Pediatric Cleft Palate Consult Followup

ID: Michael was seen at Regional Pediatric Clinic on January 21, 2026, accompanied by parent.

Medical History: 
- Other Diagnoses: Cleft palate, history of pneumonia

Interval History & Current Concerns:
Michael is awaiting palate surgery and has been on the surgical waitlist for approximately one year. He has been seen by the surgical team at Children's Hospital and has completed 2-3 sessions of speech therapy, with a report sent to the referring doctor. Surgery was delayed due to a recent pneumonia, with advice to wait six weeks before proceeding. The parent requests a reminder be sent to the surgeon regarding scheduling. Current concerns include parental reports of Michael sometimes sleeping on the floor at school and home, possible weakness, and episodes of seeing 'dinosaurs', 'Spiderman', and sometimes the doctor in video. Socially, Michael sometimes plays with other children but at times prefers to be alone. The parent notes 'tension' and requests regular check-ups for these symptoms. Michael is in grade 1, enjoys reading, and plays at recess.

School/Education, Services & Community Supports:
- Current Grade: Grade 1

Developmental Review:

Past Medical History:

Review of Systems:

Impression:
Michael is a child with a confirmed diagnosis of cleft palate, currently awaiting surgical intervention at Children's Hospital following recovery from pneumonia. He has completed speech therapy as part of his pre-surgical care. There are parental concerns regarding possible developmental or behavioral issues, including reported weakness, sleeping on the floor, visual phenomena, and variable social engagement. A comprehensive developmental assessment is planned to further evaluate these concerns.

Recommendations:
- Continue Current Supports: Follow up with surgical team at Children's Hospital for palate surgery scheduling; reminder to be sent to surgeon as requested.
- Future Follow-Up: Arrange comprehensive developmental assessment (45-90 minute appointment) to address behavioral and developmental concerns.