• Diet: Eats a well balanced diet with sugary snacks; food is coarsely chopped to facilitate easy swallowing. Mother reports that feeding Justin is difficult because of a significant tongue thrust.
• Home environment: Lives with both parents who work during the day. Justin attends a school for children with special needs and is in the first grade.

• Medications: Tizanidine 4 mg q80; Oxcarbazepine 450mg po q12
• Allergies: None
• Immunizations: Up to date
• Previous hospitalizations/Surgeries: Multiple admissions related to seizures and diagnostic evaluations; surgery one year ago for bilateral heel cord lengthening
• Review of systems: chokes on thin liquids and prefers to have course foods ground to facilitate swallowing4; limited joint mobility in lower extremities, upper extremities with moderate spasticity; toe-walking gait; history of grand mal seizures ~ 6 times/year – last seizure 2 months ago
• Health care: Has begun seeing a new pediatric nurse practitioner for routine health maintenance; receives physical therapy 3 times/week, occupational therapy 2 times/week and speech-language therapy 2 times/week at school

First noted to have “stiffening when held” at 8 months of age. Feeding difficulties and slow weight gain became apparent at 10 months of age. Had first seizure at 11 months for which he was hospitalized. A diagnostic work up of the seizure and failure to thrive resulted in a diagnosis of spastic cerebral palsy. He was started on anticonvulsant therapy. During infancy and early childhood, his weight gain was slow and developmental milestones were delayed. He sat without support at 13 months; talked at 28 months; and, walked with significant assistance at 30 months. Currently walking well with bilateral leg braces.

• Height: 125 cm (75%); Weight: 21 kg (25 %)
• Mobility: uses leg braces to ambulate without difficulty; has frequent falls due to ataxia
• Cognition: testing for learning disability revealed that Justin performs at grade level

Complete primary dentition with two loose teeth (upper left lateral incisor and upper left canine) and two fractured teeth (lower left lateral incisor and lower left canine); and healed frenulum laceration. Significant tongue thrust; bruxism during sleep; xerostomia; oral hypersensitivity to solids and hyperactive gag reflex; poor oral hygiene. Last visit to dentist 2 years ago; difficulty sitting still in exam chair due to lower extremity spasticity.