Client Note (Lucas)
Lucas
(Client ID 041)
| Name: Lucas |
Treatment Diagnoses: amblyopia, strabismus, ADHD |
Evaluation Date: 4 weeks ago | MR #: 000-041 |
| Age: 7yrs, 2mos |
Level of Education: attending 2nd grade |
Pediatrician: Cynthia Washington |
Insurance: BCBS |
| Gender Identity: Male | Pronouns: he/him |
Race/Ethnicity: Caucasian |
Primary Language: English |
| History of present illness: 7-year-old male child with amblyopia, strabismus, and ADHD which affect his function at school and home. | |
| Past medical history: right distal radial buckle fracture age 3 | |
| Birth history: Born at 38 weeks weighing 7lbs, 5oz. |
| Parental concerns: Mom has concerns about Lucas’ ability to copy words from the smartboard, play safely during school recess. Also reports that Lucas trips on the steps at home and needs reminders to be careful. | |
| Home Environment: Lucas lives at home with his mom and dad in a two-story home (no steps to enter). He wears prescription glasses. No other special equipment at home. | |
| School: Lucas attends a 2nd grade general education classroom in a neighborhood school. He has a 504 plan for accommodations for his visual impairment, including enlarged materials, preferential seating, 200% time for any assignments requiring extended visual concentration, teacher check for understanding, and option to have materials read to him or use of screen reader installed on his laptop. He does not receive therapy services at school but participates in outpatient vision therapy and occupational therapy. | |
| Interests: science, Uno and other card games, play on ipad |
| methylphenidate |
Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.