Mock 11

In this scenario, a young child presents with delayed milestones and signs of anxiety, a situation that requires a sensitive and thorough approach in a General Practice setting. This example will guide IMGs (International Medical Graduates) on how to address developmental concerns effectively and empathetically.

Clinical Scenario: Delayed Walking and Signs of Anxiety in a Toddler

Where You Are: General Practice Clinic

Who the Patient Is: A 15-month-old boy, James

Other Information About the Patient: James' mother calls the clinic, concerned about his development and behavior.

Patient Prompts

• Mother's Report Over the Phone:
  • Onset: "He hasn't started walking yet, unlike other kids his age."
  • Duration: "He's been slow to meet other milestones, too, like standing without support."
  • Progression: "He hasn't shown much progress over the last few months."
  • Aggravating Factors: "He becomes very upset with loud noises or when unfamiliar people are near."
  • Relieving Factors: "He seems calmer and more content when it's quiet and he's in familiar surroundings with family."
  • Past Medical History: No significant health issues noted so far.
  • Regular Medications: None.
  • Allergies: No known allergies.
  • Smoking and Alcohol Intake: Not applicable.
  • Use of Recreational Drugs: Not applicable.
  • Occupational History: Not applicable, as the patient is a toddler.
  • Simulated Examination Findings: As the consultation is over the phone, physical examination findings are not available. An in-person visit is required for assessment.

Scenario Clinchers

• Patient Concerns: (Reported by mother) Worry about delayed walking and reactions to sensory inputs.
• Clinchers and Important Points for the Doctors: The delayed motor milestones coupled with heightened anxiety in certain situations suggest the need for a thorough developmental and possibly neurological evaluation.

What You Must Do:

• Immediate Actions:
  • Reassure the mother that it’s important to assess James in person to better understand his development and any possible interventions.
  • Schedule an early appointment for an in-depth assessment.
• Diagnostic Steps:
  • Plan a comprehensive physical examination focusing on neurological and developmental assessment during the visit.
  • Utilize developmental screening tools appropriate for James' age.
  • Consider referral to a pediatrician or developmental specialist for further evaluation.
  • Discuss the potential need for auditory and sensory processing evaluations if sensory sensitivities continue to be a concern.

Differential Diagnosis

• Developmental delay (e.g., motor delays, possibly global developmental delays)
• Autism spectrum disorder (consider sensory issues and social interaction challenges)
• Musculoskeletal issues (e.g., hypotonia, cerebral palsy)
• General anxiety or sensory processing disorder

Typical Question to Rule Out Differentials: "Can James pull himself to stand, and how does he react to being held or touching different textures? How does he interact with close family members compared to strangers?"

Red Flags

• Inability to bear weight on legs or pull to stand by 15 months.
• Persistent toe-walking.
• Lack of response to social cues or names.
• Extreme distress in response to sensory stimuli without apparent cause.

Actions Doctor Should Do

• Conduct a detailed and gentle examination to evaluate James's motor skills, response to sensory inputs, and interaction behaviors.
• Provide parental guidance on developmental stimulation activities and how to create a supportive environment at home.
• Refer to specialists as needed based on initial findings for targeted intervention and support.

Referral Needs

• Type of Referral: Routine referral to pediatric developmental services and a pediatric neurologist or physiotherapist if motor delays are confirmed.
• Reason for Referral: Comprehensive developmental evaluation to identify the cause of delayed milestones and appropriate intervention plans, including physical therapy, occupational therapy, or other specialist interventions depending on findings.

This scenario provides a structured approach to managing concerns about a toddler's delayed milestones and anxiety, highlighting the importance of early and comprehensive evaluation and the involvement of multidisciplinary care to support the child’s development effectively.