Full Case Management: Real life example

Male age 8

PC: Parents note: Behavioural problems front & foremost in his presentation now. History of febrile convulsions attributable to tummy bugs as we do not vaccinate our kids owing to familial adverse reactions….I think the trauma of these signaled a downturn in his development & we’ve been struggling to get back on the ladder! Awaiting autism assessment to avail of appropriate services at school…(they did get this in the end)

History:

Some family emotional trauma, arguing, during pregnancy.

Likely to have mouldy furniture as brought in from a very old house

Planned preg

h/o birth control pill 4 years prior 

Mum dentist by trade 

No medication in pregnancy 

Ultrasound x 1

Placenta previa had acupuncture and baby turned 

Natural labour

Gas and air 

Breast fed straight away and for a few weeks, then combo fed. Stopped BF around 4-5 mths (mum wanted to)

Hes a very loud baby, Big baby!

generally well, engaged with us

Crawled ok but later than should have

Speech started to come in late and it didnt develop this well after this

Walked at 18 mths 

Discovered sensitive to cows milk so swapped to goats  

Unvaccinated 

Age 3

Febrile convulsions from a stomach bug x 2 episodes of this 

Vomiting and diarrhoea and fever convulsions 

Sociable 

But was behind his peers

Behind in toilet training and feeding himself 

Sleep became difficult 

Hid under the table, pre school, probably overwhelming with sound and too many children

Age 3.5

Wheezing when had a upper respiratory bug 

Laboured breathing , nebulised and oxygen 

Probably had strep (sister had)

Given a couple of Antibiotics and Steroids 

but steroid would send him crazy, hyper 

So late in teething 2 years behind only just getting 5 year old molars now 

Behaviours:

Only just feeding himself (age 8)

Hates stuff on his hands 

Dislikes chewing -ve lumps , have to mash foods

Likes to chew non edible things !

Chews bedding and clothes

He’s a worrier

He doesnt speak enough words to explain 

He lost connection with other kids, but wants to seek out contact with other kids but cant speak enough to know how to initiate play

Doesnt like failure , wont say anything until its right, 

He knows he’s behind

Isolated from other kids 

Aggression started March 2023…started to take him out the classroom

Would rip things, stuff off the walls

Pulls others hair

Kick or bite 

Sharing is a problem 

Might lash out 

Still loves a baby bottle for comfort , 3 bottles of goats milk a day, has it cold 

When guts are bad he is “crazy”, ++pungent stool for weeks recently ….used to eat foam car seat 

Licks handrail but stops when we say 

Hyperactive

Likes to annoy, provocative 

Knows not to annoy the cat but he knelt on the cat purposely

He needs an audience to misbehave 

Can seem sorry but will just do it again

Breaks boundaries 

Rarely acts out on a threat, just to get a reaction 

Replays the scenario and may laugh, devious 

Annoying 

Fine on his own but loves affection, seeks out a hug

Used to be afraid of dogs, but now own 2, hes ok unless they jump up

Might touch our cat now but still scared 

Gestures 

Rubbing ears or scratching chest , finger posturing 

Tic phase, shoulder shrug a year ago 

Sleep 

Good, 9 hours 

Falls asleep on the sofa carry him to bed but can go in his bed

Bit more clingy now

Sweat during his sleep, +++ especially on first sleep esp on head. 

Grinds teeth 

Can awake cold, likes to be snug and warm 

Digestion/bowels

BM recently on the toilet

Regular 

Belches rotten egg type

Recent bout of loose, smelly stool few months, undigested food

Diet

Good diet 

Removed MSG 

likes Chips 

Eggs and avocado

Yogurt, stewed apple

-ve beef

Eats chicken thats mashed up 

Eats crisps

On the whole have to mash food, -ve lumps in the food 

We give Zinc and Probiotics 

1st prescription:

Lac Humanum 10M 1 x week

Tarantula hispanica 200c 2 x week

poly fungi 30c 2 x week

poly bowel 30c 2 x week

1st follow up 8 weeks later:

Mum feels Tarantula helped!

1st few weeks…he was more present, calm

But trying to destroy his toys and looking at me and laughing again, communicating this way…wants to annoy us 

Expanded palate, eating beef pork and chicken pears apples, all these new things 

Still mashed….even tried mashed potato with butter 

Lac Humanum ……not craving the bottle anymore, wouldnt panic about it, more willing to try newer cups!!

Stool: Better formed than it was

Had conjunctivitis, bloated stomach,

Sleeps well, 9.30pm-7am 

Trying to encourage him to express in sentences, struggles to do

Needs more expressive language 

But Language/words improved noticeably 

Used to really ++sweat at night, feet and head but not as much now

Still sucking objects and straps like seatbelts.

2nd prescription

Tarentula 1M 

Poly fungi 200c

Poly bowel . 200c

Lac humanum 50M

2nd follow up 8 weeks later:

Making a big difference 

Tarentula made a huge difference

Some Oppositional behaviour at the moment …goading a bit

Nips the carers to see their reactions …not as bad as it was

Had a bug…tired, conjunctivitis, sinus , eyes stuck together then influenza A….he slept a whole week! But was fine no medication given……

His gut….smells bad…lingers

Lot of chewing, straps on school bags

Really good and focussed at school, best academic work he has done

Mental maths is very good 

Likes maths 

Likes spelling, reading

Reading comprehension still poor…(gestalt 4 processor)

Impatience, cant wait , gets angry might throw something (but will choose something that wont break)

Communication….really improving but not yet up to 8 year old.

Likes trampoline , walking the dogs, playing with dogs 

Loves getting in a lift

Likes to be on the go

Down time is ipad…educational reading etc

Music he likes listening to

Observing other kids now and says hello back….!

Not so destructive now  

Drinks more water now

Likes peri peri spicey foods….

Still prefers softer food, 

Good appetite 

Light green discharge from eyes…

Wipes nose to eyes

Nasal discharges green 

Relaxed about certain things , not worried about the bottle at all now so hes fully using cups

Bowel movements now good, well formed once a day

Wouldnt usually let me go to brush back teeth but yesterday he did!!

Wants his big sister with him, conversation and fun with her…anything she does he wants to copy !!

He will now sit with mum and look at a book

He now Uunderstands “not a good choice” and he decides…

Can still be a little unpredictable 

Went to sound therapy using bowls…then he sobbed for 2 days after!!

Likes the vibration

3rd prescription

Syphilinum 1M single dose

Dental amalgam 12c (mum fillings)

Tarantula 10M 

Mercury 30c

Poly organ support 

3rd Follow up

Sister had strep throat

Hes had Whooping cough…but hes ok  …he had antibiotics

Bored ++Likes the new ! 

Running around in boredom 

Constant movement at the moment like ADHD

Making a noise while moving around 

Settles when sister comes home 

Need rigorous exercise 

Making verbal noise, disrupts the house but goading me again

Trying to destroy a toy

We have to keep him constantly stimulated

Sleeps ok

But Not angry anymore, not destructive

Very intelligent 

Seeking out alphabets 

Gestalt language 

He can read the words but not always understand the instruction 

Needs a container or he’s all over the place 

Hes calmer when his sister is home …very attuned to her…when shes away he feels it 

Eating dinner with a spoon now 

Flight risk, impulse to run 

Craving food 

Got big belly..maybe bloated …..(post antibiotic) 

4th prescription

Poly antibiotic 4 x 4

Tub bov 1M 1 x week

4th follow up

Going very well, speech doing well

100 piece jigsaws on his own…gets frustrated if cant find the piece and other times he’s chilled

Loves his therapeutic music sits 10 mins now

Hes playing with boys and girls better

Respecting others boundaries…had fun playing together 

Tub….he calmed….it settles him ….few weeks ago was last dose..

Wants to walk alongside and not hold hand 

Goading has calmed a lot ….

Tummy rumbles a lot …even after food 

Eating the same 

Started to eat more independently will eat all of it alone….

Can correct him now with just words…! 

Speech …can have now a back and forth conversation with us! Emerging ….

Clear in requests

Excellent on a bike ….follows our instructions within reason 

School work (home)...writing sentences of his own head !!

Might be starting to realise that hes different …

2 new cats….Loves the cats , loves them, no fear

5th prescription

Poly metal 30c (hair test revealed some high heavy metals as suspected)

Tub bov LM3

5th follow up

Shows some mild defiance …im in charge before he sits down and does work…

But then settles and does some fantastic work 

Not the destructive kid he was 

he gets more enjoyment from life, colouring and writing notes

Sat an hour at a time 

Now sits and does Jigsaws on his own 

He is speaking ..sentences together and can say what he wants 

Hes copying things he hears kids say 

Not being difficult at the moment 

Trying different foods…. 

Growing very well too…massive growth spurt 

6th Prescription

Tub bov LM4

Poly metal 200c

Case ongoing