Z: bh"` I childI`8TIIS -- . . I . io A . i kazaa Ch1ldren's Hospital of Wisconsin PATIENT: Curtis, Karmari MRN: 2299421 DOB: 09/ VISIT 46865000 ADMISSION DATE: LOCATION: W04 W04l3 A DATE OF SERVICE: PROVIDER: ALICE SWENSON, MD CHILD ADVOCACY CONSULTATION . REQUEST FOR REFERRAL: Dr. Lal from the Surgery Department requested that Child Advocacy evaluate 2-year l-?month-old Karmari Curtis for possible physical abuse. He is evaluated on the Intensive Care Unit on 4 West and is accompanied by his mother, Williette Famolu. CHIEF COMPLAINT: Abdominal trauma. HISTORY OF PRESENT EVENTS: The records from outside emergency department as well as from Children's Hospital of Wisconsin_ were reviewed on the inpatient unit. A history of present events was then obtained from Karmari's mother, Williette. Williette states that in the days prior to Karmari's presentation for medical care on he was in his usual state of good health. She states that on Saturday, Karmari was cared for by mother's boyfi?iend, Cory Benson. Williette noticed the following day in the morning that there was a color change to Karmari's penis, but she attributed it to a diaper rash. On the night prior to Karmari's presentation for medical care, Williette states that Karmari was in his normal state of good health. He went to bed at his usual time and woke up on at his usual time around 7 a.m. He ate his normal breakfast which was 2 bananas, orange juice, and some oatmeal. He was picked up by his daycare at 9:20 a.m. in a van. Williette states that she spoke to the daycare between I and 2 p.m. when she called to remind them that he had ointment in his bag for his diaper rash. The daycare said that he was fine. Williette states that she was going to be working until 8:30 p.m. but she did not want Karmari to stay at the daycare that whole time. Usually her own father, Joseph Famolu, takes care of Karmari and p_icks him up from daycare if needed. Joseph was not availabl_e so Williette asked Cory to pick up Karmari after his own work. Williette got a call around 6:52 p.m. at which time Cory told her that he had picked up Karmari and he was fme. Cory told Williette that he would pick her up around 8:40 because she usually did not get out until a little late. Williette said that she would try to get out as close to 8:30 as she could. Williette states that during this conversation she heard Karmari whining. Also during this conversation Cory spoke to Williette about wanting her to help him discipline Karmari. Williette states that she told Cory that is was fine ifCory wanted to tell Karmari when he did something wrong but that he was not allowed to use physical discipline. Cory told Williette that he would never put his hands on Karmari. Williette then got a call from Cory around 8:30 p.m. saying that Karmari had been sleeping and he was getting him ready. _He said that he had eaten that evening. He also stated that Karmari had pooped and he had to change his diaper. At 8:49 Cory picked up Williette from work. Karmari was lying in the back seat, not in his car seat, and looked like he was tired. Cory told Williette that Karmari was exhausted from having played football. Kamiari seemed to be mumbling in the back seat. When they got to Cory's house, in order to change Karmari's diaper, Williette picked up Karmari and noticed that he was very pale and his lips looked dark. He wanted water so she gave him some. She went to change Karmari and noticed that had bruising on his chest and his belly. She also noted that his belly seemed wider than Page 'l I Children's Hospital of WI PATIENT: Curtis, Karmari MRN: 229942l VISIT 46865000 usual. She said that the lower abdomen looked red or purple and she thought there might be intemal bleeding. She also noticed that Karmari's penis was purplish blue. When Williette asked Cory what had happened, he said that they had been playing tackle football and Karmari fell. At one point, Cory pushed Karmari and he (Karmari) hit himself on the edge of a bed. At this point, Williette brought Karmari to Aurora Sinai Emergency Department ftom where he was transferred to Children's Hospital of Wisconsin. Williette states that she has had no previous concerns about Cory hurting Karmari. She states that Cory has taken care of Karmari on his own about 4 times. PAST MEDICAL HISTORY: Karmari is a generally healthy boy. He was born on time by normal spontaneous vaginal delivery. Mother and baby went home after 4 days, and mother states the delay in discharge was because they needed to make sure he was "okay." Karmari is up to date in his immunizations. He is allergic to azithromycin. He has never been hospitalized ovemight. He has never had any surgeries. He has never had any broken bones or stitches. He has never had any seizures. He has no history of easy bruising or easy bleeding. They are currently working on potty training. He is developmentally keeping up with other kids his age, running and jumping, and trying to skip. Mother describes him as a generally happy, interactive child. He is followed for his primary care at Columbia St. Mary's by Dr. Hanson. . FAMILY HISTORY: Mother states that she, herself] bruises somewhat easily but has no diagnosis of a - bleeding diathesis. There is no family history of easy bleeding. There is a 7-year--old cousin with poor . dentition described as teeth overlapping but no history of lack of enamel or early hearing loss. There is a maternal grandmother with hypertension. There is no family history of diabetes or heart disease. SOCIAL HISTORY: Karmari lives at home with his mother and his maternal grandfather. He attends Bright Beginnings Daycare. When not in the care of his mother, he is usually cared for by his matemal grandfather. Karmari's father lives in Phoenix, AZ. REVIEW OF SYSTEMS: Karmari isjust getting over a cold: approximately a week before this presentation, he had runny, stuffy nose, fever, and cough. Over the last week he has not had any fever, but he does continue to have a stuffy nose. He has not had any seizure, runny nose, cough, vomiting or constipation. He has had diarrhea over the last week with about 6 loose stools a day. He has had diaper rash on his bottom. He has had no other rashes. The abdominal and chest bruising was noted on 10/25, the day prior to this evaluation. A complete 14-point review of systems was otherwise negative. PHYSICAL EXAMINATION: I GENERAL: Karmari is an obviously uncomfortable and very unhappy 2-year-old boy. He is fussy and difficult to console. HEENT: Head normocephalic, atraumatic. Ears: TMs clear. Eyes: Pupils equal, round, and reactive to light. Nose: No discharge. Mouth: intact frenula. Oropharynx: Clear. NG tube visualized in the posterior oropharynx. NECK: Soft, supple. No HEART: Sl, S2. No murmurs. Regular rate and LUNGS: Mild with some splinting. No wheezes or crackles are noted. ABDOMEN: Diffusely extremely tender with no bowel sounds appreciated. There is obvious abdominal bruising noted (see below in skin exam). Unable to palpate for organomegaly due to patient discomfort. SKIN: Warm and well perfused. Dif`f`usely over the abdominal area there is red bruising with some linear components noted. On the chest area, there is an area of brownish bruising. The entire penis is purplish . . 2 rf}. Page 2 . ChiIdren's Hospital of WI . PATIENT: Curtis, Karmari MRN: 2299421 VISIT 46865000 in color and nonblanching. On the buttocks, there is a ring of blanching hyperpigrnentation surrounding the gluteal cleft. Digital photographs were taken to accurately document these findings. . GU: Uncircumcised, Tanner 1, bruising as noted above. MUSCULOSKELETAL: Appears to move all 4 extremities well and without deficit, although patient has somewhat decreased activity level. . - NEUROLOGIC: Grossly intact and nonfocal. . LABORATORY STUDIES: Admission ALT 5353 (normal high 35). Admission AST 10,128 (normal high 58). Admission glucose 205 (normal high 100). Admission hemoglobin 8.4 (normal low 11.5). Admission platelet count 551,000 (normal high 450,000). Amylase 574 (normal high 81). . Lipase 6273 (normal high 300). Coagulation studies: Normal PTT. PT elevated at 16.6 (normal high 13.6). RADIOLOGIC STUDIES: CT abdomen and pelvis: CT of the abdomen shows multiple liver lacerations including lacerations extending from the anterior aspect of the caudate lobe into segments 4a and 8. Lacerations also involve the anterior capsule of segment 8, segment 5/8 extending to the left portal vein bifurcation and segment 5 which extends to the falciform ligament. There is a probable additional small laceration in segment 6 lateral to the gallbladder fossa. There is marked periportal low attenuation which may represent edema or periportal blood. The spleen, pancreas, and kidneys appear intact. The right adrenal gland appears enlarged and may be secondary to adrenal hemorrhage or adjacent hematoma. There are multiple loops of mildly dilated fluid-filled small bowel with mild bowel wall thickening. Head CT shows some sinus opacification, otherwise normal. SUMMARY: In summary, Karmari is a 2-year l-month--old boy with the following problem list: 1. Child Physical Abuse, severe and life--threatening, including:. Abdominal Trauma: Karmari presented for medical care with multiple liver lacerations and massively elevated liver function tests as well as elevated pancreatic function tests. The history .. provided was of a game of tackle football. Karmari has evidence of significant extensive abdominal bruising with linear components and massive intemal injuries. . This clinical picture is not consistent with any injury that would have occurred during I household fall nor any injury that Karmari could have inflicted upon himself. As such, this presentation is virtually diagnostic of abusive or inflicted abdominal trauma. These injuries are quite severe and could easily have resulted in death had Karmari not been brought for medical attention when he was. Indeed, at the current time Karmari's condition is quite - serious and life-threatening. The full extent of Karmari's abdominal injuries is not known at this point, and he may have injuries to other organs including the pancreas and the bowel. wil_l need to be observed clinically to determine the extent of his injuries. It is important . to note that Karmari would have been immediately after sustaining these 3 Page 3 ChiIdren's Hospita|_ofW1 PATIENT: Curtis, Karmari MRN: 2299421 VISIT 46865000 injuries. As such, any time that Karmari was noted to*be acting normal, playing, eating, interacting, such as at daycare, would have preceded the events that caused these injuries. 2. Protection: it is of the utmost importance that Karmari be protected from further abuse by the - perpetrator of these injuries. 3. Reporting: this injuries have been reported to law enforcement and child protection. 4. Pending laboratory studies: urine drug investigation screen and urinalysis are pending at the time of this report. 5. Skeletal survey: Karmari will have a skeletal survey when he is stable in order to evaluate for any occult fractures. I-le will need a followup skeletal survey 2 weeks after the initial. 6. Well-child care: Karmari should follow up with his primary care pediatrician after discharge from the hospital. ELEMENTS OF CONSULTATION: The outside hospital records and inpatient records were reviewed on the inpatient unit. This took approximately 30 minutes. History was obtained and physical exam was performed which took approximately 1 hour. Greater than 50% was spent in coordination of care. The films were reviewed with the radiologist which took approximately 10 minutes. This report was dictated on 10/26/2010 which took approximately 30 minutes. This report was edited on 10/26/2010 which took approximately 15 minutes. Electronically Signed by - ALICE SWENSON, MD 10/26/2010 01:45 Dictated by: ALICE SWENSON, MD ADS\scs 10/26/2010 11:47 A 10/26/2010 12:41 Job 667804 Document ID: 601598 cc: COLUMBIA-ST HEA DAVE LAL, MD . Children' Spccialty Group - . Pediatric Surgery Clinic Children's Transport and Central Scheduling . PO Box 1997, Milwaukee WI 53201 Center (414) 607-5280 chute phone: (414) 266-6420 .(414) 266-2460 (817) 607-5280 Clinic Fax: (414) 266-1627 (800) 266-0366 - Sag EXHIBIT Consultatlon 46885000, Ftnat Genera! gs ur it *9 . Hospital of Wisconsin i - Curtis, Kannari MRN: 2299421 DOB: 09/ 16/2008 VISIT 46865000 ADMISSION DATE: 10/26/2010 LOCATION: W10 Wl005 A DATE OF SERVICE: 11/ 1 5/2010 PROVIDER: ALICE SWENSON, MD - CHILD ADVOCACY CONSULTATION REQUEST FOR REFERRAL: 'Ihe Milwaukee Police Depaitment Sensitive Crimes Unit requested that Child Advocacy evaluate crime ceue photo taken on 11/9 and 11/ 11!20 10 regarding the case of the physical abuse of Karmari Curtis. CHIEF abdominal trauma including liver laceration, pancreatic injury and adrenal hemorrhage. PHOTOGRAPHS REVIEWED: Two photo DVDs were provided. The tirst photo DVD is dated 11/9/20 10 and contains the following photos which are reviewed on DVD and in hard copy: A photograph of Karmari Curti wearing a green camouflage shirt and looking at the camera. . A photograph of Karmari Curtis standing without ashirt but wearing jeans. There is a measuring tape held next to Karmari at standing height. Karmari appears to be approximately 34 inches tall based on the measuring tape. A close up photo of Karmari presumably standing next to the yellow measuring tape. Again, his height is noted to be 34 and 35 Digital photograph of Karmari, this time wearing a shirt, again with the yellow tape measure held next to him. Again, his height is noted to be between 34 and 35 inches. It is estimated that his abdomen is at approximately 16 to 21 inches. A close up photo of Karmari's upper body and face with the yellow measuring tape next to him. Again, his height appears to be between 34 and 35 inches. There is afinger pointing to his chest between 23 and 24 inches. Digital photograph ofthe torso and legs of Karmari Curtis. The umbilicus appearsto be at approximately 18 inches. 'l`he chest. appears to he between 21 and 22 inches. A close up photo ct`Karmari Cuttis's abdomen. The yellow tape measure is again noted. The abdomen appears to fall between 17 and 21 inches approximately. The lower part of Karmari Curtiss body in jeans. 'I`he yellow tape measure is again noted. Again, . the tunbilicus is noted to be between 17 and 18 inches, although the tape measure is somewhat diagonal in this photograph. PATIENT: Curtis, Kannari MRN: 2299421 VISIT 46865000 Card noting Milwaukee Police Department photographic record sheet, 507 E. Locust Street, date 1 ll'9/2010, 1 a.m. Incident Child neglect/physical abuse, photographer Castro, camera body 43 678, number of photos 9. . A second photo disc is reviewed dated 1/2010. The following photos are reviewed. - A photograph of the corner of a mattress and box spring on a metal frame. The distance from the floor to the bottom ofthe box spring appears to be approximately 7 inches. The distance from the bottom of the box spring to the top ofthe box spring appears to go from 7 to 16 inches. The distance from the bottom of the mattress to the top ofthe mattress appears to go from 17 to 25 inches. The mattress, box spring and frame are again measured. Again, the distance from the floor to the bottom ofthe box spring is approximately 7 inches. The distance from the bottom ofthe box spring to the top ofthe box spring is from 7 to 16 inches (a total of 9 inches}. The distance from the bottom of the mattress to the top ofthe mattress is approximately from 17 to 24 inches (approximately 7 inches). . . A closeup ofthe corner ofthe mattres with a brown sheet over it. A yellow tape measure is held against the corner. 'l`he total height ofthe mattress itself appears to be approximately 9 inches. Measurement ofthe corner ofthe box spring. From the bottom of the box spring to the top appears to be approximately 9 inches. No pecific patterns are noted on the box spring other than several areas of stitching. A closeup ofthe corner ofthe box spring. Plastic cover on the corner is noted which reads Simmons. 'I'he yellow tape measures the distance from the floor to the bottom ofthe box pring. This is approximately 7 inches. A photograph ofthe bed previously noted. No measuring device is noted in this photograph. A photograph of the room including the bed. A card noting Milwaukee Police Department photographic record sheet, location 2224 W. Wisconsin #510, CAD #10-315-0420, assignment phy-abuse-child, number of photos 8, photographer J. Young RADIOLOGIC STUDIES: Follow-up skeletal survey was performed on ll/09/2010. This did not demonstrate any fractures. SUMMARY: In summary, Karmari is an almost 26-month-old boy who initially presented for medical care on 10/25i20l0. Kannari presented with severe grade 4 liver lacerations, adrenal hemorrhage and pancreatic injury. Karmari's injuries were so significant as to have been life-threatening at the time of presentation. Notably Karmari required admission to the Pediatric Intensive Care Unit and was unable to eat for several days. It is clear that Karmari could have died had care been delayed any longer. These injuries were extremely severe. The history provided at the time of admission was that the abdonrinal injuries were sustained accidentally when Karrnari ran into the comer of anrattress and box spring. Karrnari, as a 2-yeanold child, would be unable to create enough force to have caused such significant and massive injuries to himself. Review ofthe photographs of Karmari and ofthe scene - indicate that Karmari's abdomen falls at approximately 17 to 22 inches. Based on the photographs ofthe scene, this would mean that his abdomen would have run into either the comer of the mattress or possibly the top ofthe box spring. These items could not have caused the significant injurie Karmari sustained. . A mattress and box spring are relatively soft and have no clear patterns to explain the linear appearance of the bruising on Karmari's abdomen. In addition, Karmari had _bruisi.ng to both his abdomen and hi chest suggesting more than one impact The history provided of an accidental fall into a mattress and box 7 - PATIENT: Curtis, Karmari MRN: 2299421 VISIT 46865000 spring is not consistent with Karmari's injuries, particularly given the photographs ofthe scene that are reviewed at this time. Taken as a whole, the clinical picture is of a child who was the victim of at least one an probably several massive blunt impacts to the abdomen and chest, causing bruising, some with linear components and massive internal injuries. No history of signiticant accidental trauma has been provided to explain these findings. As such these findings are diagnostic of severe inflicted ELEMENTS OF CONSULTATION: outside photographs were reviewed which took approximately 20 minutes. This report was dictated on 11/ 1 5/201 0 which took approximately 15 minutes and was edited on 5/2010 which took approximately I5 minutes. Electronically Signed by ALICE SWENSON, MD 11/15/2010 12:43 l' Dictated by: ALICE SWENSON, MD ll/15/201011:26 A ll}15/2010 12:12 Job 685378 Document ID: 617681 ec: I 8 . I