comprehensive medical assessments nhsggc illustrative cases
TRANSCRIPT
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