Pediatric Evaluation and Plan of Care
Pediatric Evaluation and Plan of Care
Pediatric Evaluation and Plan of Care
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infant displaying delayed gross and fine motor skills, limited reactivity to stimuli, and mild
regulation problems. The developmental trajectory of Leo has been meticulously observed, and
this complete evaluation seeks to formulate a customized intervention strategy to facilitate his
regular physical therapy sessions, a structured Home Exercise Program (HEP), and a supportive
home setting, the objective is to enhance Leo's motor skill development, sensory stimulation, and
general interaction with the external environment. This strategy aims to enhance the
Date of Birth: January 24, 2023 Current Age: 8 months and 5 days
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I. DATA COLLECTION
The prenatal history of the individual under consideration does not present any notable or
significant findings.
The birth weight of the individual in question was recorded as 3.2 kilograms.
The APGAR score of the newborn was recorded as 9 at 1 minute after birth and remained at 9 at
The current medical practitioners and experts include Dr. Smith, who specializes in pediatrics.
B. Overview of Function:
The individual exhibits delayed development in both fine and gross motor skills, as seen by
Feeding: The process of moving from exclusive breastfeeding to the introduction of solid foods.
The topic of discussion is to the daily routines that individuals engage in on a regular basis.
The topic of discussion revolves around participation and the various barriers associated with it.
The individual exhibits reduced levels of vigilance, limited engagement in social relationships,
The topic of discussion pertains to familial matters, including concerns, expectations, and goals.
vigilance.
II. EXAMINATION
In the domain of gross motor skills, the prone position is of particular interest. The individual
exhibits a restricted capacity to raise their head, while also experiencing challenges in rolling
The utilization of transitions has not been made in the text thus far.
The individual exhibits restricted manual dexterity, characterized by a limited ability to grip
objects, as well as suboptimal coordination between their hand movements and visual perception.
Activities of Daily Living (ADLs) encompass the fundamental tasks of feeding and dressing that
The individual exhibits an intact sucking reflex in the oral motor domain, although encounters
The individual has restricted responsiveness to auditory stimuli and displays little vocalization in
The neuromuscular system exhibits characteristics such as suboptimal muscle grading, restricted
Musculoskeletal: The range of motion is within normal limits throughout, with the exception of
The individual has some physical limitations, including limited head control, a weak grasp, and
The cardiovascular system appears to be within the expected range and does not present any
notable issues.
Regulatory concerns pertaining to state regulation and engagement are of a somewhat moderate
nature.
The individual may exhibit a delayed response to sensory stimuli, which could potentially be
In terms of perceptual and cognitive abilities, the individual demonstrates a restricted capacity to
The raw score for reflexes in individuals under 12 months of age can be converted to an age
equivalent, percentile, and standard score. The above sequence of numbers, 5 5 25 x, pertains to
the concept of stationary skills. The above sequence of numbers, namely 32, 9, 75, and 12,
pertains to the topic of locomotor skills. The data provided consists of four numerical values: 30,
6, 37, and 9. These values pertain to the domain of object manipulation, specifically for those
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who have been engaged in this activity for a period exceeding 12 months. The sum of standard
scores is 29.
The individual in question is an 8-month-old child, both chronologically and adjusted for their
age. The patient presents to the physical therapy evaluation with delayed gross and fine motor
V. RECOMMENDATIONS / GOALS:
A. Recommendations:
The patient undergoes weekly physical therapy sessions, adheres to a daily Home Exercise
Program (HEP), and attends routine pediatric check-ups for monitoring purposes.
D. GOALS:
INTERVENTION PLANNING:
One area of focus in therapeutic interventions is sensory stimulation activities. These activities
aim to engage and stimulate the senses in order to promote cognitive, emotional, and physical
well-being.
tactile and auditory stimulation. These exercises may include utilizing toys with various textures
The recommended time frame for this activity is 15 minutes, to be performed twice day.
Motor skill development exercises are an essential component of physical education programs.
These exercises focus on enhancing the coordination, control, and precision of movements
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To enhance gross motor skills, it is recommended to incorporate daily exercises that specifically
focus on developing head and trunk control. These exercises should encompass supervised
The recommended time frame for this activity is 20 minutes, to be performed twice day.
This document aims to present comprehensive guidelines for the Home Exercise Program (HEP)
Provide recommendations for using adaptive strategies to enhance the development of motor
Please furnish a printed outline of the High Energy Physics (HEP) topic, accompanied by visual
early intervention and parental support in facilitating a child's developmental advancement. The
objective is to enhance Leo's head and trunk control, grasp and object manipulation abilities, and
stimulation, targeted motor skill exercises, and consistent parental involvement. The partnership
between the healthcare team and Leo's family is crucial in guaranteeing the effective execution
expected that Leo will attain noteworthy developmental milestones, hence facilitating a more