History Taking

Ali Mohamed is an around 4-year-old child (He will complete them in September),
who corresponds to level III CFCs, which means that he usually communicates
effectively with familiar communication partners, but not unfamiliar partners, in
most environments.
Antenatal History:
• He is the first child for his parents, after 2 consecutive miscarriages. During
pregnancy, his mother suffered from bleeding, which stopped with
medications, however, no clinical risk was mentioned for her pregnancy by
her doctors.
• Neither consanguinity nor similar cases in the family was reported.
Perinatal History:
• He was born in the 7th month of pregnancy with an emergency C-section, but
the mother didn`t mention its cause.
• He suffered from respiratory problems, which required NICU admission for
2 weeks, in addition, he suffered from Jaundice which resolved after one
week.
Post-Natal History:
• He was admitted to hospital after 1 month from birth due to fever, squinting
and possible epileptic fit that was described as abnormal movements in his
Rt. hand that happens for 4 times without mentioning a definite duration
(Follow up is needed).
• He was admitted to NICU as he stayed for 1 Month, in which he did an MRI
that revealed an anorexic brain injury without any further investigations.
Note to Doha Osama (Babies who are only 2 months don’t do MRIs, you fooled
us in this).
• He was discharged with a prescription for Tiratam (10mg/day), and then
after a while the mother decreased the dose by her own and fit arose again,
which led to his hospitalization for another 1 week and the dose of Tiratam
was increased to (15mg/day).
Disease Presentation:
• At 7 months, his mother noticed that he doesn`t roll completely, only from
prone to supine, as well as inability to sit alone like other children in his
age.
• She visited a neurologist, and she advised her to start PT, but the mother did
the exercises itself at home.
• At 12 months of age, she consulted the neurologist again as she found no
improvement so far (Incomplete rolling, inability to sit alone) and she
advised her to start PT with a physical therapist.
• At the age of 1.5 years, his rolling became better, and at the age of 2 years
old, he started crawling like a rabbit, pull to stand but without standing, sit
alone and play with objects, however, he uses his Lt. hand more than the
Rt..
• Now he can sit alone, pull to stand, and stand with assistance, walk with
maximum assistance by holding his hand anteriorly according to his mother.
Note: 1- He has an AFO, but he hasn`t been using it for a while and it needs to
be checked.
2- His mother reported a previous vague heart problem, and they should check
it before starting treatment.
Services provided:
1- PT: 6Sessions, 5 Hours each.
2- OT: 6 Sessions, 2 Hours each.
3- Speech: 6 Sessions, 2 Hours each. He is communicating through using
PECS and they are working on his verbal communication, but he is still
unable to say any words except one syllable words, such as (Mama, Baba,
Bo, ….)
Medications:
Tiratam (15mg/day)
Previous Surgeries:
An eye surgery for his squinting, at the age of 1 year old.
Requests:
• Orthopedic Consultation.
• Hip X-ray as he is sitter and has never done any hip x-rays.
• AFO check
• Seating system check.
• Neurological consultation as his dosage for tiratam didn`t change for 3
years, despite the increase in his weight.
• Nutritional consultation as his mother reported difficulties in swallowing,
especially for liquids.
• Report from his ophthalmologist for his eye operation.
• Cardiovascular consultation for his previously mentioned heart problem.
• Photos of his sleeping position.
• Photos of his figure of 8 strap while wearing it, from anterior, posterior, and
lateral view.