart to determine eligibility for social security benefits. She was not determined to be disabled (Pg. 152).

Medications include Albuterol, which is used a couple of times per month for asthma. She sees Drs. Reid and Luff at Pediatric Pulmonology Clinic at Chris Evert Children’s Hospital (Pg. 154). She takes Motrin probably twice per month for fever. She was seen in the Cleft Palate Clinic at Chris Evert Children’s Hospital by a team of doctors, an audiologist and ST (Pg. 155). She saw a Dr. Ostrow, plastic surgeon, who recommended surgery for the cleft palate. The surgery would hopefully be done in November (Pg. 156). Melissa underwent evaluation for SSI and her IQ was below average but not severe enough to qualify her for benefits (Pg. 158).

Melissa has been attending the ABC Day Care Center since 6/01. She just started using after school care in 8/11/03. She attends Maplewood Elementary School during the day. She is in an ESE program for 3-4 year olds (Pg. 164). Nora drives her to school in the morning and a bus takes her to after school care at the end of the school day (Pg. 165).

Nora’s mother helps her at home. She watches the children one night a week for her to go to school and every other Friday night. They spend the night with her (Pg. 166). Her friend watches them on the other night that she goes to school (Pg. 168).

The most profound issue with Melissa is the hydrocephalus (Pg. 173). The second issue would be gross motor skills. She does not have much coordination and does not move as fluidly as her other children. She does not run or walk as well as her other children. She spends a lot of time alone, as she can not keep up with them. Then there is her speech. She is hypernasal and speaks through her nose (Pg. 174). She can understand about 75% of what Melissa says. She estimates people that do not know her can probably understand 45-50% of what she says. She has her heart condition (Pg. 175).

Melissa’s asthma is aggravated by drastic changes in weather (Pg. 178). In the spring, her allergies flare up and she has difficulty breathing. She has a nebulizer and uses it a couple of times a month (Pg. 179). There are no limitations related to her heart. Melissa tires easily compared to the other children. Speech difficulties cause isolation and frustration. She gets frustrated repeating things. She is getting to the age where she realizes she is different (Pg. 180).

Gross motor wise, she does not appear as sure on her feet as a four-year old would. She is a little hesitant about climbing. She is not allowed to ascend stairs by herself (Pg. 181). Her run is more of a fast paced walk. She does not believe Melissa has a gait disturbance (Pg. 182). She walks more like a toddler, a little wobbly.

Fine motor wise, she does not color in the lines. She does not hold a pencil or crayon correctly (Pg. 183). She has pretty good motion with her arms and hands. She does not hold scissors correctly and can not cut (Pg. 184).

Melissa has had two shunt revisions since she was six months old (Pg. 185). Her understanding is that Melissa will never be able to have the shunt permanently removed. With regard to how the shunt affects her daily activities, Melissa cognitively does not think or play like a four-year old. She does not make relations to the world as a typical four and a half year old would (Pg. 186).

Melissa is friendly. She has something about her that draws you to her. Everyone falls in love with her (Pg. 187). She will finish up the Pre-K program and have testing done late fall, early spring. They have IEP meeting every year (Pg. 188). At the next meeting, a decision will be made as to whether Melissa will go into a mainstream kindergarten (Pg. 189).

Because of Melissa’s condition, she only accepts jobs with a degree of flexibility due to her follow up appointments (Pg. 192). She always has to monitor her health. She can only live a certain distance from where Chris Evert Children’s Hospital is. Melissa is more work. You have to spend a great deal of time explaining things to her (Pg. 193).

Melissa eats normally now. It has not been determined whether she will need surgery or some kind of medical action as it relates to the wound from the feeding tube (Pg. 194). Melissa can put on shorts, panties. She needs a bit of help. She can not button or pull up a zipper. She can put her shirt on but it is usually backwards. She can put her velcro shoes on (Pg. 195). She can put the toothbrush in her mouth but can not do the brushing motion. She is toilet trained but needs assistance with cleaning herself (Pg. 196). She does not have any eye difficulties other than the crossing. Vision is normal. She is able to get in and out of the car by herself (Pg. 198). She can drink out of a normal cup and holds the cup appropriately. She can take off her clothes and shoes. She can get herself into the bathtub (Pg. 200). She sits in the bathtub. She tries to wash her own hair (Pg. 201). She can put her nightgown on by herself (Pg. 202).

Melissa has follow up renal ultrasound scheduled. She had nephrocalcinosis when an infant and because of that has a plethora of follow up appointments. At the Cleft Palate Clinic, it was determined that she has some hearing loss so follow up is necessary with audiologist (Pg. 205). All her therapies started again last week with the start of the new school year. (Pg. 206). She receives all therapies 90 minutes per week (Pg. 207).

Melissa’s father. Last worked for Smelser Marine painting boats. He sustained a lower back injury and has not worked since February 9, 2002 (Pg. 5). He worked painting boats at Tunnell Marine prior to Smelser Marine (Pg. 5). He has a tenth grade education (Pg. 6).

He gets the kids every other weekend. He has also watched them while Nora was in school (Pg. 25). He pays child support (Pg. 26). He attends Melissa’s annual school conference (Pg. 30). At the last one, school personnel stated Melissa had made some strides and that there was work to be done. They seemed pretty happy with where she was at (Pg 31).

It is very hard for him to watch Melissa struggle and to see her isolated somewhat from the other children because she can not do a lot of the activities they are doing (Pg. 31). He bought all the girls bicycles and Melissa still will not get on her bike. He was treated for depression in 2000 (Pg. 32). He relates his depression to Melissa and the other children (Pg. 33). He was also battling alcoholism (Pg. 34).

Melissa is visibly smaller than her siblings (Pg. 40). She is very uneasy on her feet and he walks behind her (Pg. 43). In comparison to her siblings, Melissa does not dress herself as well. She does not get her shoes on the right feet. She does not write. She clenches her fist with whatever writing utensils she is using (Pg. 44). She does not process as quickly as them (Pg. 45).

Records Reviewed:

Broward County School Records: 1999 - 2004
Chris Evert Children’s Hospital: 5/18/99 – 8/17/99; 1/6/01 – 1/7/01; 2/23/01; 3/18/01; 3/19/01 – 3/24/01; 8/8/01 – 8/13/01; 8/18/01: 8/23/01; 2/27/03; 9/15/03; 12/12/03; 2/11/04; 2/20/04 - 2/21/04
Attorney Information Sheet
Kalavitis, Nick M.D.; 12/15/99; 7/20/00
Martins, Clyde M.D.: 9/9/99 – 2/23/01
McDaniel, Charles M.D.: 10/12/99
Medical Bills

Depositions Reviewed:

Wingerd, Nora: 3/5/03; 8/27/03
Wingerd, Tony: 8/27/03

ADDENDUM: 7/21/04

PEDIATRIC CARDIOLOGY ASSOCIATES.: 8/26/99 – 10/21/03

Denning, Patrick M.D.: 8/26/99
Follow up for Tetralogy of Fallot, S/P repair on 7/13/99. Melissa was gaining weight quite well. Mother and nurse were concerned about medications.

Cardiovascular examination revealed a II/VI systolic ejection murmur best heard at the left mid to left upper sternal border; however, it radiated throughout the precordium. ECG revealed sinus rhythm with right bundle branch block pattern. Chest x-ray revealed normal heart size and pulmonary blood flow appeared adequate.

Plan was to check Melissa’s electrolytes. If they looked good, hopefully they could stop some of her supplements.

Bryden, Joseph M.D.: 9/16/99
Melissa was doing well. She did not have any signs of fluid retention or heart failure and Lasix was cut back.

Pilgrim, Ronald M.D.: 1/13/00
No sign of heart failure. She had a soft systolic murmur. EKG revealed normal sinus rhythm with a right bundle block pattern. She was doing well. She had a cleft palate procedure scheduled and plan was to obtain echocardiogram and EKG prior to surgery.

Pilgrim, Ronald M.D.: 5/9/00
Melissa was doing well. Follow up evaluation in 8 months recommended with an electrocardiogram. Activities were normal for age. She would require SBE (subacute bacterial endocarditis) prophylaxis for dental, ENT, GI and GU procedures. Advised to discontinue Diuril.

Quijano, Rafael M.D.: 9/15/03
Melissa was 4 years old. She was scheduled to undergo strabismus surgery in the future. She was not on any medications. She was doing well except that she seemed to have a little bit less stamina than her siblings. They needed to schedule a battery of non-invasive testing. Plan was to obtain echocardiogram and electrocardiogram.

Report addendum indicates echocardiogram looked very good. There was only very mild pulmonary insufficiency with function of the right ventricle in a normal range. Melissa would require repeat electrocardiogram in one year.

Records Reviewed :

Pediatric Cardiology Associates: 8/26/99 – 10/21/03

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Activities Of Daily Living

Sleep Pattern

Arises: 7:15 a.m.
Retires: 9:00 p.m.
Average Hours Sleep/24 Hours: 10-12 hours
Sleep Difficulties: No problems sleeping. She has to have a nap.

Independence In

Dressing: She tries to dress herself, but puts clothes on backward. Buttons and snaps a problem.
Housework: She does not follow directions to pick up toys. She can follow one step directions, but past that she needs cues.
Cooking: Not age appropriate.
Laundry: She can do this at age appropriate level.
Yard Work: She can do this at age appropriate level.

Social Activities

Organizations Pre/Post: No.
Volunteer Work Pre/Post: No.
Socialization Pre/Post: Melissa’s disability does hamper the family’s ability to socialize and/or travel. She tires easily and demands so much more attention than the other three children. It is difficult for mom to take all 4 of them at one time, because of the attention Melissa requires.
Hobbies (Present): She likes music. She likes riding her tricycle. She likes having books read to her.

Personal Habits

Smoking: No smoking in the home.
Alcohol: No.
Drugs: No.
History of Abuse and/or Treatment Programs: Yes. Her father is an alcoholic. Maternal grandfather and great-grandmother were both alcoholics.

Socioeconomic Status

Number in Residence: 6, Mom, Mom’s fiancé, four children.
Type of Residence: Block home, single-story. No modifications.

Income

S.S.I. : Ended 9/2003.
Medicaid: Yes, but this may expire 6/2004. Application to renew has been submitted.

Education & Training

Highest Grade Completed: Will begin preschool/kindergarten program in August 2004.
Last School Attended: Maplewood Elementary.
Miscellaneous Education Information: Transdisciplinary Program is for students who will eventually be mainstreamed, but who currently need extra support initially. This is effectively an extra year of Preschool so she will go to kindergarten the next year as well.

Observations

Orientation: Alert and oriented to age appropriate level.
Stream of Thought: Clear and age appropriate, but definitely immature even for five-year old.
Approach Toward Evaluation: Open and not fearful of examiner. Difficult to keep on task.
Attitudes/Insight: Positive. Limited but not inconsistent with age.
Appearance : Very active, well cared for five year old Caucasian female.

Tests Administered

Test Administration: As part of this evaluation process, Melissa was administered the Slosson Intelligence Test (SIT-R3) and the Peabody Picture Vocabulary Test-Revised.

On the Slosson Intelligence Test-Revised-3, Melissa demonstrated a raw score of 22 with a mean age equivalent of 2.5, a T-score of 36, and a percentile rank of 8%. Her total standard score (IQ) is 77, with a confidence interval of 95%. At her age the standard error of measurement is plus or minus ten points (IQ 67-87).

On the Peabody Picture Vocabulary Test-Revised, Melissa developed a raw score of 41 and a Standard score of 81. This placed her at 10% giving her a mean age equivalent