Institute for Child Development – Schneider Pediatric Hospital
Director: Dr. Dov Inbar; Head Nurse: Ilanit Posnanski
Tel: 03-9253614; Fax: 03-9253871
Code no. of visit: 158879xxxx
Summary of examination 5/9/10
To the attention of:
a) Social Welfare Dept. of Municipality
b) National Insurance Institute
c) Pediatrician in local clinic Dr. Monica Finkelstein
Gili xxxxxx– 10 month old infant with general developmental retardation resulting from intra-uterine congenital infection with CMV virus.
Gili underwent examination today for the first time by myself and by the social worker Ms. Frieda Weisman. She was also examined by physiotherapist Ms. Nili Arbel.
Medical history: born in USA at 41st week of pregnancy, normal delivery, weight 2,750 gr. At 5 weeks urine test detected CMV positive.
After immigration to Israel diagnosis made, ambulatory treatment and follow-up by Professor Amir in Children's Dept C – Medicine = Ganciclovir. As a result of retinitis ultrasound of head showed existence of fluorescent blood vessels in both sides of thalamus in the brain .
Thorough examination was conducted of both the eyes and fields of vision, showing physiological laboratory values of VEP ERG to be normal for her age. She is being monitored in optical clinic due to “squint” (strabismus). Hearing tests were carried out, monitoring in ENT clinic and audiology. She can hear today.
Mother xxxxxx – aged 26, father xxxxx aged 29, both healthy. Children – sister of 5 and brother of 3.5 – both healthy.
Physiotherapist's report attached.
Diagnosis: GLOBAL DEVELOPMENTAL DELAY
MICROCEPHALY
S/P CONGENITAL MICROCEPHALY
Today's developmental function is in region of D.Q =45 points
INDICES
Cicumference of head 41.7
Physical examination – no signs of dysmorphism
Neurological examination
10 month old infant with few developmental achievements.
Gross motor skills – head falls back when pulling child into sitting position, does not support legs when put into standing position, does not crawl and does not sit when put into sitting position. Is able to roll from side to side. Conforms with development of 5 months. Language and speech – no imitation of speech sounds, no varied syllables – conforms to level of 5 months.
Fine motor skills – doesn't use hands in play relative to her age.. Conforms with level of under 4 months.
Social skills – does not play "peekabo", doesn’t feed herself, doesn’t try to reach objects and doesn’t object to toy or rattle being taken away from her. Conforms to level of under 4 months. General level of function D.Q. = 45 points
Neurologically the child has hypotonia and suffers from a deficiency in reactions including falling back of head when pulled into sitting position.
(A line here still needs translation.)
Follows object sideways with her eyes, squint STRABISMUS. Reacts to noises.
I spoke with the mother about the situation and our recommendations.
Recommendations for treatment
Placement in a suitable rehabilitative day center where the child will receive treatment to advance development, physiotherapy, occupational therapy, speech therapy.
Mother reports that child suffered brief convulsions at home last week including inclination of head to left side and intensified low muscle tone in lower limbs. Event lasted only a few seconds without breathing problem. Request for EEG during sleep. Follow up and treatment in clinic of Professor Yaakov Amir in Children's Dept C.
Also optical clinic and audiology.
Neuro-development depending on her situation – in the institute.
Signed – Dr. Dov Inbar –Head of Insititute
No comments:
Post a Comment