Age: 0.2
Sex: M
Vaccine: DTP, MMR
Symptoms: Speech disorder
Clinical narrative: Pt has high fever's of 103.6F, not eating well, red rash shortly after shots. It was reported every time. Autism. Note attached, the problem has been reported to the Dr since the age of 1 year and nothing was ever done. Mother has gone on her own to someone else that states her child has autism traits/PPD.  There were not other sheets scanned it states (over). Per doc 213823, mother states the following: "My child is a PDP, however he is going to take test so we can make the correct diagnosis of what type of autism the patient has". Doc 213823 also states the following: behavioral, adaptive, cognitive, speech delays and difficulties, poor social interaction skills, poor impulse control, poor attention, lack of danger awareness, stereotypical behavior, personal hygiene, fine gross motor difficulties, textures food, self stimualtion, sensory difficulties. 60 day follow up states that pt has not recovered. Pt was giving PDD label in August 2002 for speech, social skill, fine, gross motor skills, attention span poor, off task, below average age. Pt was accompanied to the evaluation by his mother and younger sister. Mother reports that he is in good physical health and takes no medications. Pt is currently getting speech therapy twice a week at hospital due to apraxic speech. He has recently had a PT evaluation at the therapy center and will be receiving physical therapy servoices as well. Mother reports that he will be going to elementary next year in the pre-kindergarten class and will be receiving speech therapy also while at school. Pt was very qiet and shy in behavior. This could be due to severe speech problems. He would gesture or shake his head yes or no, but would not speak to the therapist. He required a lot of encouragement to try to participate in any activities. Mother, therapist and younger sister would all get in an activity to try to encourage him to participate. Most of the time, he would just shake his head no and sit down on the floor unwilling to participate. He seemed to do better once Mom left the room, with visual demonstration and physical prompting to initiate activity. Pt is able to feed himself independently with a spoon or fork. However, Mother says he demonstates an awkward grasps. Showing therapist, it was more of a palmer grasp. He is able to drink from a regular cup independently. Pt is able to dress himself. However, he may need assistance with putting on socks and with clothing fastners. Mother reports that she usually uses elastic pants. Today during the assessment, he was observed to unbutton and button a large button on an vest. Pt reportedly has a severe speech delay. However, he was not observed to say much to the therapist today. Mother reports that he does say single words such as "Mom, Dad, Hi, Bye" and occasionally will puttwo words together. He typically communicates through body gestures and he is learning sign language and can sign "Mom, Dad,eat, drink, stop, wait and frog". Pt has a tricycle that he has brought tothe therapy center for PT that he enjoys riding. However, he has difficulty doing sa at this time. He did enjoy playing ball. Pt demonstrates overall muscle weakness in both arms and legs. He had difficulty with weight bearing activities. He was unable to wheelbarrow walk without collapsing. He had difficulty pedaling the bike, pushing down with his legs in order to pedal the bike. He demonstrates mildly low tone. he demonstrates an upright posture when performing activities and while sitting at the table. Vision appears to be intact. He was able to visually tract an object in all planes. Mother reports hearing seems to be ok. Pt appeared to have difficulty with sensory processing, especially with vestibular and proprioceptive processing. This allows you to know where you are in soace and the relationship of objects around you. He had difficulty with spatial orientation, balance, unable to do the balance beam or unwilling to stand in one foot with therapist's assistance. He wouls seem to be constantly leaning back on the wall or sliding himself down the wall to sit, squeezing objects that he holds in his hands such as writing utensils or feeding utensils to try to get more proprioceptive feedback to where he is in space. He had difficulty in planning an activity as to where to start and what step comes next. he required a lot of visual and "hands on" to perform a one to two step motor sequence activity. Pt was able to walk independently. He does demonstrate difficulty with balancing activities. He had difficulty with the balance beam, not wanting to alternate his feet and to put one foot in front of the other, but would just scoot himself along the beam. He is unable to demonstrate alternating foot pattern descending stairs. He tends to at times, drag his right leg. He has difficulty pedaling a tricycle which is being addressed right now in physical therapy. He had difficulty catching a ball from 10 feet away and had difficulty throwing an object to hit a target. At this time, he has not established a dominant hand. He tends to switch hands when performing activities. He demonstrates awkward graps such as when holding a spoon or crayons. he tends to use shoulder movements instead of more defined finger moevments when coloring. He was observed to squeeze the crayon and press very hard when asked to color in a shape and take minimal regard to the boundaries, scribbling in all directions. He was able to hold scissors with his right hand and open and close them to cut out a square with 75% accuacy. He was able to complete small manipulatives such as Legos, stacking objects. He did have difficulty with finger isolation when asked to count with his fingers or imitate finger play such as "Itsy Bitsy Spider." He was not observed to sign anything in imitation oftherapist when she asked him things that he could sign per Mother's report. Pt had difficulty tracing through a 1/2in curvy maze with two deviations noted. He shows minimal regards to boundaries when coloring. He was able to imitate a vertical and horizontal line: however, had difficulty with a good circle, and he was able to trace a circle with dotted lines to stay on. He was unable to copy a smiley face with eyes, nose, and mouth with a model provided. This was not addressed due to speech delay. He demonstrates inattention during sit down activities, however, required a lot of encouragement to participate in activities. He had difficulty following verbal directions requiring visual demonstration possibly due to difficulty in understanding/processing the directions. Pt is a 5 1/2 year old boy who demonstrates difficulty with overall sensory processing which makes it difficult for him to move around his environment in a safe, secure manner. He also has diminished strength which makes daily activities difficult for him.