Tuesday, June 24, 2014

30th Hospital Stay


Yes it's official.
Liam has had his 30th hospital stay.
We've had a hell of a week!!
On the 17th Liam was taken to Children's hospital ER.
He was vomiting,
running a fever,
and required oxygen.
By the time we got to ER,
it's an hour drive,
Liam was breathing very heavy.
So heavy that it had the nurse scared.
She put an oxygen mask on him and pumped 13 litters into it.
I had had him on only 1 1/2 litters.
After quiet some time on 13 liters and an hour treatment
his breathing calmed down.

They took blood for labs.
Checking all the usual possibilities like mediport infection.
At the end of getting the blood out of the mediport,
it clogged up on them.
A blood clot got lodged and they were unable to get it out.
They called the doc and had to place an IV in his hand.
Thanks to all the time he's had to heal his veins,
getting an IV was a snap.
Through the IV they gave Liam fluids,
and some very powerful heavy duty antibiotics just in case it was a mediport infecion.
They used TPA to try an break up the clot.
It was very hard for them to get the TPA into the mediport.
The nurse pushed with all her might to get it in.
Two hours later it was still clogged.

By this time we already knew Liam was being admitted.
One for the clot in his mediport.
Two for his labs showing elevated white blood count.
Three not tolerating feeds.
Four his sudden oxygen requirement.
Good news was the xray of his lungs looked clear.

At 6am on the 18th we were still in ER.
Justin came to stay with Liam so I could rush home and work at 8:30am.
Later that morning the nurses in ER tried again to draw from his mediport.
They were again,
unsuccessful.
So they pushed TPA again.
My husband said that the nurse pushed even harder.
He said she pushed the TPA with all she had and was straining to get it in.
Then after a few hours they tried to draw blood.
hey got very very little. Just pulled enough into the needle line before stopping.
They were quick to announce that his mediport was now unclogged.
HMM....

Still because it was barely working they continued to use the IV in his hand.
Smart move on their part considering how this story ends.

They didn't start Liam's feeds back up until late afternoon on the 18th.
He was able to tolerate a full bolus of 4oz of Pediatric Compleate.
His 12 hour continuos bolus also went very well.
He continued to need oxygen and get breathing treatments around the clock.
At 11am on the 19th they took Liam completely off oxygen.
He tolerated room air perfectly at this point.
The "doctor" told us that if Liam tolerated room air for 24 hours,
then he would be allowed to go home.
Meanwhile his blood cultures came back negative.
Meaning no mediport infection.
(theres more to this just wait)
We still had no clue what was wrong with Liam.

On thursday the 19th at 7pm I arrived in Liam's hospital room.
I almost couldn't function while away from him knowing he was sick.
I felt horrible for not being by his side.
I even had a break down and cried about it.
I was so happy to be back at his side and caring for him.
He was happy to see me too.
Mommy gave him loads and loads of cuddles and anything he asked for.
I had took one look at Liam IV in his hand,
and explained to the nurse I felt his hand looked really puffy like it was blown.
She said that yes his hand was puffy but it was fine.
I told her i really felt it was gone.
She felt his hand and said it was fine.
I didn't want to make waves.
I knew that sometimes Liams hand did get pudgy when it was taped like that,
but I also knew that when it was red and puffy like that,
chanced were good it was blown.
I took her word though since she'd been watching him for two nights now.

During the night on the 19th/20th Liam started vomiting.
I honestly thought it was from coughing so much.
Because he started coughing before he vomited the nurses agreed.
We were even able to continue the feed.
He ended up doing this twice in the matter of 30 minutes.
The only major problem we saw was that he would start his coughing attacks,
about 30 minutes before his treatment was due.
Thankfully all the RT's were right on time.

On Friday the 20th the Doctors and "doctor" declared that Liam was good to go home.
When we finally got the discharge paper work it was around 5pm.
First to come out was the mediport.
They'd kept the mediport needle in just in case.
The nurse flushed it with hepran,
like we always do.
Then took off the dressing and out came the needle.
No hassle,
no pulling,
not like normal.
What came out with the needle?
All the hepran she had just pushed.
You know what a blown IV look like?
Well this looked just like that but bigger and on his chest.
I staired at it and then at her in question.
My brain tried to process what the situation was and what it all meant.
At the same time both the nurse and I mentally hit our heads on that metaphoric wall.
We started talking about how the heck this could happen.
After talking about everything from ER to then,
we were able to come to a conclusion we both agreed on.
The ER nurse was NOT supposed to push the TPA (or anything else) that hard.
Why?
Because it could cause the needle to dislodge.
And what had happened here?
The needle dislodged!!
Thankfully we didn't use it!

So then we called the "doctor" and notified him of what had happened.
He came in to talk to me so I asked what the side effects were.
I mean we just put in a whole months worth of TPA straight into Liam's chest cavity.
A medicine that's supposed to prevent the blood in the mediport from clotting.
What was his responce?
That the body would absorb it in time and he would be fine.
No side effects.
Really??
The charge nurse came in later to let me know this happened once to an adult patients mediport she was working with and his entire left side swelled up pretty bad and was red.
But yea the "doctor" said no side effects.
Thankfully there are nurses there who care and let me know what the possibilities were.
Seriously we've had some amazing nurses in this journey.
Ones I would have been lost without.

Finally it was time for the discharge instructions.
The nurse and I were going through the paper work,
and we were both confounded and pissed at what we were reading.
The "doctor" wrote a bunch of symptoms and diagnosis that Liam never had.
He wrote that Liam was on meds he was never on.
He also stated that Liam had a broviac instead of a mediport.
BIG DIFFERENCE!!!
The nurse apologozed profusely for this.
That's when I learned that the "doctor"
was actually a second year med student.
REALLY???
I was fumming pissed.
No wonder he seemed like he knew nothing and had NO answers for us!
Instead of waiting around for notes at this point,
I made noted on her copy of the paperwork before signing it.
She made several notes of her own.
She said this guy was on her list because he was always screwing up.

Putting our frustration and anger aside,
it was time to get the IV out of Liam's hand.
Guess what we find?
His IV had blown as well!!
I told the nurse how I had thought it was the night before,
but when I brought it up to the night nurse she insured me it was fine.
At this point our poor nurse was at her wits end.
She explained that she was going to talk to the head doctor of that group,
explain what had happened with the other "doctor",
as well as make a incident report.
She said it needed to be documented in case Liam ended up having symptoms from it.
She had our back all the way.
After I dressed Liam and we grabbed all our stuff,
we left.
As we walked through past the nurse's station we found our nurse on the phone.
Sure enough she was already making the complaints and incident reports.
I swear this lady had a heart of gold.
I can only hope that if and when Liam has  to go back,
that we get her again.
I truely love her for honestly caring about our little lamb.

What's going on now?
Well Liam hasn't gotten better.
In fact since he's been discharged he's gotten worse.
The next day (21st)
Liam started running fevers.
101.6 on saturday morning.
I almost rushed him back that very minute.
In fact he was looking so bad on saturday morning that I called into work and started packing our bags.
Justin talked to me and convinced me to calm down and take a few steps before rushing off.
We gave him motrin and a cool shower and he cooled off.
He was also breathing fast and coughing so we gave an early treatment.
At this point we were doing albuterol very 4 hours.
His pulmacurt and atravant in the morning and night.
At nights he was vomiting his formula feeds.
We had to stop them as soon as that happened.
It wasn't just some vomit but full on perjectile.
On sunday we was still running fevers.
I went and bought gatoraide to run through his tube to keep him hydrated.
We also had to start using atrovant every 4 hours.
Liam was getting a treatment every 2 hours at this point.
He was also needing oxygen at night.
Sunday night/ Monday morning ay 1am he started vomiting without even coughing.
Again it was perjectile.
I stopped the formula and started gatoraide.
During the late mornings and into the evening Liam seemed fine.
If it wasn't for all the coughing you'd never know he was sick.

Monday I had to call into work again.
Liam had to go see our pediatrician.
It was mandatory.
Liam's cough and the way he behaved screamed it was time.
Our pediatrician gave him a combined albuterol/atrovant treatment so he could hear the before and after in Liam's lungs.
Thankfully he said the wheeze pretty much went away,
and it didn't sound like pnuemonia.
So we went home with a different breathing treatment plan.
Albuterol every 3 hours.
Atrovant every 6 hours
This has helped but Liam is still so congested.
We also started gatoraide boluses in the daytime.
This is to ensure he stays hydrated.
And our pedi is ok with oxygen use at night.
He said whatever helps Liam stay home longer.

Today Liam has thrown up twice on his boluses.
He barely tolerates 2 oz when his normal is 4.
This had be extremely worried.
I called home every break I had to check on him.
Every time Liam wasn't running a fever,
refused to eat anything,
and was running amok like normal.
Still the very low calorie intake was so stressful.

Our pedi,
who is amazing and the best EVER,
made a house call tonight to check on him.
Liam's lungs have a wheeze here and there,
but are moving air well.
He said to keep doing what we're doing.
Lower the night feed rate so he keeps the formula down.
That way he gets calories in him.
He said he's ok with oxygen usage at night.
He feels that Liam can still stay home at this point.
Thank Heavens because I was so worried.
We are to text him tomarrow letting him know how Liam's doing.
Yes text him,
as in his personal cell phone.
Thats how awesome our pediatrician is.

In other good news,
the Pediatric Compleate was approved my insurance and will be delivered tomarrow.
We were first told it would not be covered,
because it's made by nestle.
Well that worker was thankfully wrong.
Our GI gave us a case of it a few weeks ago to try.
The transition from Elecare JR to Compleate was seemless.
Liam has never tollerated something so quickly and seemlessly before.
Compleate isn't an actual formula because it is not milk based.
It's actual food blended up.
When I was blending foods and pushing them through Liams gtube
we saw an immediate response.
He was more energetic.
He stopped retching and vomiting,
And he started packing on the weight faster than ever.
That says alot because Liam seldomly gains weight.
When we tried a whole case of Compleate,
I saw an immediate response.
No retching or vomiting.
More energetic.
And from one day to the next I could see weight gain in his belly.

Justin thought I was joking and didn't believe me.
But one look at Liam's belly and he was shocked.
There was a belly begining.
This was exciting.
So when we were told monday that it wouldn't be covered,
we were both so very frustrated and angry.
Compleate had given us hope,
and that hope had been ripped from out eyes.
God must have heard our prayers and given us a miracle.
We are so excited that his Compleate will be here tomarrow.
We hope that he tollerates it better right now than the formula.
I say that just because he is sick and not tolerating much of anything.
Already in this bought of sickness,
Liam has lost weight.
You can see it by just looking at him.
No need for scales with him because its very visable.

I feel so blessed that this prayer has been answered.
And if insurance hadn't covered it,
I have a very dear friend with a CDH baby of her own who is on Compleate.
She offered to supply us with some knowing how hard it is for these kids to gain weight.
I absolutely love that I have grown so close to a few mom's with CDHers,
and that we can help each other out when we can.

In other news:
Lanie has a bad ear infection.
It just started hurting last night.
She came to me crying in pain so I took her to urgent care.
The doctor there was shocked it had only started hurting that day.
She said it looked like it had been brewing for some time now.
I'm really glad we caught it before it became even worse.
Lanie hasn't complaint very much at all over it.
I fear that it could be because she knows we're under alot of stress as it is that she doesn't want to cause us more.
I sat her down and explained to her that she never should fear telling us anything.
That is shes hurting she needs to let us know so we can help.
I told her shes too young to worry.
She promised me that she hadn't been keeping it from us.
So then I started thinking that because she used to have ear infections chronically,
that she built up a tollerance to the pain.
Kind of like I built of a tollerance to my back pain.
I've only gotten worse.
Physical Therapy did strengthen my core like we wanted it too.
Only it didn't solve the problem.
In fact it might have made it worse in some ways.
I still have the pins and needles pain all over.
My upper spine cracks alot and stays sore.
My whole body stays sore for the pins and needles feeling.
The longer I'm on my feet the number and worse they get.
I missed last fridays appointment because I was at the hospital with Liam,
so I can't get into him again until July 7th.
He wants me to take meds to detox the aspertame poisoning he feels never went away.
He's also referring me to a nuerologist.
I have an MRI tomarrow.
Hoping we get some news from that very soon.
I just need to know what the problem is so that I can fix it asap.
The pain had climbed to a new level that my body is having a hard time getting used to so I can block it out.
I might have 1 decent day out of 10.
Today was my last PT appointment.
They did their last evaluation.
They feel I've outgrown what they can do for me and she also felt really bad she couldn't help make the pain go away.
I'm actually sad to see it stop.
I really liked them and think they were doing great with me.
But all good things must come to an end.
Now I need to hold myself accountable and get to the gym.
I know what I have to do to continue to strengthen my muscles and need to stick with it.

Now to reward those whose read the whole blog post:







Sunday, June 15, 2014

Hidden Sacrifices


I saw this on Facebook and had to share. As a caregiver to a medically complex child I know all too well the sacrifices that need to be made. We give up everything, even ourselves for our loved ones. 

What we do goes unnoticed and underappriciated. We suffer along with our loved ones and put our pain aside to make room to ease their pain and suffering. 

We don't do it for recognition. We do it because we love the person we are caring for. It's simple. 

As a caregiver I give up the majority of my time to take care of my child. I give up sleep every night and am often exhausted. I spend a lot of time worrying about what needs to be done for Liam. I have no "free" time, no time to myself. I'm often asleep as soon as my head hits the pillow to only be up half the night with my son. 

Money that would be "extra" that could be used on maybe buying something extra is used to put gas in the car to get Liam to his many appointments. Regular maintenance like oil changes and tires as well. There are meds insurance doesn't buy that we have too. 

We don't do this for the recognition. We do it without complaint because we love Liam. Because he is our son and he deserves the chance at a normal life. So if we have to give up some sleep and buy extras to help move him towards a healthy future then that's what we will do. 









Saturday, June 14, 2014

Aspertame Poisoning Part 2

My doctor thinks my body never detoxed on it's own when I had aspertame poisoning back in December. He feels I still have it. He also feels I have permanent nerve damage from it. I've never been the same since I had it. My eye sight was affected. I can't see as far and everything is blurry to some extend or another. This sucks. My MRI is scheduled for the 25th. Next week I go back and will be referred to a nurologist. I'm on tramadol and a maxed dose of gabbapenton. And am on  flexeril. It's not working, none of it. I just woke up to both arms completely numb. After moving them around the feeling started comming back. Back in December it got so bad I couldn't hardly walk. I'm sharing all this because it's important to spread awareness about aspartame poisoning. What is aspertame? It's an artificial sweetner and preservative. It's found most commonly and diet drinks. Like diet Pepsi, diet coke and more. You can get aspertame poisoning by drinking too much. Aspertame it self causes bad things like headaches and more. Aspertame poisoning can lead to symptoms of MS and eventually death if not cought. It also leaves long term permanent damage. Going through it the first time was utter hell. Going through it again is not just hell for my body but scary. I say again because it's the second bout of intense pain. I've stayed away from anything with aspertame in it since December. Next week when I go to the doctor he warned me that if the symptoms didn't get better I would have to take meds that would detox my body. These meds themselves can cause horrible effects and damage of their own. 


I feel like I'm on a roller coaster ride through hell sometimes. 

Friday, June 13, 2014

Summer Fun

Summer is here! This means outside fun like swimming, playing on the swing set and more. Liam is having. Blast living it up. Lanie has done a great job helping her little brother through all the fun stuff. Teaching him what to do. 

We've been to the park to play in the sprinklers twice already. 


Liam had a GI appointment. He lost 2 pounds from being sick with bronchitis a few weeks ago. Were trying him on a new feed. It's called Nestle Complete and it's basically blended food. He's am reading gaining a belly and it's only been 2 days!! 
(After 2 days of Complete)
(Before complete)

And today we've had some backyard fun. Liam's been climbing the playset all by himself. He can now climb down the ladder by himself! It was amazing to watch. We also set the little swimming pool up and our boxer dog thinks it's doe drinking and has been sneaking drinks lol. 

We've been doing some reading as well. I got my consultant kit for Usborne books so every day the kids get to read a new book. 




We love summer!





Thursday, June 12, 2014

My Health Update



I haven't blogged much about what's been going on with me, my health. 
For some reason it's easier for me to give short updates on facebook versus blogging.
Why?
Because when I sit down to write a blog post I let it all out.
I hold nothing back.
I haven't wanted to go into detail about my pain because I didn't want it to see as if I was complaining.
It is what is it.
So here goes...

For the last few months my body has been riddled with pain.
It started with my back,
My doctor,
who is absolutely amazing BTW,
has been doing is absolute best to fix me.
He ordered an Xray.
Xray shows the early stages of digenerate disk disease.
Seriously no big deal because everyone gets it as they age.
Other than that the Xray had nothing to say.
Because I've been in pain since 2008 its considered chronic.
My doctor referred me to Physical therapy.
I've been going for like a month now.
They felt that if I strengthened my core that it was help my back pain.
The reason is because my core is so weal that my back is having to work harder to make up for that.
My core is getting alot stronger.
I can feel it.
Back pain isn't getting better.
As of two weeks ago things got worse.
Out of nowhere my left leg from hip down got that tingly numb pain feeling like when you foot falls asleep.
It has only gotten worse from there.
My physical therapist thinks I have permanent nerve damage from when I had aspertame poisoning back in December.
I went to the doctor as soon as this happened and he added Gabbapenton to my meds.
He felt this would make my nerves talk to my brain and help the pain go away.
We had also started Naproxin.
As of yesterday the "sleepy foot" feeling has affected my whole body.
I saw my doctor today.
I had too.
Ive been in so much pain.
I almost went to ER last night because I hurt so back.
The pain was so intense I vomited.
Today I went to talk to him.
I told him everything.
He switched my pain med to tramadol.
A pretty heavy dose too.
He also maxed out my Gabbapenton.
He said that if this doesn't help to come back immediately.
I have to go back next week to follow up.
After I left he went and reviewed my medical file all the way back to December.
He called me and asked why it wasn't in my file that I had aspertame poisoning.
I told him I wasn't sure but the doctor that treated me for it didn't seem to helpful.
He asked how I was diagnosed.
I explained how I read an article about aspertame poisoning and it had sounded exactly like what I was going through so I stopped all diet sodas and artificial sweeteners immediately.
Within a few days I felt amazing.
Pain was almost gone.
I explained how when I went to that doctor I told him everything and he agreed that I had aspertame poisoning.
I also told my now doctor that the old doctor had said to just stay away from all artificial sugars to let my body detox it out and if I didn't feel better in a month to go back and get detox meds.
My now doctor said that he felt the aspertame poisoning never cleared up and that he felt its been reaking havok this entire time.
He said that I needed to go back next week to follow up and that he was refering me to nurology because I obviously had some damage that needed to be treated.
We've been waiting 3 weeks for insurance to approve an MRI and I finnaly got the call and will be having it done on the 25th.

I feel scared.
I don't want to go through this again yet here I am.
There are days I can barely walk.
But I now I can do this.
Im strong and Ive survived this bout of pain once already.
Im trying to stay positive.

Thursday, June 5, 2014

Enjoy it now

"Enjoy it now because you'll miss it when its gone"
How very true this is. Things have been changing for us here..again. As it always seems to do. 
*I started working
*Tomarrow is Lanie's LAST DAY OF KINDERGARTEN!
*Liam's feeds are changing daily depending on what he chooses to eat.
*Liam will be going to preschool next year!!

Theres just alot going on. I miss being home with my babies.
I miss the cuddles.
The cars.
The tea parties,
Nap time.
Free time.

Its only been a week. I'm constantly worrying about everything at home.
Is Liam eating enough?
Drinking enough?
Is Justin compensating with bolus feeds?
Did Lanie do her homework?
Did she have a good day at school?
Did the animals get fed?
Did the dishes or laundry get done?

Its a terrible mess in my head. What I love about working is that it's been so busy that I don't have time to worry unless on break. Don't even ask about the pay because yea it sucks but it's better than nothing. When I'm home I try to enjoy the time with  my family but Im too exhausted even for that. Hopefully my body will adjust soon.

Meanwhile both kids are thriving and doing great. I say Liam is "thriving" because to me every breathe he takes is success. He goes back to the GI soon so we will see! 

Tuesday, June 3, 2014

IEP

When the words "special education" was used Monday during Liam's IEP meeting my heart sank. Not because he needs the extra assistance it provides but because my fear that others will lump him into a category and make fun of him or think ill of him. I fear that they will tease him and call him names like "stupid" because that's what kids, and even some adults do these days.

I fear they will never give him a chance. Liam is very smart. He is bright, intelligent and adorable. He's just behind because of all the time he spent at the hospital due to being sick. Thanks again for that CDH! But now he is stronger, and healthier. He's starting to catch up and will do so quickly with the help of merely observing his peers. 

So why special Ed? Well during the IEP meeting I was given report by a physical therapist, phycologist, speech pathologist, special education teacher and more. I learned a lot about my baby boy as well as saw him through a different light.

As much as I hated hearing that Liam required Special education, I not only knew he would but expected it. I want Liam to get the best and get caught up as best be can as early as possible. This great team of ladies who assessed Liam had his best interest at heart as they worked with him to evaluate. They were all in agreement that he is behind but they feel that its because of all the medical needs he had and spending so much time in the hospital. They all feel that he will thrive in a preschool setting with other kids his age who are developing typically. Intellectually Liam doesnt qualify for special ed but they feel that because he still has many medical needs that he will benefit greatly from being apart of these classes.

Everyone who was a part of Liams IEP assessment was smitten with with. The education Specialist told me that looks alone dont fool her and although he is very adorable but his personality is sweet. What you see is what you get.  The report I was given and discussed in our meeting were lengthy and numerous. I sumerized them as best I could so that you could still get an idea of Liam.

Yes I am sharing them because I am not and will not ever be ashamed of my son. His progress in the last year alone has been HUGE. In the last year he started talking, walking, eating and becoming his own person. I am very proud of his progress. Along the way he has become more onry (a typical boy at the age of 2) but has continued to keep his sweet personality and mentality.

Liam was born the "underdog" with all the statistics stacked against him. Time and time again he has proven the victor, the survivor, the one to prove everyone wrong. I will always stand by cheering him on as he goes through life doing the impossible. Everything Liam does is "impossible" because he wasn't even expected to survive. The doctors were positive CDH would win and that my baby boy would grow wings and fly up to heaven to be with God. But Liam decided he wanted to fight. He wanted to prove them wrong and show everyone that nothing is impossible "for the very word impossible says that everything is possible".

With each new experience I go through with Liam I learn something new, get a new outlook on things. This process of IEP meetings and assessments has taught me a few things:
1) IEP's aren't as bad as I was told they'd be. I'm sure it depends on who your working with but the team we have are amazing people.
2) Special education is just another word for extra help. Liam's always needed extra help along the way rather its breathing, feeding, walking or now learning. I feel lucky and blessed that this team wants to help Liam and are doing everything they can to do so.
3) I am actually ready and excited for this next stop in our journey with Liam. Preschool!! It's a crazy thought but to think we've gone from almost constant hospital stays and from one illness to another to preschool. Again I feel blessed that Liam has come this far and is now actually able to attend preschool! This time last year even daycare was NOT an option because a "simple" cold would land him in the hospital. But here he is. Healed, on the mend and oh so blessed!!
4) I need to stop being such a worry wort and let Liam fly. Liam falls, or runs into the wall because he wasn't looking or whatever and I freak out. He however just laughs and takes off again. Liam doesn't need me to worry about him constantly anymore. Its time I start treating him like a "normal" almost 3 year old. He can't succeed if I continue to baby him. However I can still kiss the boo boo's when he asks and cuddle as he wished. And sneak in as many kisses as I can before he grows out of that! *sigh* My baby is no longer a baby. He's not even a toddler really but a little "big boy".

So without further adue, Liams IEP Assessment:

Please keep in mind Liam was 34 months old when the assessment was done.

Speech and Language Assessment:
cognitive: 24-30 months understands the concept of 1. Identifies rooms in the house. demonstrates use of objects, enjoys tactical books and engages in make believe play.
receptive language: 24-30 months follows 1 step directions, points to pics and names animals and objects, and knows many body parts.
expressive language: 24 months. Liam uses 2 word sentences, uses elaborate jargon, uses intelligible words 65% of the time, echoes prominent or last word heard and imitates environmental sounds.
comments: Liam made good progress from the transitional planning meetng (TP). During the assessment meeting he imitated alot of words and it was hard to determine what an imitation was and when he was trying to communicate something because he imitated what the assessors would say or ask.
non-speech test for receptive language: 29-34 months
non-speech test for expressive language: 22-26 months.

**Speech Therapy is recommended

Physical Therapy Assessment:
Gross Motor Functional Level: Complete to 20 months with scattered skills to 26 months.
Meaning that developmentally on the physical level Liam can do all goals for kids up to the age of 20 months but only some goals for kids 20 months and up. He can walk up the stairs using holding onto someones hand or a rail putting one foot on the step followed  by the second foot on the same step but doesn't alternate feet or do one foot on each step. Liam does not jump but easily walks sideways and backwards.
Playground motility: Liam requires moderate assistance accessing the climbing walls. He is able to go up and down the stairs and slide down the slide on his own and transition from level to unlevel ground.
Mildly low muscle tone, mild muscle weakness overall, range of motion is within normal limits. Liam exhibits moderate pronation of both feet. Left foot exhibits mild forefoot adduction. Exhibits ankle instability bilaterally.
Gait: walks forward with a mildly wide base of support. Exhibits mild foot drop in swing phase of gait and tends to trip when walking and running.
Posture: exhibits wide base of support in sitting and very mild upper thoracic scoliosis with mild rib malformation.
Object Manipulation: throws a ball forward underhanded but does not catch. Kicks a ball with his right leg.
Strengths: Liam is a very social little boy who enjoyed exploring the therapy environment. He enjoys climbing activities, and attempting new motor skills. He exhibits good walking and running skills and easily squats in play and resumes standing.
Concerns: Liam exhibits mild to moderate delays in his gross motor development. He is not yet jumping and exhibits difficulty descending stairs. He is not yet catching a ball. Liam requires moderate assistance climbing on the playground climbing equipment.
Reccomendations: It is anticipated that Liam will be independent in his classroom mobility. He will require stand by supervision to moderate assistance. Liam would benefit from educationally based physical therapy services to address playground safety and mobility ans stair climbing.

Bright Start Present Levels:
                                                 28 Month age Equivalent   ;   35 Month Equivalent
Fine Motor:                                       19 months
Gross Motor:                                     18 months                          24 months
Cognitive Delevopment                       18 months                         24-30 months
Communication Development
Receptive:                                         18 months                           24-30 months
Expressive:                                      18 months                             24 months
Social/Emotional:                          24-36 months                          30-36 months
Adaptive:                                       12 months                                  18 months

Development Assesment: Cognitive 87 19th percentil, age equivalent 27 months, average
Communication 18%tile adequate
Daily living skills 12%tile moderate low
Socialization 45%tile adequate
Motor skills 2%tile low
Adaptive Composite 10%tile moderately low

Special Education: Liam doesn't qualify based on intellectual disability but does because health reason.

Education Specialist Report:
Pre-literacy: Liam was able to right a book, turn the pages of a chunky book and look at the pictures with interest.
Pre-Math: When presented with color bowls Liam was able to sort like colored bears to corresponding bowls. With minimal verbal prompts, he was heard to count by rote from 1-8 when pointing to objects in a book.
*According to Bright Start developmental levels. Liam is able to show the concept of one and give one of many. He is able to engage in simple make believe activities.
Communication skills:
Receptive:According to mom Liam can talk but there are days that he is quiet, but he can be prompted to use familiar phrases such as "thank you". According to Bright Start levels Liam is able to follow one step directions, knows many body parts, and can point to pictures of animals and objects.
Expressive: When comfortable, Liam will repeat prompted one or two word expressions. He is able to identify verbally a variety of farm animals, colors and familiar request.
Fine Motor skills: During assesment Liam was observed to use his left hand more often than his right when doing fine motor tasks and he used light touch when grasping items. (Liams touch, speech were light. She feels that this just might be a part of who Liam is)
Gross Motor Skills: Parent stated Liam has difficulty running due to the braces on his feet (needs them for pronation. Because of the pronation he falls) He can push with two feet when on a bike. According to Bright Start Liam is able to step up and down the stairs holding onto the rail and can climb up onto furnature.
Social Emotional/Behavior: Liam was cooperative and friendly during the assessment with adult examiners. He was interested in the testing tools and made good effort to comply with adult requests. According  to Bright Start levels Liam initiate own play requires supervision to carry out ideas. He makes his demands known and can initiate his own play.
Skills Adaptive/Daily Living Skills: According to mom, Liam shows awareness that he has a soiled diaper but is not yet potty tained. Parent stated that he assists in dressing. Mom states that Liam is still tube fed but does not deny food. He is efficient at "chew and swollow" and mom is not concerned about a chocking hazard.
Conclusions: Liam has health issues that need to be addressed for present levels from the nurse. Mom reports that Liam enjoys doing puzzles and playing with cars and trains.

Recommendations:
1) It is recommended that Liam participate in preschool activities that support language opportunities throughout the school day and appropriate social interaction with typically developing peers.
2) It is also recommended that Liam participate in preschool activities that introduce curriculum that prepares students for Kindergarten.