Monti Case Study

Monti has been seen at Coordinated Movements since April 10,2015 an outpatient occupational therapy clinic, referred for evaluation and treatment. Based on evaluation results outpatient occupational therapy was recommended for Monti to enhance his gross motor skills, fine motor skills, visual motor skills, and range of motion, social skills, sensory processing, and oral motor skills. At the time of referral Monti was receiving OT and PT through Charles County Infants and Toddlers Program 1x per week. Additionally, Monti was receiving physical therapy at coordinated movements.

At the time present time of referral it was evident Monti displayed impaired neuromusculoskeletal functions involving the left upper extremity including his range of motion, strength, and his increased muscle tone. Monti presented with left hemiparesis and preferred hand positioning was fisted. Additionally, Monti displayed difficulties with gross motor skills including bilateral integration, crossing midline, balance, and completing reciprocal movement patterns. He presents with left side visual neglect impacted his ability to navigate and engage in play activities. Monti displays a difficult time organizing and motor planning age appropriate gross motor activities. Monti appears to be very guarded of the LUE during play activities becoming completely emotional dysregulated

Mom reports Monti is still in the process of toilet training and is dependent for bathing activities. During dressing activities mom reports Monti is able to place the right arm and leg through clothing garments however requires assistance for the left side of the body. Monti is not a picky eater therefore he enjoys a variety of foods without difficulty. Furthermore, mom reports Monti was using a g-tube for feeding for liquids every other night due to Monti’s risk for