Procedure History

Pregnancy:
Mother was 29 years old and mother of two boys, ages 13 months and 3.5 years at time of delivery. She received prenatal care and lives an active healthy lifestyle; non-smoker, avid exercise, conscious diet, no drug use, no alcohol use during pregnancy. Routine screening for Syphilis, Hepatitis, HIV, Rubella Group B Strep all negative.

Both previous births were vaginal, came naturally (non-induced) at 38 weeks 2 days and were without complications. First child weight was 7lbs 0oz and second was 9lbs 0oz. Because of relatively large baby weight with respect to mother’s size, induction was planned months in advance with the intent of cancelling if mom/baby was not measuring large like previous baby. Induction date (5/22) was at gestational age of 37 weeks 6 days.

At 36 week check-up the baby was measuring 36-weeks. At 37-week check-up baby was measuring 40 weeks, therefore stayed with planned induction.

May 22, 2006: Delivery
Induction was planned May 22, 2006 scheduled induction at 36-weeks 6-days. Smooth, uneventful delivery. Excess amniotic fluid noted during delivery.

Birth Weight: 7lbs 0oz. APCAR score 9/9.

May 23, 2006: Swallow Study

Mild apnea while attempting feeds.
1st Swallow study showed aspiration
IV / no oral feeds (NPO).
Short apnea spells noticed even while not feeding. Recommended Nissen for Reflux.

May 24, 2006: Note

Transported via ambulance to Presbyterian St. Luke’s Hospital in Denver (PSL)

May 25, 2006: Video Esophogram
History: Severe reflux with aspiration, rule out swallowing disorder. With the patient seated in the erect lateral position, video fluoroscopy was performed with the Speech Therapist. Ivovue was presented from a regular nipple. Multiple swallows were observed. No aspiration was seen. The patient expressed the contrast without difficulty from the nipple. Slight intermittent delay in the hypopharynx was seen only. No nasopharyngeal reflux. Patient did exhibit stridor. The nasl airway appears relatively non-aerated. Suggest further evaluation by clinical methods of this latter to confirm patency. Impression: Normal swallowing study in respect of the oral and hypopharyngeal phases. This patient did incur stridor however during feeding and the nasopharynx appears relatively nonaerated. Recommend clinical correlation of this latter.
May 25, 2006: Upper GI Contrast
History: Rule out malrotation Findings: Images of the esophagus show no extrinsic compression or intrinsic obstruction. Subsequently, the patient had uncontrolled reflux with high-grade reflux to the orppharynx and pooling of barium within the esophagus. Two episodes of aspiration were seen. One was mild and the other was moderate severity. A poor cough reflex was elicited. Images of the stomach show antrum to be contracted. There appears to be antral spasm present. Gastric emptying was somewhat delayed. The C-loop appeared normal, however. No evidence of malrotation was seen. There is residual barium in the colon from a prior study. Small bowel follow-through: Two subsequent overhead images were obtained at 1413 and 1730 hours. The initial image at 1430 hours shows partial gastric emptying. There is residual barium in the esophagus compatible with reflux. The small bowel loops are normal in caliber. Subsequent image at 1730 hours shows barium has traversed the small bowel and had reached the colon. No evidence of small bowel obstruction is seen on this study. Impression:1)       High-grade, repetitive reflux2)       Antral spasm. Asperation occurred during the study. No evidence of malrotation3)       No evidence of small bowel obstruction. There is evidence of reflux.
May 26, 2006: Laparoscopy, Nissen and modified Ladd procedure

Preoperative diagnosis: Reflux with aspiration

Postoperative diagnosis: Reflux with aspiration, plus hiatal hernia, plus incomplete rotation

Procedure: Exploratory laparoscopy, laparoscopic Nissen fundoplasty, and modified Ladd procedure.

May 26, 2006: X-Ray, Chest
History: Check tube placement. Patient is postoperative Findings: Lungs are adequately expanded. There is some minor infiltrate at the lung bases particularly on the right. No pneumothorax or pleural effusion. ET tube is satisfactory. Abdomen shows mild fullness. There is still contrast within the colon. This reaches the rectum. No free air is seen.

May 27, 2006: Parents notes
11:00am Feeding attempts
6:00pm 1st major(?) Apnea episode
6:30pm 2nd major(?) Apnea episode
7:00pm 3rd major(?) Apnea episode required re-intubation. 3.5mm tube used for pre-op intubation no longer fit. Required 3.0mm tube. Full resuscitation required (chest compressions). Time of hypoxia (no/low oxygen) unknown by parents.

May 27, 2006: X-Ray, Chest
Comparison: 05/26/06 History: Line and tube placement Findings: An endotracheal tube is at the T2-3 level above the level of the carina. Residual contrast is noted within the descending colon. Decreased aeration is noted of the lungs with mild haziness noted in the left lower lobe. The patient is also rotated on the current film. Conclusion:1)       Endotracheal tube at the T2-3 level2)       Mildly decreased aeration noted in the left lower lobe with no consolidation noted.
May 28, 2006: Parents note
Started antibiotics & steroids, assuming apnea spells were due to swollen/agitated airway cause by infection resulting from bile pushed back up through system from intestinal malrotation in utero.
May 28, 2006: X-Ray, Chest
Comparison: 05/27/2006History: Line tube placement Findings: Endotracheal tube at the T1-2 level. Oragastric tube in the stomach. Mild residual contract noted within the splenic flexure. Lungs appear clear with improved aeration. Conclusion: 1)       Improved aeration noted of the lungs2)       Endotracheal tube at the T1-2 level
May 30, 2006: X-Ray, Chest/Abdomen
HISTORY: Patient is status post bronchoscopy.

FINDINGS: Right upper lobe atelectasis is seen. Streaky infiltrates
are present in the lungs. Lung volumes are reduced from before. No
pneumothorax is seen. There is some mild infiltrate in the right
middle lobe also. Bowel loops are mildly gassy. The pelvis is obscured
by radioprotector, which is inappropriate. Bony structures appear
grossly unremarkable.

IMPRESSION:
RIGHT UPPER LOBE ATELECTASIS. STREAKY INFILTRATES ARE PRESENT IN
THE LUNGS. NO FREE AIR.
May 30, 2006: X-Ray, Chest
History: Evaluate pulmonary status Comparison: May 28, 505 hours Findings: The heart size is normal. Streaky infiltrate is present in the perihilar regions, mild in degree. A little infiltrate is also present in the right middle lobe. Monor streakiness in the lingual. Pulmonary expansion aeration are adequate. No pneumothorax is seen. NG tube tip reaches the stomach at least. An ET tuce is present with its tip at T1-2 level. Impression: Mild infiltrate. Satisfactory hardware grossly.
May 30, 2006: Flexible Bronchoscopy
Elective extubation was done prior to bronchoscopy. Procedure: The bronchoscope was passed through the right naris and was poisedon the larynyx when the endotracheal tube was taken out. Epiglottis structures were visualized. The epiglottis appears to be mega-shaped and mild floppiness is noted. Arytenoids appeared to be normal and did not appear to be inflamed. Vocal cords showed normal anatomy and mobility with ability to come to midline to protect the airway. Subglottic space was normal. Tracheal lumen appeared to be normal. No defects or clefts were noted. Carina appeared to be sharp. Right and left mainstem bronchi seen. On the left side, left upper lobe and left lower lobe were normal. On the right side, right upper lobe, bronchus intermedius, right middle and right lower lobe were normal. Segmental bronchial anatomy on both sides was within normal limits. Secretions were noted but bronchoalveolar lavage (BAL) was not done as she has recently been treated. Conclusions: Mild inflammation of nasal passages. The bronchoscope was introduced also through left naris and it appears to be tight with some swelling present. Mild laryngomalacia was present. Distal airway anatomy appears to be normal.
May 31, 2006: CT, Head

HISTORY: Patient with neurological posturing.

FINDINGS: Ventricles are normal in size. No midline shift is seen.
There appears to be a tiny fleck of hemorrhage in the right anterior
parietal brain, see image 20, series 2. No evidence of general matrix
or intraventricular hemorrhage is seen. Posterior fossa structures
appear normal.

The venous sinuses appear to be patent. No abnormality of the
extraaxial compartment is seen. The gray/white matter appears grossly
normal. Bony structures show maxillary antral and posterior ethmoid
opacification.

IMPRESSION: NO STRUCTURAL ABNORMALITY NOTED. TINY FLECK OF HEMORRHAGE IS
PRESENT IN THE ANTERIOR RIGHT PARIETAL BRAIN. BRAIN IS
STRUCTURALLY UNREMARKABLE. NO INFARCT IS IDENTIFIED ON THIS
STUDY.
June 03, 2006: Parents note
Low sodium noted. Began supplements
Fever
Discontinued (DC) Reglan
Started on antibiotics
High Platelets noted (1million +)

June 03, 2006: Abdomen 1 VW Portable
Reason for study: Infection Examination demonstrates a nonobstructive bowel gas pattern. No organomegaly, free air, or free fluid are seen. Nasogastric tube tip lies in the region of the mid-body of stomach.
Impression: No acute intra-abdominal process noted
June 05, 2006: MRI, Brain

HISTORY: Apneic episodes. Patient with reflux.

FINDINGS: Ventricular sizes are normal. No midline shift is seen. No
intracranial hemorrhage is evident. An IV is projected over the
fontanelle region. Corpus callosum is intact. The cerebellum appears
unremarkable with a normal craniocervical junction. No evidence of
Chiari malformation is seen. No evidence of an infarct is
appreciated. Venous sinuses appear unremarkable. There appears to be
opacification of the maxillary antra which small in caliber. Mild
ethmoid opacification also. The pituitary appears normal.

IMPRESSION:
NORMAL INTRACRANIAL CONTENTS. NO EVIDENCE OF CHIARI I
MALFORMATION.
June 04, 2006: EEG
View Report (pdf) Notable points:
Frontal sharp transients and delta brushes are noted
Impression: EEG is well within the range of normal variation for age.
June 05, 2006: X-Ray, Abdomen,
Findings: Liver size is mildly enlarged. Bowel loops are partially aerated, gas reaches the rectum. No free air or intravascular gas is seen. There is some bubbliness in the flanks. Mild pneumatosis is not excluded. Suggest follow-up. Impression: Bowel loops are decompressed with gas reaching the rectum. Mild bubblinessis present. Difficult to exclude mild pneumatosis at this time.
June 08, 2006: Upper GI

HISTORY: Evaluate for reflux.

FINDINGS: Initial image shows the bowel loops to be gassy. An NG
tube is present with its tip in the body of the stomach. Study was
performed through the patient's G-tube. C-loop is redundant. This
appears unremarkable. No convincing evidence of malrotation. A
fundoplication is present. This is a slightly unusual configuration,
no reflux is seen however. Subsequently the esophagus was injected.
See frames 11-15. The esophagus shows no evidence of a vascular ring.
Esophageal clearance of barium was delayed and showed to and fro flow
of barium. Subsequently aspiration was noted. This was mild to
moderate in degree.

Small bowel loops appear unremarkable. Overhead images obtained at the
end of the study appears to show clearance of the prior aspiration.

IMPRESSION:
REDUNDANT C-LOOP. CONVINCING EVIDENCE OF MALROTATION IS NOT SEEN
HOWEVER. FUNDOPLICATION APPEARS TO HAVE SOMEWHAT DIFFERENT
CONFIGURATION TO NORMALLY SEEN. NO REFLUX WAS SEEN HOWEVER. POOR
EMPTYING OF THE ESOPHAGUS IS SEEN HERE, PATIENT SUBSEQUENTLY
ASPIRATED. THIS WAS CLEARED BY THE TIME OF COMPLETION OF THE
STUDY. June 12, 2006: GI Tube inserted
June 17, 2006: PSL Discharge
June 22, 2006: Visit Endocrinologist

July 14, 2006: Ultrasound, Abdomen
Ultrasound images is limited due to significant patient motion and
poor cooperation.
Abdominal ultrasound: No abnormality of liver, spleen or pancreas
was appreciated. Both kidneys are well visualized and appear
normal. The kidneys are normal in size, axis and echogenicity.
There is no evidence of hydronephrosis. The gallbladder is well
seen in is normal. There is no evidence of intrahepatic or
extrahepatic biliary dilatation.
Imaging of the ovaries demonstrate mild enlargement bilaterally
with multiple follicles.

Impression: Normal abdominal ultrasound. Non-specific
enlargement of the ovaries bilaterally with multiple follicles
present. This can be seen with maternal estrogen stimulation.
August 04, 2006: Parent note
Sleepless night. May have had seizure (11:00am). Admitted at Denver’s Children Hospital ER.
EEG results abnormal. Low signal amplitude. Imbalanced signal. Given antibiotics
Spinal Tap
August 04, 2006: CT, Brain
Cranial CT: Axial images base to vertex without intravenous
contrast. The ventricular size is normal. No abnormal extra
axial fluid collections are identified. There is no shift of
midline. No focal areas of abnormal attenuation the brain
apparent. No bony abnormality is identified. No structural
abnormalities identified.

Impression: Normal study.
August 07, 2006: EEG
View Report (pdf) Notable points:
Admitted to ER for potential seizure activity
Trace shows tremendous amount of movement artifact marring interpretation
Baby never slept, restless, kicking, writhing all four limbs, right side restrain to avoid dislodgement of IV
Interpretable channels seem lowish in amplitude with movement artifact
Showing low amplitude record on left side
Laying on right side so movement artifacts greater
No epileptiform or rhythmic features suggesting ongoing seizures
Normal gains are difficult to read so much was run w/ reduced gains
Occasional quite (no movement artifacts) while baby is sucking
Impression: Probably normal waking only EEG. The youngster never asleep and seldom relaxed. Movement artifact seemed to account for all the sharp slow wave changes on the EEG. The findings suggest the youngster’s wild movements are not on an epileptic basis; perhaps they reflect significant basal ganglia damage and release phenomena on that basis but that is speculative.
August 07, 2006: MRI, Brain
Cranial MRI: T1 axial, T2 axial, flair axial, sagittal T1,
diffusion weighted axial, gradient echo axial and T2 coronal
images were obtained. The ventricular size is normal. No
abnormal extra axial fluid collections are identified. There is
no shift of midline. Myelinization is normal for age. No focal
areas of abnormal signal intensity appreciated. No evidence of
intracranial hemorrhage. No abnormality on the diffusion weighted
sequences apparent.

Impression: Normal study.
August 13, 2006: Parent note
Notice Anya’s skin tastes salty
August 30, 2006: RF, Modified BA
Nectar thick by bottle and honey thick by bottle consistencies
were given in a Haberman fast flow technique.

Tiny boluses were formed. There was pooling in the pyriform
sinuses which resulted in aspiration continually. A constant drip
of contrast into the airway noted. The patient did cough.

Impression: Aspiration.
September 15, 2006: CR, Chest
Two views of the chest.

A pH probe is identified in the lower thoracic esophagus with tip
1.1 cm above the gastroesophageal junction. Perihilar
peribronchial thickening without focal infiltrates. Heart size
and pulmonary vessels within normal limits. Normal situs.

Impression: Airways disease and hyperexpansion. The pH probe is
in the distal esophagus.
September 16, 2006: CR, Chest
Two view chest: There is diffuse bronchial parabronchial
prominence with hyperinflation but without focal consolidation.

Impression: Airways disease without focal consolidation.
October 23, 2006: EEG
View Report (pdf) Notable points:
Sleep deprived for study.
Awake and moving constantly
Poorly regulated slow activity seen
Poorly regulated 2 to 4 hertz rhythms seen in posterior right
Voltage amplitudes are fairly depressed and flattened
Generally aroung 5-10 microvolt range
No epileptiform
150 heart rate sinus rhythm noted
Muscle and movement artifact obscure record
Impression: This EEG is technically quite difficult to review due to the motion and movement artifact seen throughout the tracing. In general, the background amplitudes are fairly flattened and low for age, with poor variability. No sleep spindles for sleep morphology was appreciated. There were no epileptiform discharges noted.
November 05, 2006: CR, Abdomen
Supine upright and decubitus views on the abdomen were performed. The patient
has a gastrostomy tube which projects over the stomach. An air collection is
present at the gastroesophageal junction which is consistent with a slipped
Nissen. The bowel pattern appears nonobstructed and no mass is seen within
the abdomen. The bowel gas pattern somewhat disorganized and no free air is
seen.
Impression: Findings compatible with slipped Nissen. Nonobstructed bowel gas
pattern..
November 06, 2006: Flouro, Upper GI
No comparison. Barium was introduced through the indwelling gastrostomy tube.
The configuration of the fundus is consistent with previous fundoplication.
Barium extends into the rap portion of the fundus which appears to extend
above the diaphragmatic hiatus. There was no gastroesophageal reflux. Barium
empties into normal appearing duodenal bulb and duodenal c-loop.
Impression:
Satisfactory position of gastrostomy tube. At least part of the
fundoplication wrap extends above the diaphragmatic hiatus. No
gastroesophageal reflux. No delay in gastric emptying.
November 08, 2006: X-Ray, Chest
Prior chest radiograph nine 9/16/06.
Frontal and lateral views of the chest: The lungs are hyperaerated on the
frontal view. There is mild peribronchial thickening. No airspace
consolidation or pleural effusion is seen. The cardiothymic silhouette is
normal. There is normal situs. There is slight elevation of the right
hemidiaphragm consistent with minimal atelectasis in the right upper lobe. A
gastrostomy tube is present.
Impression: Hyperaeration with mild peribronchial thickening consistent with
airways disease. Minimal right upper lobe atelectasis.