Case bits Flashcards
Introduction
I had the pleasure of speaking to ‘Craig’, ‘Ollie’s father’. ‘Ollie’ is a ‘7 year old boy’ with an overarching diagnosis of ‘main issue/genetic syndrome’ resulting in ‘this that and the other’, whose other medical issues include ‘this that and the other’. He lives with an ‘main family issue’ family, who ‘hint at any other social issues’.
Treating teams, medications, allergies, immunisations
His medical team lead is the ‘x’ team, with involvement from ‘other teams and which allied health’. His current medications are ‘whatever roles’, with some/no side effects, and previously trialled ‘xx’ medications ceased due to ineffectiveness/side effects. There are no allergies, and immunisations are in accordance with the schedule, in addition to fluvax/covid ‘for the whole family’.
Birth history
Ollie’s birthday history involves being born at term with an ‘uncomplicated antenatal and postnatal course’ OR ‘antenatal course including xxx and postnatal course including xxx.’
Medical issues
Moving on to Ollie’s medical issues - first, his overarching diagnosis is xxxx, atributed to xxx, which first presented at ‘age’ with ‘whatever symptoms’ with investigations finding ‘xxx’. This was initially treated with ‘xxxx’, and his current regimen is ‘xxx’. His current status/baseline is xxxx, reflecting significant improvement/deterioration/stability, and impacts xxxxx. Future plans are for xxxx.
Systems review
The systems review was only significant for xxxx, however there are no recent assessments of hearing/vision/dental health/bone density. He feeds/toilets/showers/dresses independently, mobilising xxxx with a feeding regimen of xxx.
Developmental history
Ollie’s developmental age was consistent with xxx for gross motor given he is ‘walking’, xxx for fine motor given he ‘has a pincer grip’, xxx for social given he ‘has pretend play’ and xxx for language given he ‘has 5 words’. There are no hearing/vision concerns.
Family history
To briefly discuss the family history, this is a family of background, with a history of xxxx in sibling/mum/dad; xxx relevant in distant family, and otherwise atopy and cardiovascular disease in adulthood.
Social history
Moving on to the social history
This is a ‘single’ income, ‘two’ car ‘nuclear’ family who live in a ‘metropolitan/regional/rural’ area ‘however far’ from their nearest hospital and ‘however far’ from their tertiary hospital, in a (accommodation - eg 2 storey mortgaged house with modifications), with whatever custody arrangements. They are experiencing some financial stress as while mum’s income continues and they receive whatever extra payments, dad’s plumber income has been affected by covid, and the NDIS package of 50 000 dollars covers only xxxx and does not cover xxxx.
The family are well prepared for emergency situations, with a good understanding of crisis plans, ambulance cover and well-educated local hospitals.
There is a significant impact on the family due to xxx, xxx and xxx, and their current support mechanisms of xxx and xxx are insufficient with increasing stress/fighting/etc.
?????
The HEADSS screen identified xxxx issues
_____
Looking to the future, while plans are for xxx, ??without discussion of palliation??, mum’s greatest hope is xxxx
o/e
On examination, the salient findings reported to me indicate xxx, xxx and xxx, noting ?appropriate growth and observations within normal range. I would also like to examine for xxxx - looking at xxx, xx and xx; for eg malnutrition, looking for xxx,xxx and xx; and eg something else, looking for xxx and xx and xxx.
Summary
In summary, Ollie is an 8 year old boy with overarching syndrome whose resulting (trajectory information). This is in the context of a family who I am concerned (main 3 social issues).
