FORT COLLLl\IlS YOUTH CLINIC, PC

1200 East Elizabeth StreetFort Collins, CO 80524

Fax (970)482-2635

1214 Oak Park DriveFort Collins, CO 80525

Fax (970)207-9967(970)267-9510

1455 West Main, Ste 160Windsor, CO 80550

Fax (970)674-0911

PatientID: 306731Patient Name: WOLFBRAND LEVERETTDate of Birth: 07/11/2001 4 yrs, 1 mth

Date of Service: 08/24/2005HANSONMD

FAMILY lllSTORY:Not pertinent to the history of present illness. Noncontributory.GENERAL :FAMIL Y .ILLNESS POSITIVE HISTORY OF HYPERTENSION.! eczema in grandparents

. HISTORY OF PRESENT U,LNESS; Wolfbrand is rubbing at his nose intermittently. No SignsisyIilptoins of ."alLergies other than this. Dad feels it is a habit. Discussed trial of triaminic to see if this will help. Also . 'discussed self exploration and being socially appropriate .

.IDSTORY:PROV -Bx-30 week preemie.

PHYSICAL EXAM:GENERAL APPEARA.l\fCE: Well hydrated, active child in no distress.HEAD/EARSINOSE/THROAT: Head is normocephalic. TM's normal with good landmarks andmobility. Nose without discharge. Oropharynx unremarkable. No tonsillar erythema or hypertrophy.EYES: Normal red reflex and alignment.NECKffHYROID: Supple without thyromegaly or significant lymphadenopathy.RESPIRATORY: Clear to auscultation. Normal respiratory effort.CARDIOVASCULAR: Regular rhythm. No murmurs. Femoral pulses 2+ and symmetric bilaterally.GI: Soft, nontender, without masses. Active bowel sounds throughout. No hepatomegaly noted. Nohernias are present. No splenomegaly noted.au: Normal male. Tanner Stage m.LYMPHATICS: No significant lymphadenopathy in the axillae or groin.MUSCULOSKELETAL;

EXTREMITlESIDIGITS/SPINE: Full ROM. Normal muscle strength and tone. No evidence ofscoliosis.

SKIN: Without significant pathology.NEUROLOGIC: CNs n-XII grossly mtact, Deep tendon reflexes 2+/4+ and symmetrical, No Babinski orclonus. Nonnal sensation to touch. No other neurological findings.PSYCHIATRIC: Judgment appropriate. Oriented. Nonnal memory. Mood and affect appropriate.

ASSESSMEi'ITIPLAN:V20.2-ROlJTll\TE \\r'ELL CARE

ASSESSMENT: healthy 4 year old. Discussed ways to deal with him rubbing his nose and self".exploration.

ANTICIPATORY CARE: Anticipatory guidelines were discussed including: reviewing immunization .status, allergy prevention, injury prevention, the use of car safety restraints, bicycle helmet, rules of theroad, discussion of nutrition and healthy lifestyle, setting goals, responsibility, emerging independence,social interaction with family and peers, dental care, gun safety and personal safety.

RETURN VISIT: Return for next scheduled well visit. Encouraged to call with concerns or changes in

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YOUTH CLINIC, PC

Fort Collins, CO 80524Fax (970)482-2635

Fort Collins, CO 80525. Fax (970)207-9967

(970)267 •.9510

2965 Rocky Mountain AveSuite 260

Loveland, CO 80538Fax (970)461-8611

1200 Elizabeth St 1214 Oak Park Dr

PatientID: 306731Patient Name: WOLFBRA1\TD LEVERETTDate of Birth: 07111/2001 5 yrs, 11 mthsM CO BLUE SHIELD

Date of Service: 06/26/2007. HANSONMD

OFFICE VISITNURSE: Olinda Ross RN.ACCOMPANIED BY; Mother .

.CONCERNSh itchy skin and making funny sounds'VITALS;

WEIGHT: 21.31884 kg. (47)PULSE:88 Apical, RegularRESP:24TEMP: 98.4°f. Tympanic

CURRENT ALLERGY LIST:NKDA

CURRE1\T'f MEDICATION LIST:PULMICORT OOiALATION SUSPENSION 0.25MG/2ML, USE AS DIRECI'EDALBUTEROL SULFATE INHALATION NEBULIZATION SOLUTION (25 MG/3ML) 0.083%, USE0/5 ML (2.5 MG) MIXED WITH 3 CC NSIBRONCHOSALINE

IMMUNIZATION STATUS: Immunizations are current

HISTORY OF PRESENT ILLNESS: here with mom due to complaints of being itchy with increase aetivities.,with reading and Writing. NO skin breakdown or dry skin or sores. No new detergents or-lotions or .soaps.

HISTORY:765.14-PREMATURITY 1000~1249 GRAMSNo chronic or reoccurring illness

PHYSICAL EXAM:GENERAL APPEARANCE: Well hydrated, active child in no distress,SKIN: Without significantpathology. skin normal throughout

ASSESSMEN1IPLA.'N':306.3-ITCH PSYCHOGENIC

ASSESSMENT: itch due to stress - to see John Murray to help with desentizationREFERRALS: Occupational Therapist John Murray

RETURN VISIT: Instructed to call if not improving. Instructed to return earlier than the next regularly scheduledappointment if not improving. Encouraged to call with concerns or changes regarding condition.VERIFICATION OF ANCILLARY DOCUMENTATION: Portions of the chart wen: completed by ancillarypersonnel and reviewed by the provider.

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YOUTH CLINIC, PC

1200 Elizabeth St 1214 Oak Park Dr 2965 Rocky Mountain AveSuite 260

Loveland, CO 80538Fax (970)461-8611

Fort Collins, CO 80524Fax (970)482-2635

, Fort Collins, CO 80525Fax (970)207.9967

(970)267-9510

PatientID: 306731Patient Name: WOLFBRAND LEVERETTDate of Birth; 07111/200.1 ,,6 yrs, 0 mthsM CO BLUE SHIELD

Date of Service; 07/2812007BAKER PAC

OFFICE VISITWEEKEND OFFICE VISIT,NURSE:, Cindy Towne RN.ACCOMPANIED BY; Mother.CONCERNS: Complains of a rash, dry skin., widespread at times, penis bas rash and feet' -sk.iD.ted; Constipationo . ,poncernsCURRE1-,l1' ALLERGY LIST:

'NKDAOTC MEDICATIONS: BENADRYL. CLARlTIN.llvfMUNIZATION STATUS: Immunizations are current.

mSTORY OF PRESENT ILLNESS:01:

CONSTIPATION: Has not had a,stqol for a couple of days. Mom gave a suppository last night,~d had a s.ma1I,barder stoar He has struggled v.rith this off and on. '

SKIN: ~s had a rash that is coming and going the last couple of days. Looks worse at night andis, gone,by the morning. No new lotions, soaps, detergents, etc, It was a little worse on his penis this moroing,

HISTORY: , «: AA.lC /"/7/;; ::>. ·"-A1L1AIJJJ~! 'A/~No chronic or reoccurring illness ' .»H'7"- D / G.C>/'07- lA.-'l-tlcH HAbr.>Ei'?v, qnrr~1V /. ITM,1\NY 'IEAe.s~~I<£-clMl73i;Vg'FJ£}) BY

PHYSICAL EXAM: V<tA.-nr/..e.tJ€eGT'r ;rJQ-':p.j()-/3t''1GENERAL APPEARANCE: Well hydrated, active child in no distress.HEADIEA.R.SINOSEII'fmOAT; Head is normocephalic. TM's normal with good landmarks and "mobility. Nose without discharge. Oropharynx unremarkable. No tonsillar erythema or hypertrophy.EYES: No erythema or discharge,NECK!IHYROID: Supple without thyromegaly or significant lymphadenopathy.RESPIRATORY: Clear to auscultation. Normal respiratory effort.CARDIOVASCULAR: Regular rhythm. No murmurs.'SKIN: Has hive like lesion on his right forearm and a similar lesion on lower right abdomen, Skin on' 'penis is a little swollen and has similar residual lesion. '

ASSESSMENTIPLAN:" 782.l-RASH NONSPECIFIC looks morelike urticaria. Will have mom use Benadryl and

Hydrocortisone pm. , . ';,'- 564.00-CONSTIP ATION, UNSPEClFlED discussed increasing fluids aswell as ,Useof Miralax..

RETh'RN VISIT: Encouraged to call with concerns or changes regarding condition.VERlFICATION OF ANCILLARY DOCUMENTATION; Portions of the chart were-completed by ancillarypersonnel and reviewed by the provider,

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PatientID: 306731Patient Name: WOLFBRAND LEVERETTDate of Birth: 07/1112001

Date of Service: 11113/2001

Date: 11/13/2001 Provider: VAUGHN W. HANSON MD Note ID; 490236 *WBLL CARE-4MONTH

Wolfbrand is here for a 4 month old examination. He was born at 30 weekspremature.

PARENTAL CONCERNS; Mom notes he had URI symptoms about 2-3 weeks ago andthat cleared. She did follow up with Dr. Barrios, pediatric GI at PSL andJaad a barium enema due to concerns about possible Hirschsprung. Barium enema.was completely normal. Wolfbrand is to go back to see Dr. Barrios on the21st and they still need to give Wolfbrand 1 suppository or 2 suppositoriesdaily

to::get him to stool. Without suppositories he will go 2-3 stools without..stooling and gets quite uncomfortable and will get so fussy he won't eat.,.Anticipate that with time he will outgrow the tight sphincter.

AllERGIES: NKDA IMMUNIZATIONS; Up to date.MEDICATIONS; REGLAN, ZM1'fAC (outgrowing doses)

HISTORYDIETARY: Nursing, in a good routine. Gets formula as needed. Mom is

also pumping milk.ELIMINATION: See above.SLEEP HABITS: Waking I-2X/night, developing bedtime routine and sleep

pattern.SPEECH: Beginning to coo, will smile. not yet laughing or squealing.

Is at about the 2 to 2 112 month developmental level withspeech.

DAY CARE: He has a private nanny at home while both parents areworking.

SOCIAL HISTORY: No change from previous visitDEVELOPMENT: Visually tracks. He will hold his head up prone: Has a

grasp, but not yet reaching. Tends to noise. Not rolling.Has no pincer reflex.

HT: 1'10.25" % -5 WT: 11.88 % 3 OFC: 15.75" %-5(2 MONTHPERCENTILES) HT: 50% WT: 75% ope: 50%

PHYSICAL EXAMINATIONGENERAL: This is an alert, social infant.HEAD: Anterior fontanel; soft and flat. A little bit of flattening of

the right occipital area.EYES: EOMI, PERRL with bilateral red reflex. Lenses; clear

bilaterally. Sclerae: clear. Conjugate gaze.TMs: Clear and mobile. Normal landmarks and good light reflex.PHARYNX: Clear.NECK: Supple with no adenopathy. Full ROM.

October 17, 2001

Jeffrey Rosensweig/M.D.Pediatric GI Clinic1601 E. 19th Ave.Denver, CO 80218

RE: Wolfbrand LeverettDOS: 07/11/01

Dear Dr. Rosensweig:

I am referringWolfbrand Leverett to you for consideration ofpossible low Hirschsprung's. This is a thirty week infant whowas born at Poudre Valley Hospital. He did have Hyaline Membrane·Disease and was on a ventilator. He had some difficulty weaningfrom the ventilator and subsequently developed mild chronic lungdisease, being weaned off oxygen less than one month ago. Duringthe hospitalization there were concerns regarding his stooling inthat he required Glycerine suppositories to help him stool. Hewas also having some harder stools while in the hospital. Sincebeing discharged mom has noted that Wolfbrand stains considerablyto stool. She has gone up to two days without giving him aGlycerine suppository and during that time he will strain fairlypersistently without producing a stool. Once he has a Glycerinesuppository he will stool. She describes the stool as thickerpaste.

Iam refeningWoJfbrand to you for consideration of possibleHirschsprul1g's versus his inability to relax his anal sphincterto stool. If it is the latter problem, with time this willobviously resolve. However, with the problems he had in thenursery and ongoing problems now since being discharged home fromthe hospital, I would appreciate your thoughts and evaluation youdeem appropriate for the consideration of a low Hirschsprung'sdisease. The parents have been a delight to work with and seeingWolfbrand should be an enjoyable visit for you.

Sincerely,

Vaughn W. Hanson, M.D.,F.A.AP.

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PatientID: 306731Patient Name: WOLFBRAt'lD LEVERETTDate of Birth: 0711112001

Date of Service: 10/16/2001

Date: 1011612001 Provider: VAUGHN W. HANSON MD Note ID: 490231 *OFFICE VISIT~OFFICE VISIT

Wolfbrand is a 3 month old here for follow-up. He was born at 30 weekspremature by an urgent C-section due to concerns about an abruption. He wason the ventilator for HMD and subsequently developed chronic lung disease. Heremained on 02 at the time of discharge. He was weaned off of his oxygensomewhere around the middle of September and since then has done very well.

FEN: He continues to gain weight without any difficulty. He is currentlybeing breast fed and given formula, up to maybe 80 cc after nursing or beinggiven 50 cc of breast milk and 60 cc of formula for somewhere around 3 112 to4 ounces per feeding. He is eating 6 times per day. He has gained almost 4pounds since he was last seen on 9114/01.

GI: Mom is concerned regarding his stooling pattern in that if she does notgive him a GLYCERINE SUPPOSITORY daily he will not stool. She has watchedhim for up to 2 days and he continues to strain and attempt stooling, withoutany success. She notes that his stools were somewhat pasty, She did trysome dark Karo Syrup, which seems to be helping him a little bit as hisstools are a little bit softer. He is getting 1 tsp po bid of dark KaroSyrup in his bottle. She notes that in the nursery he had problems withstooling and had some stools that were constipated, also required GLYCERINESUPPOSITORIES in the nursery to facilitate stooling. Wolfbrand is on ZANTAC.26 cc q12 hours and REGLAN .2 cc q6h for GER. He remains asymptomatic. Theplan is to allow him to outgrow these medications and if he remains.asymptomatic will discontinue them at that time.

A.~'EMIA: Wolfbrand had a BeT done on 9114/01 and that was 35. He looks verypink today. I did not recheck his HCT. He remains on a multivitamin withiron, 1cc per day.

SOCIAL HISTORY: Momhas a Ph.D. in Genetics/Biology. She is currentlyworking on cancer research at the vet hospital at CSU. Her mother is herevisiting from Belgium and w111be leaving this Saturday. Dad is a brew masterat New Belgium Brewery here in Fort Collins.

ALLERGIES: NKDAMEDICATIONS; ZANTAC .26 cc po q12 hours

REGLA.N" .2 cc q6hMULTIVITAMIN WITH IRON. 1 ec qd,DARK KARO SYRUP, 1 tsp po bid.

IMMUNIZATIONS: Up to date for a 2 month old infant.

PHYSICAL EXAMINATION;

TEMP: 99.6 PULSE; 120 RESP: 60 \VT; 9-12#

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PatientID: 306731Patient Name: WOLFBRAND LEVERETTDate of Birth: 07/11/2001

Date of Service: 10/16/2001

Date: 10116/2001 Provider: VAUGHN W. HANSON MD Note ID: 490231 *OFFICE VISIT-OFFICE VISIT

GENERAL: Pleasant 3 month old who is alert and social in NAD.I-IEAD: He does have some moulding on the right side of his head. He

prefers looking to the right, he will turn his head to the leftthough and will come left without difficulty.

EARS: Bilateral TMs are clear. Normal landmarks, good light reflex.PHARYNX: Clear, no erythema or exudate. Tonsils not enlarged.NARES; Clear, no discharge noted.NECK: Supple, no adenopathy palpable.LUNGS: Clear with symmetric breath sounds.HEART: RRR. normal 81 and 82. No murmurs.ABDOMEN: Soft and nontender, Liver and spleen are nonpalpable,SKJN: Clear, no rash.ANUS: Appears to have normal tone, normal patency. Rectal exam not

done today. No evidence of any rectal tears.

IMPRESSION1. Three month old infant born at 30 weeks premature showing good weight

gam,2. History of constipation. Question whether it is due to incoordination of

relaxing his sphincter versus possible 1mV'Hirschsprung's3. History of chronic lung disease that is slowly resolving. He went off

oxygen less than 1 month ago and seems to be doing fairly well.4. History ofGER which is quiet.

PLAN1. Continue with ZANT AC and REGLAN as outlined above. Will let him outgrow. the doses and then discontinue. Is showing no current signs of GER.2. Observation for pulmonary symptoms and referral for SYNAGIS is in the

works.3. Referral to pediatric GI at Children's Hospital to rule out a low

Hirschsprung's.4. Observation of the anemia, which seems to be resolving.5. Follow up at 4 months of age for a well care check and immunizations at

that time.

Vaughn W. Hanson. M.D.l1cvb

ELECTRON1CALLY SIGNED BY VAUGHN HANSON MD ON 2001-10-17