|Early morning story time in Mommy and Daddy's bed with Allie, Andrew, and Baby (the bunny)|
Reason for Consultation
The patient was a 3-and-1/2-year-old, bright, preschool age girl with a history of a right hemiplegia secondary to an intrauterine stroke. The patient has fine and gross motor skill delays secondary to her in utero stroke. She returns today to discuss her neurodevelopmental profile, overall progress, and treatment plan. During this 60 minute visit, more than 50% of the time was spent in counseling and care coordination.
The patient is using language to request and to comment and to initiate with others including her friends. Her mother has observed her in good interactive play when there have been play dates in place. The patient is able to take shoes and socks off and is working on other dressing skills.
The patient continues to be strong-willed but this does not seem to interfere with day-to-day activities. She did demonstrate her strong-willed tendencies during office today and was reluctant to give up using the red marker. These behaviors did not interfere by mother's report with the patient's preschool program. (The doctor's note was generous with this comment. Allie dictated almost all of the activities that they did, including where the doctor should sit, which markers he should use, and she insisted on testing his reflexes after he tested hers. At one point he looked at me, smiled, and said "she has CEO potential!")
The patient has a tendency to keep her right hand in a more fisted position but uses her right hand well to assist her left hand. The patient's hand can be opened and she did not seem overly sensitive to my touching her right arm or hand. She does have some increased muscle tone on the right side, especially the right upper extremity over the right lower extremity. Muscle mass and strength seem good. She had a tendency to keep her right upper extremity slightly flexed at the elbow. She does have increased tone in her right ankle but can assume the functional flat-foot position. When walking, she does have a toe-heel strike pattern on the right and the heel-toe strike pattern on the left. Her heel tendon reflexes were brisk on the right at 3+ and 2 to 3+ on the left. She does have a plantar extensor response on the right and a flexor response on the left. (When I first read this, I didn't think he was right about the toe-heel pattern with her right foot. I keep telling myself that really she had a flat foot pattern with her right, but after the evaluation I took an honest look at it and he is totally right. It's funny that after all this time dealing with the therapists that I'm still sometimes oblivious to what is really happening. It reminds me of when she was just a couple months old and I kept telling myself 'it's OK that she's not using her right hand *that* much. I think it's getting better...')
During developmental testing today, selected items from the Gesell and other developmental tests were administered. The patient did imitate a circle and a cross with the latter emerging at 3-1/2 to 4 years of age. She made an excellent attempt at a four sided square. When writing, she she does prefer her left hand as would be expected, and goes between a fisted and emerging tripod grasp. The patient was able to identify objects by use and could tell me that she had two eyes, skills that typically emerge between 3 and 3-1/2 years of age. She answered all "what" questions that typically emerge between 3 and 4 years of age. She identified expressively 4 pictures, typically seen by 4 years of age, but did need a prompt when "labeling the watch." When the examiner gave her "wa," she followed through and said, "watch," which might suggest some minor difficulties with retrieval of language. The patient also drew a picture of her mother with a head, eyes, mouth, ears, and legs, which would be consistent with a child around 3-1/2 years of age. (I don't think Allie had an issue with recalling the word "watch". He pointed to a picture of a watch and she started telling him about the cool watch that her BFF Abby gave her. She kept saying "I have one just like that at home" or "Mine is cool" or "Mommy and Daddy have them". I think she just didn't understand that he wanted her to say "watch".
The patient was an engaging, interactive, and very capable 3-1/2 year old girl with a history of a right hemiplegia secondary to an intrauterine stroke. She does have a hand preference for her left but uses her right hand to assist well. She continues to have a toe-heel strike pattern on the right side but is not using any orthotics presently. It has been recommended that she undergo a gait analysis. We did discuss that working with an experienced physical therapist in the community, both from a treatment standpoint but also asking the question about what orthotics and other tests are needed, could be quite helpful. The patient's developmental evaluation today is quiet consistent with a child who is 3 to 4 years of age. She is articulate, bright, and veery capable despite her motor difficulties.
- We did discuss the patient's gains and the ongoing work she is doing with the Infants and Toddlers Program and with her private OT. I would suggest continuing these services. I did suggest a private PT look at her gait and help decide whether she would need any additional orthotics, as well as suggesting if additional assessments, such as gait analysis would be needed.
- I was glad to hear that the patient had been seizure free now for 2-1/2 years and looking forward to hearing what the child neurologist has to say about her overall treatment plan.
- The patient will continue to see her physiatrist and her pediatric ophthalmologist.
- I would continue to have the patient attend a typical preschool program and to provide ongoing play opportunities with friends to facilitate peer-to-peer interaction.
- We did discuss early reading and her interest in letters and sounds and introducing books that have rhyming, such as Dr. Seuss books. I would continue to do a lot of reading to her and begin to ask her to tell you about the story that has been read. Eventually, I would ask her what might happen next in the story, to work on making inferences, which builds on reading comprehension.
- We did discuss providing ongoing play opportunities for the patient. I would try to do this once or twice monthly with one other child. I would ask the patient to pick two activities that she would like to do with her friend. Keeping these play opportunities short, perhaps 60 to 90 minutes helps to ensure their success. Ending on a snack is a good way to make a transition to home for the playmate.
- I did suggest that I reevaluate the patient 1 or 2 years or sooner if concerns were to arise.
*****Updates since the evaluation*****
Allie met with the new PT that the developmental pediatrician recommended this past Tuesday and we really like her. She did a rigorous examination and evaluation and Allie had a lot of fun. I am excited to see the evaluation results and we will be continuing weekly private PT with her.
I have become obsessed with our local library. We went to pick out books with Allie and she was so excited. Andrew and I went back a couple days ago sand checked out a bunch of Curious George and Clifford books, which are her favorite. Even though the library is just a short walk from our house, I hadn't been going much. Allie was so hard on books that I didn't feel good about her playing with the library books. While she's much better being gentle with books, she still isn't allowed to have the library books in her bedroom and I think not having constant access to them makes them even more desirable. I asked her the other day if she'd rather watch an episode of Curious George or read a Curious George book; she chose the book. Success!
Grandma Bets was visiting from California yesterday and got to meet Andrew for the first time. I forgot to take a picture (doh!) but Andrew really liked meeting her. When I got home from dropping her off at her hotel, I went to Allie's room to kiss her goodnight. The first thing she asked was "Where did Grandma Betsy go? Will she come back soon?" We hope so!
Here is a video of Andrew waking up from a nap and Allie being obsessed with me not shutting the door. He makes the funniest noises all the time.