THAARE ZEMIN PER: 11.The types of cases came on the observation days

11. The types of cases came on the observation days

NEUROLOGY

Dr Sajeev Thomas

PATIENT 1

CHILD screming , accompanied by mother-delayed development woth attention deficit, srated walking 1 year 4 months

The doc reades out patient files aloud in English

-early birth@240th day,born as twins -low birthweight-1.700kg- responses only by gestures-social maturity of i year 8 months ( psychological evaluation)- now scheduled for nurological assessment , linguistic assessment-restless - speaks only about 5-6 words-poor imitation skills-delay in socialisation - receptive language-8-12 months ; conceptual age , chronlogical age , developmental age ,; six months after the previous therapy-EEG- no traits of fits

comments by the doc

Growth is regressive -training may be effective- presence of a twin brother can be useful for growth-must continue therapy-if the child does not retain learning, repeat instructions - parents must give training at home coninually- take care to see the boy-see that does not get affected by fever or epidemics-must give balanced nutrion ( explains the constituents of a nutritious )

-discusses the weight of the child at varius stages - 6 months ,10 kg ; 1y 6 months 5 kg, 2yrs 1 month-12 kg ; bone growth - give milk for calcium intake-

- observes his gait and walk-makes him sit forcefully and allow to stand at will - comments - seems no issues in walking-

Doctor comments : The child had therapy in walking like sand walking- had strage eating habits like eating paper, paint, mud

(observation-When the child is in the company of the father now and comparatively calm.)

Doctor comments - therapy is done every 2 days per week , the remaing done at home ,consults with paedetrician- instructs to come back after 6 motnhs-

Mother comments-When the boy has fever , the pill for fits is also given

Doctor comments :The boy had fits along with fever in March 2021)-treatment started from SAT hospital -Mother also had fits upto 8 years of age .-She had taken the pill VALPALINE - 2 pills once a day-taken pill continously for more than a year- stppped tking pills during pregnancy- first preganacy resulted in abortion as the child was withour heartbeat-now after treatment the mother does not have fits for 2 years-checks EEG and no symptoms of fits now

Discussion- normal birth weight of a child

PATIENT : 2

Hyperactive- fidgets-8 years old - writes letters as in sts 1- from a govt school in kollam dt-typical LD- the child had burns after toching the hot silencer cover of a bika parked at home.

grunts-moves aorund noisely-but responds to the doctors greetings-shows a colour picture and asks the child who draw it ? " no answer "

comments by the dctor : attention seeking behviour- consults here since 2016- undergoes occuptional therapy- UNDERGOES special education classes -

PARENT COMMENT :- sensitive to sounds - spends a lot of tome with pets like goats-

keeps schedules- replies to instructions very rarely- agressive at alight workload - cannot bear the sound od bikes -

DOC COMMENT :- HE HAS sensation fear./affinity- habituation approach is the treatment- the child must get used to the sounds- -need no medicines now-must try to increase his attention span-

PATIENT 3 :

A screaming child arrives -5year old -referred from Poona-parents NRI - child doesnot speak properly-repeats only a few sounds-parents rarely use Malayalam

CASE HISTORY : normal delivery-38th week-no health complaints to the mother- no pregnancy/delvery problems...

child cry normal at birth- scissorian section-BW 3.6 KGS-parents not diabetic-no previous pregnancy failure- -no ICU TREATMENT-discaharged after 3 days

GROWTH AND DEVELOPMENT :

missed certain mile stones like turning uoside down- sat directly- walkd between 6 months-1 years-motor skills of 3 years - emotions normal- uttered words @1 year age , two wods like pappa an mamma @18 months ; speech lock @2years- continues crying a lot ,can not stop crying(PARENT doubts ASD )

DOC COMMENTS (CASE HISTORY)

immunisation done- selective hearing- sleep habits abnormal- sleep pattern changes - 14 kd @2yrs, 15 hg @5 years, downwards shift in weight/asthama/ dry skin/ cold breathing/ dry cough

hearing test not done - not minding others reponses-

PARENT COMMENTS - watches cartoons on tv- responds to cartoons-

DOC COMMENT : hearing test must be done - may be irriatted by higer frequencies -(hopes he cooperates with the test !)

DOC ANALYSIS : - NOT USING MOTHER TOUNGUE - depends on the amount of language used @home -not moving away/ moving ears away even if the phone sound is louder -no problems with vision- shows learning capacity- hearing assessment to be done -

MOTHER COMMENTS : the child does not use verbs . - does not use mlayalam much 2home - a mixed use-

DOC PRESCRIPTIONS :

Speech and langauge assessment- developmental assessment- cognitive assessment - psychological evaluation- next appointment after taking these tests within a week

FATHER COMMENTS

- NOT HAPPY ABOUT the time lag @ the hospital and loopholes in covid protocol

PATIENT 4-

A grown up (45 years old) man acccompanied by his doctor brother- referral case from Sree Chithra-under treatment for more than 7 years - pervious consutation march 21-hypothyroid-passive posture- hand movement problems-extra temporal behaviour-severe headache- memory issues-nausia-postoral headache-metabolism affected- generalised epilepsy -

DOCTOR ANALYSIS

any recent issues od fits ? / sleep ?/ addicted to watching tv / PREVIOUS fit on dec2019-EEG DONE JAN 2019-MRI scan done - generally passive - low resposes- may be medicine induced -psychosis-hallucinations- side effect of medicine ?

DOCTOR ADVICE

-SERVES GOOD- HE IS ok now- split the dose into 3 tomes daily-pushing sodium might do good -(to the patients's doctor brother )need much depend on google info

PATIENT 5

A restless girl-pancky-extends her hand towards the doc expecting injection-pinches her mother-

-delay in growth- marginal ASD- group therapy-speech therapy interrupted by lockdown- cant write- less sounds produced-language delay-inattention-referral from CDC-

PREGNANCY DETAILS-

scissarion section -BW 2.45-2.75 -sat / walked @9months-1 yrs- no speech even @ 1 years- started saying " vellam " ( malayalam word for water) , more gestures , more movements ,proper immunisation -eye test in KMS -NORMAL-hearing @birth normal - not decipher words - no retention of learning- colour concepts- reconised and matched-

Discussion on CASE HISTORY

no link between dialogues and action- analysis : network connectivity not right - help provided by special education- do not remeber the sequence of events

Effect of therapy

-use of cartoons-started verbal communication -no social issues- concentrate on language issues-mapping domain , physical development assessment , psycho cognitive assessment , language assessment -BLOOD COUNT /THYROID /

PATIENT 6 :

kid - 2 1/2 years old- wt 10.500kg,-SECOND APPOINTMENT- more obstinate -attack of its

MOTHER -Ph.D holder , FATHER - TECHEE

EEG - test for fits- electrical sparks creates fits-

sedation - obstinate more -can not rule out epilepsy-

Mother says -Child started using more words after an attack of fits-

( DOC-fits may subside within first 6 years, antihistamines cause fits for eg VICKS )

PATIENT 7

A lean boy-5years 2 months- respones like that of a bird-ko,ko-points out at the door-laughs without provocation-language devpt 1 year 11 months- meditative, curious eye coordination

CASE HISTORY

EEG NORMAL-continued attack of Rubella-acute language problem- poor language output-language therapy for two years- obstinate- uncontrolled emotions- frustrations-

growth not satisfactory-genetic tests from CDC normal-

DOC ADVICE

-letter to pediatrician to check growth- endocrine deficiency

PATIENT 8

3YEARS boy continuing therapies-4 times unsuccessful attempt for EEG - EEG done recently- repeats sounds- no proper replies-

CASE HISTORY

-ASD ? -attention problems - hyper active

speech language tests

more tests,VSMs,SFPs,CARs

DOC COMMENT- vaccination done - Rubella can affect brain and heart -

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

SPEECH PATHOLOGY

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

CASE 1: 5 YEAR OLD GIRL

PROBLEM : MENTAL RETARDATION-

Mental retardation is a developmental disability that first appear in children under the age of 18. It can be defined as an intellectual functioning level that is well below average and significant limitation in daily living skills.Treatment can help.But the condition can't be cured .Lifelong support is needed .She was completely silent.She does not talk to any one.

STEP 1 :

The trainer tried to interact with her by showing picturised story and she begins to respond little by little with the help of the trainer.

This kind of a session is really helpful for the kids who is not interacting with others .

Let me thank my colleague ABIDA for providing this input after her posting for observation at the speech pathology department .

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

Lingustics

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

Bindukala-

Postings for observations in Linguistics

Case 1 -14 Yr boy-comorbidity -hyperactive

the boy was mild MR and Hyperactive.He is fidgetting, restless, and easily bored.he has trouble in sitting quiet.Such children may rush through things and make careless mistakes .

Previous history.

This boy came to the ICCONS when he was in second standard.now he is in 8th standard.heis a native from kollam.he is very much active in everything except in studying.He mostly consulted the doctors at ICCONS online 8during the outbrek of the pandemic.

obseved activity :reading aloud online

the trainer asked the student to read aloud from his textbook online.when he made a few mistakes , the thrainer inervenes and corrects him on the spot and helped him read correctly a whole paragraph.

ASD 1

ASD 2

DYSPRAXIA

PSYCHOLOGY

Postings for observations

Case 1:

Doctor ANIL and KARTHIK :4 years-babbles- does not focus -sits in a closed chair-typical autism--normal upto 3 years-the doctor keeps touching and holding the child by hand and speaks softly(to get him focussed)--uses bigger dolls and coloured rings - gives loud, clearcut emphatic instructions as if you were guiding an elephant.-

starts playing with differently coloured rings placing back in around a an iron stick.- the boy loses attention intermittently- the doctor keeps touching and holding the child by hand and speaks softly(to get him focussed)-when the child finshes placinga ring the doctor says "good boy" as reinforcement/ compliment.The doc touches the rings and counts each ring seperately aloud .

GAME 2

2.SQURE BOXES REPLACEMENT GAME - placing and replacing the buliding squares of the same colour- the activities repeated with different colours

3.the doctor askas the boy to call his mother- the boy just looks at the door.( inattentive, yawns , shakes his knees and bables)

4. mother enters , the doc continues a game of throwning a ball with the child - mother seems to feel happy with the child )

doc - "yes . now he sits for a while and have started doing things "

************

GEN ORIENATION -25/10/21

************

MISS SHANTHI V S-CLINICAL PSYCHOLOGY 26102021

PATIENT 1 - behavioural training

BOY OF 4yrs 6 months - mild autism- restless - does not know letters- lacking attention- being trained with building blocks - repeating rhymes - reached here afteroccupational theraly from NISH -

training in LETTER IDENTIFICATION done @ICCONS -

ACTIVITY 1

learns placing letters back in their positions on a tray / letters with different colours used -

ACTIVITY 2 : THE doctor sings ABCD and places the letters cuttings in the same order. the child is encouraged to do the same .

ACTIVITY 3 : COLOURING LETTERS ON PAPER with outline of letters given-different colours used -training with oral commands like "wait" , "stop" "no"-sometimes the teacher has to compel to paint - the DOCTOR holds his hand and make him draw/paint

ACTIVITY 4 : drawing at his own will- exercises to join lines , draw over, dotted lines

ACTIVITY 5 : ALLOW THE CHILD TO DO SOMETHING IN THE ROOM AT HIS OWN PREFERENCE - he goes to a shelf in a cornes -picks upa bottle with small sphere inside he bottle - the child goes on shaking the bottle ( repetitive actions charecteristic of ASD)

ACTIVITY 6 : SHOWS an alphabet book with large fonts and very large figures( comment : the child has got a similia book at home , he has a habit of turning over the pages repeatedly- eses his preferences to effect learning )

ACTIVITY 7 : PAINTS the child's fingertips and directs to thouch a circle drawn on paper, encourages to sing rhymes , the boys seems fond of rhymes and rhythmic movements

( self obeservation- use of musical instruments may facilitate learning here)

-after 40 minute training the DOCTOR permit the boy to go out- says "goodbye"-the boy lets pouta scream of joy and goes out .

************************************************

NOTES BY CKR 27 /10/2021

Math Clinic OBSERVATIONS-

EVALUATION TOOL USED-games OBSERVED -tangrams

maths evaluation tool- diagnostic test-5% cut off - test of arithmetic ability-NIMHANS(INDIAN NORMS)

QNS- 1.count the number in each box 2. comparing the number in each box -3.read the numbers and copy it in numerals ( the doc takes the paper back without any courtesy while I was noting down a few ideas -seemed not interested in sharing this information- licensed property)

PATIENT 1

2 1/2 years autistic child - home activities mother - find out what toy he is interested- note the book he is demanding - 1 1/2 minutes provision of preference - find comfortable place - take an appointment on Monday-look for repeated activities- be calm ,slow and clear cut in giving instructions-shows a board game with colourful icons

IQ test can only be purchased by professionals

PATIENT 2

A GIRL IN 5 STD-English medium school-Parents complains about being aggressive -no emotional expressions- rigid attitude - not crying when pained - not expressing even when hurt-academically brilliant -reads selective books -fictional stories of Sudha Murthi , Anne Frank -spends most of time on TV , mobile, likes foreign culture, western culture , basically luxury loving , does not accept reality .

DOC INTERACTION WITH THE PARENTS with the help of evaluation tool

any friends - no comfort zone - no social mingling- reserved-prefers to sit at home _one of the class toppers- leadership in school activities -draws a bit -COVID induced inactivity-comfortable at home - does not like sharing-not interested in class schedule-not attending "Kuran" classes- recently backward in Maths--no doubts-microfamily only recent- thinks expressing emotions something inferior- attention deficit-not planning everything- last minute rush-highly skilled- good orator-parents worried that it seems academic performance apparently going down- says excuses for not doing things on time-intentional or not - cannot identify-whether she is lying- gadget friendly-

how long ? screen time too long - no game - blogging - web series- fictional- not reading now -recent changes for the last 2 1/2 years - pushing by mother- not accepting time schedule for routine - conflict with sibling ( 6years old ) - does not show affinity to the little child - no problem with the cousins - not reaching to the cousins - screaming aloud " Why am I scared ? Who should I fear ? About friends- Nisha is highly selective , every body is rude to me , obsessed , craves for attention , serves friends deliberately,

Doc : stubborn ? likes travels ? luxury foods ? gifts ? likes foods ? living in flat ?

PARENTS : compares herself to cousin WHO IS FINANCIALLY better.- does not help parents- not responding properly-acts smart before visitors- highly eccentric recently-

DOC : analyses : TV PREFERNCE-thyroid issues- pregnancy issues- does not like milk- fits nil- breast feeding - 9 months -feeding pattern -eats a lot foody - attitude -

milestones k ? -conversation / communication issues- relationship with father and mother- do you value her feelings-

Father- "when I am busy , I cannot"

Dislikes physical activity - not much , plays cards with cousin rarely.

finishes schedules but not on time -shouts @ her little brother - a recent dislike for schools - like walks alone - not interested in maths- keeps things safe

ready to do paid services - keeps secrets-afraid of ghost stories- it prolific ?

Doc comments to the parents

Positives - no problem in behaviour - emotional ,highly selective,

Negatives-she can not balance her expressions - may be taxing for mother and father- up skillilng is required- needs interaction with the child - no friends connection- feels attention lack from my mother - now she feels a need but no skill in creating friends - she always waits positive responses-need not reveal herself easily- need a half day session with the child - restless is not a serious problem -blogging is creativity- she is not able to finish other chores because she is lost in writing -

final observation : must do other tests for evaluation

INTERACTION WITH THE CHILD

-Asks the child many questions about her school- holy angels - CBSE - vanchiyoor-5th grade - asks about the class room- how to reach the class from the office room-( likes books -library- period of reading - like schools - extra curricular / enjoys PE / practises DANCE -study related activity / assembly / role in assembly as monitor/ house wise charge / about play ground / about teachers / some of them hard / phy punishment / yes / 4 students in a bench / I like my Hindi teacher/ some teachers allow to place the bag on the desks. others don’t. she likes her Hindi teacher- friend Neelima-enjoyed the trip from the school to magic planet - she liked the shows - describes vividly- mother often intervenes to correct the child- the child likes her cousin because he is protective and sharing-this session ends - There will be a detailed session next Monday

The child leaves with the parents .

Gen evaluation by the doctor

- She has not much problems- She articulates well - but there is a need of a detailed evaluation session-

PHYSIOTHERAPY

PAEDETRIC ASSESSMENT

PATIENT 1 : severely spastic - CP-14 years boy- birth complication ,prologed labour-

The doc hands over a copy of the evaluation tools and allows us to ask about the tool-I asked about DTR reflexes - DTR FOR deep tender reflexes-( SPASTIC-EXAGGERATED RELEXES,PLACIDITY-SLUGGISH RELEXES;NORMAL-JERKY RFLEXES)

REHBILITATION PROCESS-

SPASTIC - slow movement , placid -fast movement

PATIENT - 2

A CHILD with no neck and roll movement- CP -no movements

Therapy- Activities

-neck wedge - trunk balance nil-spine strengthening-sitting-bed -pillow-cross legged position-bog basin sitting-standing exercises-half knee standing (മുട്ടിൽ നിറുത്തുക )

DISCUSSION -GROWTH AND DEVELOPMET-NECK MUSCLES

3-6 MONTHS :critical period

rises neck @ 3 months , neck tightens @4months, turns aound and lies down with face raised within 2-2 1/2 years , (rarely… before 5 years),

causes of delay : look for Down Syndrome - comorbidities -heart problems

PATIENT : 3

A LEAN girl of 4 1/2 yrs age - one of twins -talkative , meaningful responses -spastic- delay in growth (self note :Spasticity is a condition in which muscles stiffen or tighten, preventing normal fluid movement. The muscles remain contracted and resist being stretched..)- parents being nurses-growth issues identified very early and therapy initiated on time -born early, 33 WEEKS - BW 1.100 kg-memory normal- language normal-uses past tense -slight issue in eye coordination-IQ normal-has dysarthria -leg slightly curved

THERAPY ACTIVITIES

-mobilisation and stretching MS,(rhythmic rotation RR, sustained stretching SS,PNF,),weight bearing WB, activating weak and antagonistic muscles, orthotics and assistive devices ,aquatic therapy AT, teach and prompt proper positioning ,practice functional skills, facilitate normal patterns of movement

1.LEFT HAND MS,RR,SS

2.LEFTSHOULDER MS,RR,SS

3.HELPS to turn whole body to right side - a painful attempt-neck movement not easy-cannot sit alone- bowed posture- feels like falling- gives a bog doll( a dog named Kalyani) to hold on -

4.repeats with the right side

5.sits with crossed legs for trunk balance-tries to make her crawl -teaches the sequence of movements for crawling - reinforcement , a kiss to the doll for each movement

6. make her sit on gym ball-make her lie with face upwards, make her lie with face downwards, makes her look upwards, make her try to stand by herself -holds her hand and compels her to walk - tells mother to try the same activity again- advises to do the activity at home

7. therapy for scissoring gate ( W sitting )- ball exercises- other activities tool to the mother in earlier sessions-

Discussion- the curved in the leg may become normal after 4 1/ 2 years ...hydro therapy at home will do good - if scissoring gate exists even after learning to walk , surgery is an option-

***************
Patient 4 : A kid with emotional outbursts.......3 years 6 months old boy ...referral from CD C, - treatment @ICCONS for 1 years 6 months ....hydrocephalism-ventricles affected-placid muscles-can not walk properly- alternate stepping not possible -can climb stairs up, but panicky while stepping down

THERAPY ACTIVITIES

- keeps him lying back and makes him kick in the air , make him sit , makes him walk slowly

-rotating movements-practising walking up a ramp, with fans switched off to get maximum resistance -strengthening activities-has wide stepped gait-flat foot -has got training at home to walk in sand - the doc uses loud compliments like "very good" , "good boy"

DOCTOR COMMENTS : Hyposis - protruded abdomen - language delay(making him lie, make him stand)- IQ seems not normal- can imitate- cross legged position slightly difficult for the child , just for 5-10minutes-the child has just started walking-linguistic training to be initiated soon-

ACTIVITY- MAKES HIM SIT IN CROSSLEGGED POSITION-balanced walking again- MAKES HIM CLAP - helps him step down slowly

MORE …..

REF PREETHI’S NOTES

SPECIAL EDUCATION

ACADEMIC SESSIONS

i. Introduction

ii. About the ICCONS

iii. The departments of ICCONS and the facilities

iv. Registration of patients/ cases

v. Case taking/ file Keeping

vi. Clinical and other examinations

vii. Procedure of Assessment at various departments / tests