Patient Note (Molly)
Molly
(Patient ID 022)
| Name: Molly | Age: 4 | MR #: 000-022 | |
| Gender Identity: Female | Race: Caucasian |
Admitting diagnosis: Chromosomal Abnormality - Xp11.2 |
Insurance: Medicaid |
| History of present illness: Global developmental delay due to chromosomal abnormality. Molly exhibits low muscle tone globally. She has been treated by OT, PT, and Speech since the age of 3 months. She also attends aquatic therapy. Presents with visual, speech and cognitive impairment. | |
| Past medical/surgical history: Seizures from 7.5 months to 1 year controlled with levetiracetam. No seizures noted in the last 3 years and a recent EEG showed no abnormal brainwave patterns. Eye surgery for strabismus at 11 months. Suffers with asthma and constipation. | |
| Birth History: Molly is a fraternal twin. Her twin sister is typically developing. At the 20-week ultrasound noted that Molly was not as active as her sister. They were born at 38 weeks via c-section. She stayed in the NICU for 2 days. |
| Parental Concerns: Molly lives at home with her mother and father and twin sister. Father reports that Molly is a happy child that is able to communicate what she likes and doesn’t like through facial expressions and vocalizations. She seems to understand most of what is happening around her. He is concerned that she is not able to stand, crawl, or walk. In addition, he would like for her to be able to “use her hands more.” | |
| Employment/work/school: Attends head start preschool program where she gets along well with her teachers and fellow classmates. | |
|
Milestones: Rolling: 8 months Sitting: 13 months Crawling: N/A scoots or rolls Standing: N/A Walking: N/A |
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| Interests: Molly enjoys playing with her sister and has a few toys at home that she particularly enjoys, including a cookie monster toy. |
Montelukast
Albuterol inhaler PRN
Miralax PRN
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