CASE 1    |    Sierra Burnes

CASE 2    |    Shirley Carter

CASE 3    |    Bradley Leonard (Butch) Sampson

CASE 4    |    Henry and Ertha Williams

CASE 5    |    Sherman (Red) Yoder

CASE 6    |    Charles Robert (Chip) Jones


CASE 8    |   Mrs. Millie Larsen

CASE 9    |    Ms. Julia Morales

CASE 10    |    Miss Patricia Verloren

CASE 11    |    Abel 

CASE 12    |    Heddy

CASE 13    |    NAME

CASE 14    |    NAME

CASE 15    |    NAME

CASE 16    |    NAME

CASE 17    |    NAME



AuthorsElke Zschaebitz, Erin Embry, Mary Showstark, Andy Wiss, Dawn Joosten-Hagye, Anita Simmons 

Keywords: Autism; vaccines; Developmental Delays 

Presenting Situation and Instructions for Learners 

Autism Spectrum Disorder 

Focus on mother/family 

Focus on resources and support 

Care over a life span 



Context:  This note is three months before telehealth visit  


Previous Provider Notes from Kentucky:  


Clinic: Kentucky Pediatrics; Dr. J 

Identifying Data: 6 year old patient; Abel A. 

Source: mother , Tara A. 

Reliability: Reliable  


Chief Complaint:  Follow-up autism diagnosis x 4 years (diagnosed at age 2) 

Presenting Problem and History of the Present Illness:  Abel is a 6 year old boy presenting to our suburban health clinic with his mother.  He has a history of persistent delays in expressive language, pragmatics, persistent food jags, fine and gross motor and sensory function and negative behavioral interactions that have grown progressively worse in terms of frequency. He was formerly diagnosed with autism at age 2 after these persistent speech/language and gross/fine motor delays with social deficits.  In preschool, he received early intervention speech, physical and occupational therapy. Abel’s mother works and his father travels for work for most of the month working in the mining industry. His grandmother has been watching him at home for the past year, and he just enrolled in a kindergarten classroom at a school in his community.  


Mrs. A reports that last week, she and her husband were at a grocery store with Abel when he ran off. He was found by a police officer while his mom and dad were searching in the neighboring stores. 

Mother reports feeling “exhausted’ and revealed that she and husband are having significant marital issues because they have “differing views on how to manage this”. 

He has “over the top” behavioral issues of persistent self-harm: hitting himself and kicking and screaming.   Mom notes that any changes to her routine or social outing is a nightmare. ”Going to the store with him—I get people stopping me saying that I need to control him or feed him or whatever—I don’t know what to do.” 

“He doesn’t sleep – when my husband returns from his work trips, we have had to take turns sleeping with him in order for him to be quiet so that he won’t scream and play and wake up his brother. He doesn’t sleep through the night—ever.”  

Mrs. A reported that he won’t eat the foods that his family eats, sometimes picking at them and other times throwing them on the floor in a tantrum. She admits that it is difficult to brush his teeth and maintain good oral care and admits that he has had multiple caries.  

Mother notes that he has constipation and GI issues, “because the only thing he will eat is chicken nuggets and waffles.  He denies any stomach pain, but I know he is not comfortable.” She reported a bowel movement every 3-4 days in his Pull-Up diapers, and even then he sometimes cries that “it hurts to poop.” She states he appears thin. 

The mother also reports that he was recommended for speech, occupational and physical therapy at 18 months old for possible motor and sensory integration issues.  She noted improvements in his motor functioning at the time, although she had to reduce the number of weekly therapy visits due to her work schedule. She believes he is lagging behind his peers in some areas despite receiving some speech and OT in his preschool. 

Mrs. A was told by her pediatrician to “stop comparing him to his siblings” and expressed guilt because “some woman at my daughter’s school told me he has autism because I vaccinated him.” She states that she has heard that autism also has come from air pollution and blue dye; stating she sleeps with her windows open and hopes the nearby mining town was not the cause.  


Past Medical History  

Autism Spectrum disorder: diagnosed by Developmental Pediatrician at age 2. 

Pervasive developmental disorder: diagnosed age 9 months 

Birth History: uncomplicated term birth 

Persistent social delays: speech, eye contact, developmentally appropriate social  interaction 

Gross motor skills delayed, delays in walking, in jumping, climbing stairs at 24 months.   

Lead screen: WNL at 12 months and 18 months  

Speech/language delays 

Fine and gross motor delay 

Sensory integration issues 

Health maintenancereceived one MMR vaccination 

Past Referrals:  Speech Therapy,  Occupational Therapy,  Developmental Pediatrician, Applied Behavioral Analyst (ABA) 

Past OBGYN/Birth History: Normal vaginal term birth at 40 weeks.   

Breast fed six weeks.   

Past Surgical History: Denies surgeries 
Past Psychiatric History: Denies past psychiatry history diagnosis for child   

Medications: Benadryl liquid 25 mg/10 mL po prn nightly for sleeping (uses most nights) and Target brand kids gummy vitamin, 1 po daily  

Allergies: No known drug allergies (NKDA), No known food allergies (NKFA), no environmental or latex allergies 

Family Medical History maternal grandfather: bipolar illness,  Maternal cousin (mother’s sister’s child) with developmental delays 

Psychosocial/Social history Patient lives with mom and dad and older brother aged 7 &9  in a rural environment about 30 miles out of town in Kentucky. States she will be relocating at some point to West Virginia due to husband’s work in mining.  They live in a free-standing home.  Mother and father do not smoke.  Grandmother does not smoke. 

Diet:  limited diet of only chicken nuggets, milk, waffles and occasionally more textured food like cookies or crackers.  drinks milk and water 

Sleep: poor sleep; wakes up frequently throughout the night fully awake and does not go back to sleep; does not take naps  


Activities of Daily Living (ADLs): By the mom’s report, Abel needs supervision, frequent verbal instructions and minimal-moderate assistance to dress, groom and bathe himself. He is able to feed himself using his hands (no utensils) after set up.   Sensory integration deficits with temperature : child puts on a coat in the middle of summer, and has a history of stooling in his pants until age 4, occasional nocturesis /bedwetting  approximately 8x/month.     


Sexual HistoryNot applicable 

Screenings: Hearing and Vision: WNL (within normal limits) 


Review of Systems 

General:  Denies fever, chills, weight loss or gain; states appetite is not great (as above)  

HEENT: Denies hearing deficits, denies nasal congestion,  denies any visual changes; admits to teeth being sealed and multiple caries  

Cardiovascular: Denies chest pain, palpations, dyspnea on exertion, syncope or lightheadedness 

Respiratory:  Denies cough, wheezing, or dyspnea when sitting or with exertion 

Gastrointestinal: denies heartburn, bloating, nausea, vomiting,  changes in stool quality or color, blood or mucous in stool, Admits to constipation (stooling 2x/week), large stools with WNL color; wears Pullups; Admits to frequent flatulence, stool incontinence-(sometimes has accidents during the day) 

Genitourinary: Denies dysuria, hematuria, frequency or urgency or flank pain; Admits to urinary incontinence/ nocturia 

Reproductive: NA 

Endocrine: Denies cold/heat intolerance, hair loss, dry skin, denies excessive thirst, denies skin changes 

Musculoskeletal:  Denies myalgias, swelling of the joints,  limp or weakness in extremities 

Neuro: Denies seizure activity, no headaches, Admits to developmental delays (see above in HPI) 


Physical Exam: 

Vital Signs:    

Height percentile 80%   

Weight 50%  trending stable 

Weight  20kg 

Height  120cm 

Blood Pressure:  80/50 manual cuff  

Respiratory Rate: 14 

Heart rate: 99 

Temperature: 98.4F 

BMI: 13.9 (7th percentile) 


General:  alert and oriented to person and place and  time, in no distress  child is clinging to mother with minimal engagement with toys in the room.   

Psych:  Appearing shy, reservedEye contact is minimal,  

HEENT: PERRLA, TMs clear, no nasal discharge, throat no erythema (limited view)  Visual acuity test: Unable to obtain.  

Lymph:  No axillary, cervical, epitrochlear, inguinal or femoral adenopathy 

Pulmonary: Lungs clear to percussion and auscultation bilaterally 

Cardiac: Regular rhythm without murmurs, gallops, rubs, PMI is in the 5th intercostal space, no JVD  

Abdomen:  Flat, soft, without tenderness in all quadrants with palpation, decreased but present bowel sounds. 

GU:  no CVA tenderness, no lower abdominal pressure or  lower pelvic pain 

Reproductive: Tanner Stage 1 

Musculoskeletal:  Full ROM of upper and lower extremities, WNL sensation of upper and lower extremities, appropriate muscle tone, no atrophy noted.   

Neurologic: +2 reflexes in patellar, Achilles and brachial tendons,  CN II-XII WNL, noted but difficulty getting child to follow all instructions.  

Skin:  warm and dry, good turgor 

Developmental:  speech, gross motor, fine motor delays noted 



Recent Lab work: CBC, TSH : WNL 




Report from OT:  

Alert, oriented to self and his mom. Answers orientation questions of place and time appropriately only after prompting by mother. Speech is flat with 1-3 word answers. His attention is fair, it improves with interest in the topic. Short and long term memory were not tested, nor were problem solving and safety judgement as the child became uncooperative with the OT.  


Presents with weakness at the trunk and proximal joints of the extremities (shoulders and hips). Joint laxity is noted in the wrists, hands and fingers as well as the ankles, feet and toes. Static standing balance is Fair. He can tolerate moderate displacement force. Gross motor abilities are characterized by an inability to through or catch a 12” diameter ball, inability to walk on a 3” wide balance beam resting on the floor.  


He is unable to recreate a 5-block vertical design and demonstrated frustration as he seemed to know what to do but his fine motor coordination was limited. He is able to respond to yes/no reliably with head nods and vocalizations. He loses attention when asked to follow multi-step directions.  


The Pediatric Evaluation of Disability Inventory (PEDI) was attempted but not completed due to child’s inability to attend to the tasks.  

Neurological: Positive for alteration in sensation or motor function, Negative for headaches and dizziness. His attention is fair, it improves with interest in the topic. Short and long term memory were not tested, nor were problem solving and safety judgement as the child became uncooperative with the OT.  


Report from PT:  

Abel received weekly physical therapy from 9 months to 3 years through the Early Start Program, then received yearly physical therapy reassessments and consultations through his school program from 3 years to current.  At 5.5 years, Abel was assessed using the Movement Assessment Battery for Children Checklist, 2ndedition (MABC-2). On the MABC-2, he exhibited skills in the 5th percentile for Aiming and Catching and 1stpercentile for Balance. Functionally, he independently walks and runs over level and uneven surfaces (curb, ramp, grass, sand, playground wood chips), but requires a rail to ascend and descend stairs. He is unable to perform age appropriate functional mobility, such as ascend and descend stairs without a rail, walk along a 3 inch balance beam, or throw and catch a 12 inch diameter ball. His inability to perform age appropriate functional mobility is limited by tactile hypersensitivity, poor motor planning, and poor dynamic standing balance. 


Report from Speech-Language Pathology:  


Abel presents with moderate–severe language problems. Expressive language deficits are greater than receptive and characterized by reduced variety of communicative intents, limited content and form. Impairments included decreased knowledge of grammatical constructs, audible phonological speech problems and underlying phonological processing difficulties (ability to analyze and manipulate word-sound structures) for nonword and known word-repetition tasks, reduced semantic organization for expression of thoughts or directives beyond 3 word phrases. Occasional repetition of words or phrases noted when attempting to elicit extended phrases or conversational exchanges.   

Word comprehension is a relative strength for Abel, although receptive language difficulties for sentence comprehension, understanding verbal instruction and emerging literacy skills were demonstrated.  

Pragmatically, Abel displayed little interest in social interactions or play activities with limited symbolic play. Volume was low with limited prosody. Abel exhibited little to no awareness of body language or social cues with communication partners during structured play activities and often substituted socially unacceptable forms to gain attention (i.e. pulling at clinician’s arm or clothes). Increased anxiousness and resistance noted when attempting to transition tasks when a sufficient amount of prepping was not offered.  

Cognitively, Abel demonstrated reduced sustained attention to tasks that were of less interest to him (less than 5-8 minutes), although noted improvements when prompted to select stimulus items for play (increased to 10-12 minutes on average). When prompted, Abel counted to 10, named 5 of 6 basic colors, identified 8/10 basic objects and named 5/8 familiar objects.  




ICD 10 F84.0 Autism Spectrum Disorder 

 Constipation  K59.00 

  Nocturia  R35.1 

 Behavioral disorder  F98.9 

 Speech and language delay F80.9 



Continue with care 

Fax over medical records following release of records form (signed) to receiving facility 



Community Snapshot:   Each student will determine resources in their community/state 


Recommended Referrals in new state; 

Developmental Pediatrician 

OT (Peds certified) 

PT  (Peds certified) 



Psychiatrist for medication management: to include medication for anxiety causing maladaptive behaviors and sleep issues (he has trouble sleeping) 


Individual Education Plan: School based Early intervention team- For accommodations 


Dietician: due to issue with constipation and food jags 


 ABA Therapist 


Social Worker: Discuss Respite care for family; family counseling; Support groups; psychoeducation; Autism resources