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Unit 1 Clinical Presentation Asperger’s Syndrome

Unit 1 Clinical Presentation Asperger’s Syndrome. Presenter: Dr. Susana mwanza & Dr. Jonathan Ncheengamwa Moderator: Dr. Mpabalwani 24/11/2011. L.F. Female/6 yr old Of Chilanga Referred to UTH for N eurological Assessment Presented to UTH on 13/10/2011 at 09.00hrs. c/o .

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Unit 1 Clinical Presentation Asperger’s Syndrome

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  1. Unit 1 Clinical PresentationAsperger’s Syndrome Presenter: Dr. Susana mwanza & Dr. Jonathan Ncheengamwa Moderator: Dr. Mpabalwani 24/11/2011

  2. L.F. • Female/6 yr old • Of Chilanga • Referred to UTH for Neurological Assessment • Presented to UTH on 13/10/2011 at • 09.00hrs

  3. c/o • Regression of speech • Inappropriate behaviour 4 6/12 • Inappropriate communication • Difficulties in concentration • Hyperactivity 12/12 • Not able to construct sentences However able to read and write single words

  4. Hx P/C • Well till age 2 • First noted change was loss of speech developmental mile stone previously appropriately developed

  5. PMHx • RVT-NR • No other illneses

  6. Birth Hx • 1st born • Term • SVD • 3.6kg • Cried spontaneously • Pregnancy and labour uncomplicated

  7. Feeding and <5 hx • Breast fed in under 2hrs after birth • Weaning at 4 months • Received all vaccinations according to MOH protocol

  8. FHx • Negative • No TB contact • No hx of Psychiatric disease

  9. Socio-economic Hx • Mother-House wife • Father-planner

  10. examination • Temp 35.3 deg. Celsius • Wt-22kg • Ht 123cm • Fully conscious • Afebile • Exhibiting inappropriate behaviour with • Occasional screeming

  11. Examination • RS • CVS Normal • P/A

  12. Problem • Delayed neuro-psycho-social development

  13. Plan • Consult neurologist and Child psychiatrist • Follow up in clinic 2 under Unit 1

  14. Clinic 2 review (26/10/11) • Delayed speech • Hyperactivity • Neonatal period-No jaundice • Sat by 6/12 • Stood at 9/12 • Able to feed self • Able to toilet self

  15. Social Hx • Moody • Plays alone 9even when in a group of children) • Hardly ever hugs with mum-hits her sometimes • Sometimes hits self • Can use computer on his own and captures new words easily • Says a word at a time

  16. examination • Alert • Hyperactive • Inappropriate behaviour-moving all over examination room • No dysmorphism • Systemic exam normal • Normal testis

  17. Problems • Hyperactivity • Speech delay • Autistic behaviour

  18. Review (same day0 • Noted hx of using computer beyond neurologic age • Tends to learn things on his own • Mum says unable to sustain conversations • But, able to read

  19. O/E • Alert • In his own world • Not hyperactive

  20. Diagnosis • Asperger’s syndrome

  21. Plan • To UNZA School of Education for psycosocial assessment • Review in 3/52 in clinic 2

  22. Highlights of UNZA assessment • Hyperactive tendencies • Not able to sit in one place • Always making sounds and statements • Did not make eye contact when being talked to • Unable to take formal assessment • Instead, Special Needs Assessment profile (SNAP) was administered

  23. Diagnosis • Autistic spectrum Disorders- Asperger’s Syndrome

  24. Review (9/11/2011) • Based on recommendations made at UNZA, mum was counselled • To have child enrolled to special school (Baobab or UTH)

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