January 16, 2001

RE: Triton Thomas Arnold

To Whom It May Concern:

Triton has an inherited disorder called Congenital Adrenal Hyperplasia (CAH), which involves the adrenal glands. Without the replacement of life essential hormones, this could be fatal.

The excess androgens, that Triton has, may cause rapid growth, advanced bone age, and if medications are given correctly, this will stabilize growth. However, his growth has become excessive which is probably due to missing medication occasionally. It is medically necessary to give medication EXACTLY as ordered. It can be fatal if child does not have adequate hormone replacement.

The primary problem in a patient with CAH is low cortisol. It is the hormone that helps your body react to stress. It also plays an important role in regulating blood sugar and the body's energy supply.

In the event of physical stress orof illness, the child will need a stress dose of cortisol replacement. Physical stress is characterized as fever higher than 10 1 degree Fahrenheit, strep throat, ear infection, pneumonia, vomiting, muscle strain or sprain, broken bone, or a serious accident that requires immediate medical attention or hospitalization. During time of illness or stress the body needs larger amounts of hormone to heal. People with CAH do not make enough cortisol to help the body recover from illness or injury. They also need to drink extra fluids (8-12) ounces every hour while awake) to help prevent dehydration. In other instances, if the child "looks bad" (pale, sweaty or breathing fast), feels weak and/or unable to respond normally, loses consciousness, or has a serious injury, such a broken bone, this would be considered a life-threatening emergency and a need for an injection of rapid-acting cortisol (which is to be keep on-hand) immediately!

Mother reports stress level for Triton in high during visitation with father. Mother also states father made comment that he does not think Triton needs his medication much. Mother also reported when Triton had a concussion in 1998, and father did not give appropriate dosage for medical crisis.

Triton needs to maintain a low stress level and continue medication as directed in order to maintain a healthy life.

Sincerely,

Rae Lynn Johnson, RN, CDE

Endocrinology Specialty Nurse

Stephen Kemp, MD, PhD

Chief, Professor of Pediatrics