Patient Note (Liam)
Liam
(Patient ID 038)
| Name: Liam | Age: 7 | Gender Identity: Male | Race: Asian |
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Diagnosis: ADHD-combined presentation, intellectual disability, central auditory processing disorder (CAPD), language disorder, language-based learning disorder, developmental coordination disorder, developmental trauma disorder, nystagmus, pseudoesotropia of both eyes, primary optic atrophy of both eyes, astigmatism of both eyes |
Insurance: Cigna, Medicaid (TEFRA) | ||
| Current Medical History: Liam was recently diagnosed with an intellectual disability as the result of his three-year eligibility evaluation at school and with CAPD as a result of audiology testing. His diagnoses of ID, CAPD, and ADHD significantly impact his ability to perform and participate in self-care tasks, school tasks, play, and social participation opportunities. He presents with skill deficits in the following areas: speech/language, executive function, working memory, motor planning, emotional regulation, sensory processing, fine motor, visual-motor, and balance / coordination. He has been treated by OT and Speech since the age of 4 years (upon adoption) in both school-based and outpatient settings. He also attends hippotherapy lessons weekly. | |
| Past medical/surgical history: History of extensive medical trauma (4 surgeries) and hospitalizations. He has received care from an international adoption clinic, developmental pediatrician, and pediatric urologist, and pediatric ophthalmologist. Liam and his parents also participated in Parent-Child Interaction Therapy (PCIT). | |
| Birth history: Liam was abandoned at one-day old, weighing 2lbs 3oz. Liam was cared for at an orphanage from the time of abandonment until his adoption at 3 years, 9 months. He was placed on a warming pad and fed with a dropper. No further information is known about his birth regarding prematurity or family history. |
| Parental Concerns: Liam lives at home with mom, dad, and brother who is 3.5 months older than Liam. He shares a bedroom with his brother. Liam is a happy, empathetic child who is very observant and aware of his surroundings. He is able to make his wants and needs known. Parents are concerned about his performance (thoroughness) and independence (attention to task) with self-care skills (e.g., taking a shower, brushing teeth, toileting) and social participation. Liam prefers to play near others, mostly demonstrating parallel play. | |
| School: Liam is in third grade and has an IEP. He receives all of his academic instruction in a self-contained classroom. He receives school-based speech therapy (90 minutes/week) and occupational therapy (120 minutes/month). Liam enjoys going to school; however, he has a history of maladaptive behaviors to escape math tasks. He is beginning to read and is currently performing on a kindergarten level academically. | |
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Milestones: Rolling: unknown Sitting: unknown Crawling: unknown Standing: unknown Walking: unknown Descending stairs: 4.5 years Jumping: 4.5 years Riding a bike: 6.5 years |
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| Interests: Liam enjoys playing with trains, cars, and trucks. He likes dinosaurs, school buses, and firetrucks. He likes drawing, coloring, swinging, and helping with household chores (e.g., cooking, putting away dishes, and vacuuming). Liam has recently begun to enjoy participating in sports at the YMCA with his brother. |
Adderall XR 25mg
Intuniv 2mg
Melatonin 20mg
Daily multivitamin
Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.