Physio CDS initial

Physiotherapist Note - 1 November 2024 Consent was obtained for the session and for the use of Heidi AI Health Scribe. Patient's mother, Mrs. Sarah Jones, and student physiotherapist, Mr. Alex Chen, were present during the session. Subjective Reason for Referral: Referral from paediatrician for assessment and management of developmental delay, specifically delayed gross motor milestones and asymmetry in movement, in 18-month-old patient, Master Leo Miller. Persons Present During Session and Venue: Patient, Master Leo Miller, accompanied by his mother, Mrs. Sarah Jones, and student physiotherapist, Mr. Alex Chen, were present at the clinic. History of Symptoms: * Mother reports Leo has been slow to meet gross motor milestones. He is currently 18 months old and is not yet walking independently. * He can crawl on hands and knees but demonstrates a preference for his right side, with less weight bearing through his left arm. * He can pull to stand with support but cruises only a few steps holding onto furniture. * Attempts at independent standing are brief and unstable. * Mother has attempted gentle stretching exercises suggested by a friend, with no significant improvement. * No reported pain or discomfort during movement. * No history of falls or injuries. Past Medical History Including Birth History: * Born at 38 weeks gestation via elective Caesarean section due to breech presentation. * Birth weight 3.2 kg. * No immediate postnatal complications. Apgar scores 9 and 9. * History of recurrent ear infections, managed with antibiotics. No current active infections. * No previous surgeries. Medications: * Multivitamin (over-the-counter): 1 chewable tablet daily. * No other prescription medications or herbal supplements. Developmental History: * Sat independently at 9 months (upper end of normal range). * Crawled on hands and knees at 12 months (delayed). * Pulled to stand at 15 months (delayed). * First words at 14 months (within normal range). * Mother expresses concerns about his delay in walking compared to peers. Family and Social History: * Parents are married, live in a detached house with a garden. Leo is their only child. * No known family history of developmental delay or neurological conditions. * Mother is a stay-at-home parent, father works full-time. * Good social supports, with active involvement from maternal grandparents. * No current Ministry of Education involvement. Summary of Previous Investigations: * Paediatrician's assessment at 16 months indicated mild gross motor delay. No further investigations ordered at that time. * Hearing screen at birth was normal. Patient Goals: * Short-term goals: * Improve left arm weight-bearing during crawling. * Increase duration of independent standing to 5 seconds. * Take 3-5 independent steps. * Long-term goals: * Walk independently and confidently indoors and outdoors. * Participate in age-appropriate play activities without significant motor limitations. Objective General Observation: * Alert and interactive 18-month-old male. Appears well-nourished. * Gross motor skills assessment revealed mild hypotonia noted in the trunk and left upper limb. * Reduced weight-bearing and protective responses through the left arm during crawling and transitions. * Good head control and symmetrical facial movements. * Limited ankle dorsiflexion bilaterally, more pronounced on the left (5 degrees past neutral). * Normal hip and knee range of motion. * Postural analysis showed a mild pelvic tilt to the left during standing attempts. * Vital signs within normal paediatric range for age. Treatment Education: Provided education to mother on age-appropriate gross motor milestones and the importance of encouraging symmetrical movement. Discussed strategies to promote left-sided weight-bearing, such as placing preferred toys to the left and encouraging reaching. Advised on creating a safe and stimulating environment for exploration and practice of standing and cruising. Emphasised consistency in home exercises to facilitate motor learning and neuroplasticity. Also educated on the importance of limiting prolonged time in restrictive devices. Hands-on Therapy: * Facilitation of left arm weight-bearing in quadruped, using gentle tactile cues. * Passive stretching of bilateral gastrocnemius and soleus muscles, holding for 30 seconds, 3 repetitions. * Manual facilitation of gluteal activation during sit-to-stand transitions. * Postural correction cues for trunk alignment during standing, with gentle manual support. Active Therapy and Exercises: * Crawling obstacle course to encourage varied movement patterns and promote left arm use. * Sit-to-stand training from various heights (low bench, chair) with support, aiming for 5 repetitions. * Balance retraining using a low unstable surface (e.g., pillow), practicing standing with minimal support for 15-20 seconds. * Gait training: Encouraged cruising along furniture, then taking 1-2 independent steps towards a parent for a preferred toy, repeated 5-10 times. Analysis: Master Leo Miller presents with a mild global developmental delay, predominantly affecting gross motor skills, characterised by delayed independent walking and a noted asymmetry in left upper limb weight-bearing. The hypotonia and reduced left-sided protective responses are contributing to his reliance on his right side and hesitancy in achieving independent mobility. His parental support and motivation are significant enablers for his progress. Barriers to progress include the established asymmetrical movement patterns and mild muscle tightness contributing to restricted range of motion. However, Leo's good engagement and the active involvement of his mother are strong enablers for intervention success. Plan: * Continue weekly physiotherapy sessions focusing on improving symmetrical movement, strengthening core and lower limb musculature, and promoting independent standing and walking. * Referral to Occupational Therapy for assessment of fine motor skills and sensory processing, if indicated. * Mother to continue home exercise program daily. * Follow-up with paediatrician in 3 months for review of overall development. Updates to home exercise program: * Incorporate more left-sided reaching games. * Practice standing at a low table to play with toys, encouraging weight shift. * Continue passive calf stretches. Timeline of next review: Next physiotherapy session scheduled for 8 November 2024. Likely therapy to be provided at the next appointment: Focus on dynamic balance activities, increasing independent steps, and further progression of strengthening exercises. Letters, phone calls or communications the treating therapist will complete before the next session: Send a summary report to the referring paediatrician.