Patient Information:
Name: Jane Smith
Age: 6 years
Gender: Female
Date of Admission: August 15, 2021
Presenting Complaints:
The patient, Jane Smith, was brought to the clinic by her parents due to concerns about her behavior, communication difficulties, and social interactions. They noticed that Jane had trouble making eye contact, had repetitive behaviors like hand-flapping, and exhibited limited speech and interaction with her peers.
History of Presenting Complaints:
Jane’s parents first noticed these concerns when she was around 2 years old. She wasn’t meeting typical developmental milestones like making gestures, pointing, or responding to her name. As Jane grew older, her communication and social difficulties became more apparent. She would become distressed by changes in routines and had a tendency to become fixated on specific objects or topics.
Chief Complaints:
Poor eye contact
Limited speech and communication
Repetitive behaviors
Difficulty in social interactions
Past Medical and Surgical History:
Jane had no significant past medical or surgical history. She was born full-term without complications.
Family History:
There was no family history of ASD, but there were some instances of learning disabilities on her maternal side.
Socioeconomic Status:
The family belongs to a middle-class socioeconomic background. Both parents are employed and have been actively involved in seeking the best care for Jane.
Present and Pre-morbid Functional Status:
Jane’s functional abilities were limited in terms of social interactions, communication, and adaptability to changes. She struggled to express her needs and emotions effectively.
General Health Status:
Jane’s general health was good, with no ongoing medical conditions or acute illnesses at the time of assessment.
Vitals:
Heart Rate: 85 bpm
Blood Pressure: 110/70 mmHg
Respiratory Rate: 18 breaths per minute
Temperature: 98.6°F (37°C)
Aggravating Factors:
Jane’s symptoms seemed to worsen when faced with unfamiliar environments, loud noises, or changes in routine.
Easing Factors:
Familiar and structured environments appeared to provide some comfort to Jane. Engaging her in activities she enjoyed, such as drawing and playing with specific toys, seemed to ease her anxiety.
Examination:
Physical examination showed no abnormalities. Neurological and sensory assessments were within normal limits.
Sleep and 24-hour Pattern:
Jane’s sleep pattern was disrupted, with difficulty falling asleep and frequent night awakenings.
Duration of Current Symptoms:
Jane’s symptoms had been present for around 4 years, becoming progressively more noticeable as she grew older.
Mechanism of Injury/Current Symptoms:
There was no specific injury or traumatic event that triggered Jane’s symptoms. Her current symptoms align with the core features of Autism Spectrum Disorder.
Progression Since the Current Episode:
Since the initial onset of symptoms, Jane’s difficulties in communication, social interactions, and behavior had gradually intensified.
Significant Prior History:
There were no significant events or medical history that could be linked to Jane’s condition.
Previous Treatment:
Jane had received speech therapy and occupational therapy intermittently over the past year, which had provided some improvement in her communication and adaptive skills.
Diagnostic Test/Imaging:
Formal diagnosis of Autism Spectrum Disorder was made based on clinical observations and evaluations by a multidisciplinary team, including a child psychologist and developmental pediatrician.
Differential Diagnosis:
Differential diagnoses considered included:
Social communication disorder
Intellectual disability
Specific language impairment
Postural Observation:
Jane exhibited poor postural control and coordination during physical activities.
Precaution and Contraindications:
Jane was sensitive to loud noises and unfamiliar environments. It was important to create a comfortable and predictable setting for assessments and interventions.
Functional Movement Analysis (Sign):
Jane demonstrated difficulties in imitating and initiating movements, which impacted her ability to engage in play activities with peers.
Quick Screening Tests/Clearing of Additional Joint Structures:
Quick screening tests revealed hypermobility in some of Jane’s joints. Clearance of joint instability was performed before engaging in therapeutic activities.
Range of Motion (ROM):
Jane’s range of motion was within normal limits for her age.
Special Test:
Additional assessments, such as the Modified Checklist for Autism in Toddlers (M-CHAT) and the Autism Diagnostic Observation Schedule (ADOS), were used to support the diagnosis of ASD.
Assessment:
Jane presented with clear symptoms of Autism Spectrum Disorder, including deficits in social communication and interaction, restricted interests, and repetitive behaviors.
Problem List/Complaints:
Impaired social communication
Restricted and repetitive behaviors
Speech and language difficulties
Sensory sensitivities
Sleep disturbances
Treatment:
Behavioral Interventions: Applied Behavior Analysis (ABA) therapy to target communication and social skills.
Speech and Language Therapy: To improve expressive and receptive language abilities.
Occupational Therapy: To address sensory sensitivities and fine motor difficulties.
Parent Training: Educating parents about strategies to support Jane’s development at home.
Prognosis:
With early intervention and a comprehensive treatment plan, Jane’s prognosis for improvement in communication, social interactions, and adaptive skills is optimistic.
Goals:
Improve Jane’s social communication skills, including eye contact and reciprocal interactions.
Reduce repetitive behaviors and increase engagement in age-appropriate activities.
Enhance Jane’s expressive and receptive language abilities.
Improve sensory integration and self-regulation skills.
Establish a more consistent sleep pattern.
Interventions:
Interventions included a combination of structured therapies, individualized education plans, and home-based strategies to promote Jane’s overall development.
Patient Education:
Jane’s parents were educated about the nature of Autism Spectrum Disorder, the goals of therapy, and strategies to support her at home.
Patient/Family Education:
The family was provided with resources and workshops to enhance their understanding of ASD, promote effective communication, and implement strategies to create a supportive environment.
Discharge Plan:
Upon discharge, Jane’s therapeutic interventions would continue as part of a long-term plan. Regular follow-up appointments would be scheduled to monitor progress and make any necessary adjustments to the treatment approach.
Please note that this case study is a fictional representation created for illustrative purposes and is not based on any real individual. The information provided is not a substitute for professional medical advice.