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You are working as an F1 doctor in an out-patient paediatric clinic. You have been asked to talk to Gabby Pentin, a concerned mother who has brought her 9 month old son Harry to the clinic today. Compared to Harry’s older sister, Harry seems to be “behind schedule” with his development, as he cannot yet crawl. Please take a history of Harry’s development and any other factors you think are important. Following this please perform the appropriate examination on this patient.

Your name is Gabby and today you have brought your 9-month-old son Harry to the paediatric out-patient clinic. You expected Harry to be similar to your daughter, Megan, who has had no development concerns and has just started school. You have found, however, that this is not the case and are worried he is “running behind schedule”.

HPC; When asked details, you explain how Harry has not learned how to crawl yet and often cannot stay in the sitting position you try to put him in. At first you thought he seemed too ‘floppy’ as a baby but now he seems almost like he’s resisting movements as his legs seem stiffer than normal. His arms seem to be better developed and he can lift up his head OK. Harry needs a lot of help with feeding as he doesn’t seem very coordinated, although you are impressed that he already knows he is right-handed as he only ever picks things up with his right hand. He seems settled most of the time though, and has started to make sounds. He follows your face but you are unsure if he can hear you yet. You haven’t noticed any changes in his bowels, waterworks, skin or breathing.

ICE: You are most concerned that Harry will not be able to go to normal school and that his developmental delay could cause him to miss out on ‘everyday normal things’. You want him to have the best upbringing possible and to make sure both him and Megan have the same opportunities. You would like them to both go to the same school. You hope this could be corrected with extra playgroups and tuition when he starts school, but as a single parent you are worried about lack of social and financial support for doing this.

PMH: Harry is not known to have any other medical conditions. You had Harry when you were 25 years old and had very poor antenatal clinic compliance as you were between moving areas following a break-up with your partner.

You remember the pregnancy without any problems, and gave birth to Harry in the hospital. It had been a surprisingly long labour and eventually was converted to a C-section delivery. There were no post-natal concerns but you have feel you generally haven’t had much interaction with any midwives/community follow-up. You have managed to get Harry’s vaccinations up to date.

SH: You had never planned to have another child after Megan, and your long-term partner broke up with you shortly after finding out you were expecting his baby but refused to have an abortion. Before this, you had happily lived in his flat and looked after Megan whilst he worked as a manager at a large firm. Since you found out you were pregnant, at 22 weeks, you have been rushed off your feet managing to move areas, into a new apartment, and recently now have a job as a teaching assistant at Megan’s school. You smoked for a short time before you became pregnant but do not now. Following hospitalisation from a binge-drinking session when you were 17, you have not touched alcohol since.

FH: You were adopted and so you know very little about your family history. On your ex-partner’s side, there seemed to be a prevalent history of heart attacks and strokes.

Examiner instructions The student should interact with the child, trying to build rapport with the child using his mother, wherever possible, to keep him calm. Within reason, the student should aim to use materials around him to find out which milestones the child has reached: palmar vs pincer grip picking up objects, sitting in stooped/straight-back position, distracting the child to see if he turns to auditory or visual stimuli. Try to get the child to smile/speak/interact. The student’s differential diagnosis should sound something like: ‘My top differential diagnosis would be cerebral palsy, in particular the diplegic category, as his lower limbs seem most affected. Hand dominance before the age of 1 year is always pathological. There is also some evidence of learning difficulty which is associated with cerebral palsy.’ Examples for discussion may include: - What are other causes of motor developmental delay? - What milestones are often achieved by a 9 month old child? - What are the four key areas of child development? - Are there any national tests that screen these areas of development in children? - What types of cerebral palsy do you know of? - How is cerebral palsy managed? Which healthcare professionals should be involved in the child’s care?