Comprehensive medical assessments NHSGGC Illustrative cases

Baspcan

Comprehensive medical assessmentsNHSGGC

Illustrative casesDr Laura Somerville

Case 1.

• 4 year old boy • Concerns raised by school • Pale,thin,toileting problems,physical

care/appearance• Brother cerebral palsy+complex needs• Child protection concerns.On CPR.• Chinese.Mandarin speaking• Referred for CMA

CMA

• Seen by gp.Bloods ok.• Update from school “autism”• Attended with dad ,social worker and

interpreter• Social work information• Information – delay in immunizations• Dental caries- dental extractions planned

after A+E attendance with tonsillitis

Examination

• Weight 9th height 25-50th BMI 9th centile• Shy initially. Eye contact used at times • 2-3 word sentences in Mandarin and

echolalia• “Great job” in American accent • Play on his terms• Physical examination normal tone,power,gait.• Immature pencil grasp and skills

Conclusion/Opinion

• Physical neglect –dental • Unusual social interaction• Difficulties with fine motor skills• Background history of lack of

opportunities and developmental stimulation

• Occupational therapy,SLT,paediatrician follow up

Update- review 4 months later

• Child protection register.High level of support.

• Dental extractions all primary teeth

• School- progress toileting,starting to mix with other children,eating variety of foods

• HT/wt/bmi increasing trend

• Developmental assessment(age5) speech,language and social skills 36months,fine motor skills 48months,locomotor 60 months

?Attachment?Autism?both

• Less sensory issues-food,textures,senses• Observations school,speech therapist feedback and

in the clinic suggest progress • Still issues with social interaction and communication• Particular about things eg shapes

• CAMHS suggested structured parenting assessment

• Paediatric follow up

Learning points

• Challenges in giving clear statements to social work and reporter

• Joint working with other colleagues with emotional neglect,attachment,autism

• Neglect of disabled children

Case 2

Christine ParkClinical lecturer/ Honorary post CCST StR

Paediatric Dental DeptGlasgow Dental Hospital & School

Case Study 2

• 13 year old female

• Dental concerns identified by a new general dental practitioner who raised concerns with social worker

• Social worker contacted CPU for early sharing and to request CMA

• Child already placed on Child Protection Register due to chronic neglect

Case Study 2 – Summary of Concerns

• Missed health appointments including dental• Concern raised by child’s new GDP• 84% school attendance• Taking caring role for younger siblings• Calls to Police from neighbour• Home conditions – “very poor cleanliness”• Bereavement issues• Otherwise well and healthy looking

Case 2- Dental history elicited at CMA

• Significant previous dental treatment including exposure and bonding of gold chain to buried upper incisor

• Missed essential appointments with dental hospital, not seen for 18 months

• Letter sent to GDP regarding this

Case 2- Dental history elicited at CMA

• Then seen again for 4 appointments in dental hospital

• “Social issues” noted in casenotes as reason for previous missed appts

• Missed further 4 essential appointments

• Standard letter sent no further hospital appointments, discharging patient to care of previous GDP

• Siblings missed dental GAs and letters sent to previous GDP regarding this

Case 2- Dental impact on child

• Space now lost for buried front tooth to be pulled down

• Gold chain has been sticking through oral mucosa for years

• Treatment options are now limited, remedial treatment required which is sub-optimal

• Affect on oral health and aesthetics

Case 2 - Key learning points

• Missed dental appointments one concern of many but main concern in this case

• Social history important as is rigorous follow up for dental teams in general practice and in dental hospitals

• GDPs hold info re family situations that dental hospitals etc do not have information regarding e.g siblings

• Input from health services including dental is essential in assessment of child’s circumstance

Case - Outcomes

• Child and siblings accommodated with foster family

• Close contact with social worker to ensure attendance at health appointments especially dental