Hello-

I am trying to get an objective view of a portion of my medical record. My question is, might the following portion of my medical record, a letter dated August ##, 1975 from the pediatrician treating me (Jonathan) and my mother when I was 6 years old be pertinent to any emotional problems I currently have (would like to keep these diagnosis from my adulthood unnamed in my effort to keep it as objective as possible). What might the letter indicate as far as what my emotional experience was in my early childhood? Could this experience have affected me in later life? Sorry that the letter from the pediatrician is a somewhat long and that my subjective explanation is so lacking. Thank you very much.

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August ##, 1975

To Whom it May Concern:

Re: Jonathan Doe
Medical history
Date of Birth – 3/##/1969

This letter will summarize pertinent past history on Jonathan Doe, who is now 6-4/12 years old and was first seen by me on July ##, 1975 for a physical examination and again on August ##, 1975 for consultation.

Review of Jonathan's previous chart reveals the following. In September of 1970, at age 18 months, mother complained about increased activity and power struggles. Doctor Smith, the examining physician at this time, did not feel Jonathan demonstrated any evidence of hyperactivity.

At two years of age he had only two words of language. Mother complained about his hyperactivity again, said she was fed up. Jonny was having temper tantrums and was into everything, according to mom. Mom found that she screamed a lot. Father has two jobs, both in the post office and as a **** (evening job), and there is really very little family intercommunication or contact.

Physical exam at this time seemed to indicate a bombastic, hyperactive child.
Doctor Smith’s impression at this time was that this was a poor mother-son relationship and that Jonathan had probable language delay.

In March of 1971 the visiting nurse saw Jonny and his mother in the home setting. Pertinent observations were that Mrs. Doe questioned whether Jonny was “born bad.” Lots of limit-testing behavior was noted during the home visit. Jonny looked back at mom while he was performing this behavior. Mother provided much negative reinforcement. It was apparent that there was poor parental communication in this visit. In April of 1971 the visiting nurse met with father and mother. Father made the point that mother never follows through on any discipline measure. Mother says that father never supports her. Both parents say the problem is their inter-relationship, not Jonny.

In August of 1971 the visiting nurse performed a Denver Developmental Screening Test, which was normal for Jonathan’s age of 2-1/2. Notations at this time were that Jonathan was still getting into everything. Mother says “I shouldn’t have to lock up everything, should I?” Mother did not implement any of the visiting nurse’s prior suggestions.
 
Notation on 9-71: “This mother seems to expect the child to be bad, and indeed his is.” Preschool was suggested for the boy and this was begun. Both parents went to Mrs. Baldwin in the Mental Health Service for group counseling. 12-71: “Mother is continuing group therapy with the Mental Health Service— ‘I need to tell my husband some things and I can only do it with someone there.’” 1-72, Visiting Nurse: “Mother says that the visiting nurse never told me what to do.” 5-72: Group therapy, summary of 10 sessions – “Parents blame each other for their problems rather than trying to work on them. The child appears to be the pawn in this thing.”

During the course of the 10 group therapy sessions Mrs. Baldwin felt that the parents improved somewhat. 5-73: Age 4-2/12 years. Dr. Smith now feels that he demonstrates characteristics of MBD, very bouncy in the office and rocky. 5-24-73: Mrs. Jensen, as visiting nurse, institutes behavior modification. 6-73: Visiting Nurse: “Jonathan still limit-testing, parents inconsistent in their response. Parents’ communication seems to be better. Working on behavior modification.” March 1974 – Doctor Smith, physical exam: “Transfer to Alternate Location of Medical HMO since parents live close.”

I hope this short summary of information will be useful to you.

Sincerely yours,

_______________, M.D.

8/5
 
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Please comment if you feel it may be helpful. I will explain details later after any initial comments. Thank you so much for your patience. John.