Developmental Consultation:
"It was a pleasure to see" Thomas, a 4-year-old boy, who is in nursery and was brought to the appointment by his mother.
(Begin with saying the person is a boy or girl "of many strengths including" and list 2 or 3 positive attributes) Thomas is a boy of many strengths including being very sociable, and having a good sense of humour.
Reason for Consultation:
- Concerns regarding speech development and social interaction.
History of Presenting Concerns:
- Thomas has been experiencing difficulties with speech, including limited vocabulary and difficulty forming sentences. He also struggles with social interactions, often preferring to play alone.
- These concerns have been present for approximately 6 months and have gradually worsened.
Developmental History:
- Prenatal and birth history were unremarkable.
- Gross motor milestones were achieved at the expected times. Fine motor skills are age-appropriate. Speech and language development is delayed, with limited expressive language. Adaptive functioning is age-appropriate.
- No developmental delays or regressions were reported.
Reports reviewed : School report indicates some difficulties with following instructions.
Vision and Hearing: Vision and hearing were formally assessed and found to be within normal limits. No parental concerns.
Dental health: No dental health findings.
Sleep behavior: Thomas sleeps for approximately 10 hours per night, with no reported difficulties.
Eating behavior: Thomas has a good appetite and eats a variety of foods.
Medical History:
- No significant past medical history. No previous surgeries, hospitalizations, seizures, or head injuries.
- Pregnancy and birth history were unremarkable. No resuscitation required.
- No medications or herbal supplements.
- No known allergies.
Family History:
- Father has a history of dyslexia.
- No family history of developmental disorders.
Social History:
- Thomas lives with both parents and has a supportive home environment.
- Attends nursery and is reported to be doing well, although he struggles to follow instructions.
Physical Examination:
- General physical examination findings were unremarkable. Height and weight are within the 50th percentile.
- No specific developmental assessments were performed during this visit.
Assessment:
- Thomas, a 4-year-old boy, has many strengths including being very sociable, and having a good sense of humour, but has some difficulties noted in speech and social interaction.
- Possible diagnosis of speech delay and social communication difficulties.
Plan:
- Referral to a speech therapist for further assessment and intervention.
- Follow-up appointment in 6 months to monitor progress.
- Recommend strategies for parents to support Thomas's speech and social skills development.
- Provide information about local support services for children with developmental delays.
Developmental Consultation:
"It was a pleasure to see" [Insert patient's name and age , their grade and what school they go to and who brought them to appointment.]
(Begin with saying the person is a boy or girl "of many strengths including" and list 2 or 3 positive attributes) (Mention pronouns only if said explicitly) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Reason for Consultation:
- [describe reason for developmental consultation] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
History of Presenting Concerns:
- [describe current developmental concerns, issues, or symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention duration and progression of concerns] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Developmental History:
- [describe prenatal and birth history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention milestones dividing up into gross motor and fine motor, and speech and language and adpative functioning or independence] (provide manay details abotu expressive langugage, receptive language, gestures, signs if used, play behavior, interests, any repetitive interests, tics, academics, social skills) ((only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [describe any developmental delays or regressions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Reports reviewed : (include socring on rating scales, school reports, psychoeducational assessment findings, special letters from the school otherwise omit completely)
Vision and Hearing: [Vision and hearing findings] (include whether formally assessed and findings, mention if parental concern) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Dental health: [Dental health findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Sleep behavior: [Sleep behaviour] (mention if snoring, if hard to settle, if up at night, duration orf sleep, any medication) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Eating behavior: [Eating behaviour] (Mention if selective, narrow choices, mention if low in iron, or excessive milk. If child with sleep delay, mention if not choking, or difficulty with swallowing) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Medical History:
- [describe past medical history, previous surgeries, hospitalizations, seizures, head injuries, any need for IV fluids] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [Mention pregnancy history with any exposures and birth history, gestational age, any resuscitation required or neonatal events, NICU admissions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention medications and herbal supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Family History:
- [describe relevant family medical history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention any family history of developmental disorders] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Social History:
- [describe social environment, family dynamics, and living situation] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention school or daycare attendance and performance] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Physical Examination:
- [describe general physical examination findings including percentiles of any provided growth measurements](only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention any specific developmental assessments performed] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Assessment:
- [provide a summary of the developmental assessment that begins with saying this child is of a certain age and has many strengths including and name two and who has some difficulties noted in certain areas] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention any diagnoses or differential diagnoses considered] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Plan:
- [outline the management plan, including any referrals, follow-up appointments, or interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention any recommendations for therapies or support services] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [provide any specific instructions or advice given to the patient or caregivers](only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information to include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
