Context of assessment: The student has been requested to perform a community based, developmental assessment for a child referred with a history of clumsiness.
Demographic Information
Setting: Community outpatient setting
Gender: Male
Patient age: 4 years
Main Presentation: Clumsiness, not keeping up with peers, fatigue
Student Name: Clare
Educator Name: Kate
Patient and parent Name: Sam and Heidi (mother)
Clinical History
Reason for referral to physiotherapy:
Clumsiness, not keeping up with peers, fatigue
History of presenting condition:
Kindy teacher has reported that Sam has difficulty with his gross motor skills, handwriting and scissor skills. He finds it difficult to sit still for mat time and falls over regularly. Avoids outdoor physical activities and gets frustrated with the same. Parents report Sam plays happily with 1 friend over to play at home but Kindy teacher finds he is reluctant to play with the others in a busier environment.
Investigations:
GP assessment and referral to community therapist
Consulting teams:
Local GP, Kindy teacher, PT and OT
Past medical history:
Normal childhood illnesses
Birth history:
K40 Breech delivery by planned LSCS
Hip U/S NAD
Past surgical history:
Nil
Developmental history:
Favoured head to (L) Played on tummy but poor tolerance. Rolled at 7 months. Bottom shuffled, did not crawl and walked at 18 months. Dislikes ball games, does not like activities that challenge his balance off the ground. Does not like swimming lessons. Prefers indoor activities and Nerf guns
Medications:
Nil
Social & Family History:
Youngest child of three. 2 older step brothers 14 and 17 years. Second marriage for Mum (Heidi) who works part time at Mathers shoe store when Sam is at Kindy. All 3 children live at home. 2 older siblings visit their Dad on some weekends and school holidays. Dad looks after boys on school holidays. Dad (Brian) is High School Music teacher. He plays Saxophone in a Jazz band on some weekends. Not a very sporty family.
Dad was not a sporty kid but chose choir and music programs. Dad was reportedly also clumsy as a child.
Parental concerns/goals:
Want to make sure that he is ready for Prep next year. Still not independent in ADL’s. Fussy eater.
