Age: 2.2
Sex: M
Vaccine: HIBV, MMR
Symptoms: Abdominal pain, Abnormal behaviour, Aphasia, Autism, Crying
Clinical narrative: Within 2 weeks, post vax, noticed pt not responsive to his name anymore. Lost all eye contact and seemed in a "fog", started excessive toe walking. Lost all acquired words, started holding stomach and continually crying. Looked like he was in pain. Chronic diarrhea started. Autism was dx'd after many series of tests. History of present liiness: Pt is a 23 month old little boy who s being seen for his initial evaluation through the clinic because of concerns about development. Parents report that they felt that pt's development was okay up until he was apprx. 15 months old. They report that at 14 to 15 months, pt was saying a few words such as, mama, dada, ball, and oh oh. He was interactive and would play patty cake. At about 15 months of age, they noticed that he seemed to lose words, stopped talking, and did not babble as much. He became less responsive to his name and would not come when called. He started toe walking and jumping alot. His eye contact decreased and he seemed less socially interactive. He was no longer very interested in people. He also became less interested in toys. Parents noticed that he was doing more blank staring. He quit imitating things. This past February, pt was seen by MD for a neurology evaluation. He had an abnormal EEG, although apparently it did not suggeste a clear cut seizure disorder. MD suggested, but parents opted not to start pt on medication right away. They report that pt is scheduled to have a repeat EEG next month. Pt also has a history of chronic diarrhea. MD ordered in abdominal x-ray and diagnosed constipation. He explained to parents that he felt the loose stool was actually leaking around compacted stool. He suggested they try giving pt Milk of Magnesia, mineral oil, or enemas. Parents report that pt has a long history of having watery stools. They report that the last few days, pt'a stools have been more formed, although they are not sure why. The parents have also pursued other treatments for pt. They had lab work done, which apparently indicated a number of abnormalities including a yeast infection. Therefore, pt is currently taking Acidophilus, Uvaural, garlic for the yeast infection, DMG, and Supernothera as well as vitamin C. These apparently were suggested by MD. Parents report that since February, pt has been off dairy products and gluten products. They report they noticed a slight increase in eye contact with pt once he was taken off gluten and dairy products, although he continues to diplay poor eye contact. Mother has had concerns that pt is diplaying some autistic features. Pt was seen by a psychologist last month. Who felt that pt was on the Pervasive Developmental Disorder spectrum. Mother reports that pt usually does not respond to his name. He may respond perhaps 30 % of the time. If he wants something, he will get it himself. He does not say words and mainly grunts for vocalization. He does not point to identify wants and parents report that they do not think that he ever pointed. Pt likes playing on swings and watching Barney videos. He likes pizza ans will play with puzzles and shapes sorters. Overall however, pt is not very interested in toys. He does not play with toys appropriately. He likes jumping on the trampoline and he likes jumping in general. He likes playing with strings. He walks on his toes. He has poor eye contact. At times pt will close his eyes and squint and hold his head back. He is usually oblivious to other children. If they come up to him, he may push them away. He stares off into space and likes staring at lights and fans. Parents feel that he has good motor skills. He likes climbing on things. Pt is a loner and likes being off by himself. He will sometimes laugh for no reason at all. Other times they will find him crying when he is watching Barney or at other times. Sometimes when he is crying, they wonder if he is in pain, pt does not engage in pretend play. Pt goes to bed at around 8pm or 8:30pm. He may sit in his crib for awhile, but he is usually asleep by 9pm or 9:30pm. He sleeps through the night and usually wakes up by 6:30 am or 7:30 am.