Age: 1.25
Sex: M
Vaccine: MMR
Symptoms: Agitation, Aphasia, Autism, Gastrointestinal disorder, Injection site mass
Clinical narrative: The pt experienced a fever, knot at the injection site for an extended period, fussiness, irritable, loss of skills, language, comprehension etc. 60 day follow-up dated 7/10/00 provided a corrected age. Annual follow-up states the pt has metabolic disturbances, mitochondrial problems, GI issues, PDD. Pt is now a 3 year, 9 month old child with a diagnosis of Autism Spectrum Disorder/Pervasive Developmental Disorder. Pt has been referred for a neurological consultation by his pediatrician. Pt was seen previously for a neurologial examination in June of 1998. He returns today to review his developemental and neurological status, to examine his educational and therapeutic interventions and to determine whether any adjustments or amendments need to be made in his overall program plan. Pt was accompanied to this assessment by his parents who provided much of the background information. Currently, pt has now gotton some words and is trying to imitate sounds made by others. His parents are pleased that he is now making more of an effort, whereas before he simply became frustrated. Words which he tends to use with some reasonable consistency include mam, go, bye, and dada. He has also learned to shake his head yes or no appropriately and is developing the use of the "H" constanant sounds. He currently recognizes 19 letters, all of his shapes and colors and he is currently working on generalization and can point to shapes in a book. Play skills have like wise improved as has eye contact. He has a tendency to become fixated on the same four viseo tapes but rarely asks for television. He ossupies himself with toys and can play alone for more than an hour. SOme perserverate behavior and play behavior however, can be exhibited. In terms of dressing skills, pt is now able to take off his shoes and socks and is otherwise able to help with dressing. However, he requires a good deal of repetition. From the health perspective, pt has been in good health and there has been no major medical issues. However, he continues to have eczema, which is "itchy all of the time". The parents have made an appointment to see an immunologist at hospital around elevated IGE immune titers. They have been invited to participate in an immune therapy study, headed by MD at hospital. Pt continues to participate in a home program and has had a stable, consistent therapist for some time. He aslo receives speech and language services and occupational therapy services, the later have started approxiamtely four to five months ago. originally the school occupational therapy session was listed as two 30 minute sessions per week, but has been changed to one, one hour session weekly. His current therapist is trained in sensory integration and has works for occupational therapy. More recently, pt has begun to work with a speech and language pathologist at the hospital. He is being seen twice weekly and started this service in Oct of 1998. Already the parents feel that they are seeing good forward progress and feel that Pathologist has a good relationship with pt. It is also noted that pt has been seen by MD for gastrointestinal problems and MD wants to pursue these studies which would included endoscopy. Parents indicated that pt tends to be sensitive to noises and frequently cover his ears. They wonder if there are any other therapies which might be brought to bear to help him with what appears to be auditory sensitivities. Further, parents indicate that there are periods during which pt tends to stare into space. he comes back with self stimulatory behavior and has been known during around these times, to have hand shaking behavior. A routine EEG has been performed, which is said to be within normal limits. On examination today, pt is a very pleasant, well developed, well nourished little boy who comes reaily to he examining room with his parents. Overall, he is rather quiet however, and he is still not using his language or words to initiate communication with others. Further, his non-verbal communication appears to be somewhat sparse. His height is 39 1/4 inches, his weight is 38.8 pounds and his head circumference is 50.5 centimeters. His general physical and neurological examination remains very much as they were in June of 1998 and there has been no substantial change. He does attempt to make more sounds however and can be crued to imitate.