Monday, November 27, 2006

ian's current deal

patient id:
patient name: ian rainbowjr
date of birth: date

date of service: date



evaluating clinician:
devdoc md

accompanied by:
both parents

consultation: this appointment is a consultative visit. following this visit, a report will be sent to the referring doctor. this patient is seen in consultation at the request of dr. awesome pede, md.

current diagnosis: selective mutisim by patient report, diagnosed at school.

medications:
none

current allergy list: none

chief complaints:
not making progress in ppcd, diagnosis is selective mutism, in fine and gross motoer and speech therapy once per week individually. no other diagnosis. has global development delay as well. has many sensory issues and stereotypies. [sic]

history of presenting problem:
parents first started to worry around 18 months of age; had been in eci for speech delay starting at age 27 months, never made babbling noises, never labeled things.

uses a few words now, has about 100 words but does not ever answer a direct question. ian can count to 20, knows colors and shapes. at school he will not use this knowledge. will go off in a corner with toys and count on his own but wil not use his numbers functionally.

indicates needs by crying, or just does not indicate. he will bring a cup, but this is new. very laid back, will not ask for things. no favorite toys, or tv show. not potty trained, very apathetic. not bothered by dirty diaper. will follow a point, but will not point to indicate or interest, seems to not want to do things.

walked at age 15 months. first words at age 20 months, choo-choo, made sounds only such as zoom, animal sounds. just started saying mama and dada at 4 years. said i love you once at 4 years.

has some pretend play: appears to make up stories; parents observe him talking in single words to his toys, but never tells them what the story is. often names things. likes to line up cars, races them. loves to spin wheel on cars, likes yarn, likes to lay on ground and watch wheels move or watch water run from faucet, or plays with yarn by running it through fingers.

at school likes to play alone, does not interact with kids in music time or in circle time. lays on ground and plays with toys on floor. likes to use yarn or wheels to go to sleep at nap time.

had ct at age 3 at ccmc normal, dr. brainguy ordered was at neurology at ccmc, dr. genetics did testing for fragile x, normal, and had amniocentesis but do not know what was tested but all normal. audiology behavioral audiogram could not test, think they did oae at ccmc, normal. vision seems fine.

can eat with a spoon but often plays with food instead, uses fingers for most of his eating. scribbles with crayon, cannot color in lines, cannot tell where to use different color, cannot hold pencil correctly, cannot draw a circle. no regression in development. no seizures.

regarding his selective (also called elective) mutism, parents report ian never uses normal language in any setting. his language is delayed an atypical in all settings.

past medical history conceived by ivf, g1, normal pregnancy born at 36 wks, induced due to preeclampsia, wt 4-6, in incubator 10 days, on o2 for a few days. amniocentesis normal, mom lost 2 pregnancies, now has 3 yrs old one girl one boy, doing fine.

medical no significant history of medical diseases.
surgical inguinal herniorrhaphy bilaterial.
childhood diseases/illnesses normal childhood diseases
previous immunizations all are current
other hearing normal
academic history: school: bess race elementary school. isd: crowley independent school district. ppcd.
family history: pedi family history: no consanguinity, no other developmental problems. depression runs in family. parents and siblings normal.
social history: not pertinent to the history of present illness.

    review of systems

general: brief review of systems reveals no concerns related to skin, heent, endocrine, pulmonary, cardiac, gi, gu or neurologic symptoms.
all systems reviewed and are normal except as noted. rare ear infections.

physical exam
vital signs
vs-pulse: 102 va vs machine, regular
vs-blood pressure: 119/75 right arm sitting
vs-height: 107.9 cm
vs-weight: 16 kg
head circum: 51cm upper normal range
hearing screening was attempted and this child was unable to cooperate due to lack of understanding.
vision screening was attempted and this child was unable to cooperate due to lack of understanding. audio 2005 at cooks, wnl.
physical exam eyes: no discharge, conjunctive is clear. ent: tympanic membranes clear, no nasal discharge, normal pharynx. mucous membranes moist. neck thyroid: supple neck, no adenopathy. no thyroid enlargement, tenderness, or mass. respiratory: clear to ausultation and percussion. normal respiratory effect. cardiovascular: regular rate and rhythm, no murmur. chest/breast: normal to inspection and palpitation. gastrointestinal: soft, non-tender, without masses. bowel sounds active. lymphatics: no lymphadenopahty. musculoskeletal: no join or bone abnormalities seen, no muscle weakness. skin: no rashes, normal color. neurological: the cranial nerves are intact, no sensory, motor, or cerebellar defects. reflexes are normal. no meningeal findings. genitourinary: normal in appearance, testes are descended bilaterally by history, would not let me palpate.

observations: very little eye contact even on direct request. points to objects on tests with whole hand, rarely looks up at me, often looks out of side eyes. frequently taps face or legs with one or both hands when doing tests. preoccupied with a hand full of yarn bits he brought with him. copies circle and cross but very poor grip on crayon. can name a few items on kbit but can not tell me anything about them, what they are used for, what sounds animal makes, etc.

pediatric testing materials: kauffmann brief intelligence test kbit, matricies ss90, verbal ss80. ppvt iiia peabody picture vocabulary ss87. geselle figures: can draw a simple circle or cross, not a square or triangle. holds pencil awkwardly.

gilliam autisim rating filled out by parents quotient 115, in the average risk of autism. sub scales stereotypes 10, communication 11, social 10, developmental 8. childhood autism rating scale filled out by me with some parent input score is 31, or just above the cutoff for mild autism.

299.00 infantile autism, current or active state
assessment autism plan is as follows: parent support groups such as the families for early autism treatment and the autism society of tarrant county are excellent resources for networking with other parents and increasing knowledge about applied behavior analysts and educational/advocacy issues. the feat organization puts out a newsletter and they provide information and workshops dealing with challenging behavior, helping parents deal with the school issues, etc. an autism packet has been given to parents. i explained the concept of autism to parents; ian seems to be a high functioning autistic, with iq on my screening in the lower half of normal range.

recommend: parents will present our findings and diagnosis to school and see if he can qualify for a classroom specifically for autism, if available. an aba program is often helpful; gave parents a brochure about aba and our program and others in the area. they will ask if aba techniques are available at school.

315.32 receptive language disorder (mixed) does not meet criteria for selective mutism (formerly called elective mutism) in which child talks normally in some settings and not at all in others. ian uses his language skills about equally in all settings, and they are both delayed and deviant (atypical) in all settings, his nonverbal communication is limited as well. hearing has been tested and is normal.

recommend: intense speech therapy as many times a week as possible. referred to ccmc for additional therapy to supplement school program.

315.4 developmental coordination disorder holds pencil, crayon awkwardly, delayed in his drawings. delayed in self care and has sensory issues. recommend occupational therapy as much as possible. referred to ccmc to supplement school program.

lab work: none ordered, he has had considerable already. will have parents sign releases to get work from dr. genetics, brainguy and awesome and review at next visit to see if anything else is indicated. we did discuss risk of recurrence around 5-8% for subsequent pregnancies when one child has autism.

time with patient/parent
total 90 minutes. 40 minutes testing.
return visit: 6 months or prn questions, for a one hour visit.

electronically signed by dr devdoc, md, on date

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