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Patient Details


Demographic Details Child's Name: Kumar Adwait Dwivedi Age: 3 Year 7 Month 1 Days Gender: Male DOB: 2022-07-27 Mother’s age (years): 36 years Mother’s occupation: Asst Professor Father’s age (years): 38 years Father’s occupation: Advocate in Supreme Court Type of family: Nuclear Number of family members: 3 Number of siblings: 1 Contact: 8285208935 Referred By: Doctor Informant: Parents Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Patterned behavior or activities: Sensory Concerns: Auditory: Hypersensitive Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Gestational Age: FT Birth Weight: 4 Kg Cry at birth: Cried immediately after birth NICU stay: No Past history: Hospitalization: No Seizures: No Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: Yes Others: Similar history in cousin Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 3 months Roll over: Achieved Age of attainment: 5 months Sitting without support: Achieved Age of attainment: 6 months Standing without support: Achieved Age of attainment: 9 months Walking without support: Achieved Age of attainment: 11 months Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Achieved Age of attainment: 6 months Pincer grasp: Achieved Age of attainment: 11 months Drinking from cup: Achieved Age of attainment: Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 9 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 9 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Drag for needs: Emerging Answering Questions:- Echolalia: Present Social Stranger anxiety: Achieved Age of attainment: 7 months Waving bye bye: Not achieved Response to Name Call Details: 7/10 Sitting tolerance- (in minutes) For interaction: Less than a minute For tasks: More for tasks ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : 2. Isolated Outdoor play duration: 2 hours Academic History: Is child enrolled in school: No Additional information: School discontinued Diet History: Food preferences: Picky eating, likes sweets Sleep History Total sleep duration (night): 8 hours Afternoon nap: Yes Sleep disturbances: Daily Screen Time Duration: <30 minutes Type of screen: Mobile Examination a. Vitals: b. Anthropometry: c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Chewing: Proper Swallowing: Proper Blowing: Improper Others: Sucking ab CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: Home based program 1/week General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Kumar Adwait Dwivedi
Age: 3 Year 7 Month 1 Days
Gender: Male
DOB: 2022-07-27
Mother’s age (years): 36 years
Mother’s occupation: Asst Professor
Father’s age (years): 38 years
Father’s occupation: Advocate in Supreme Court
Type of family: Nuclear
Number of family members: 3
Number of siblings: 1
Contact: 8285208935
Referred By: Doctor
Informant: Parents

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Patterned behavior or activities:
Sensory Concerns:

Auditory: Hypersensitive
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Gestational Age: FT
Birth Weight: 4 Kg
Cry at birth: Cried immediately after birth
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: Yes Others: Similar history in cousin

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 3 months
Roll over: Achieved

Age of attainment: 5 months
Sitting without support: Achieved

Age of attainment: 6 months
Standing without support: Achieved

Age of attainment: 9 months
Walking without support: Achieved

Age of attainment: 11 months

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp: Achieved

Age of attainment: 6 months

Pincer grasp: Achieved

Age of attainment: 11 months

Drinking from cup: Achieved

Age of attainment:

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 9 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 9 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Drag for needs: Emerging

Answering Questions:-

Echolalia: Present

Social

Stranger anxiety: Achieved

Age of attainment: 7 months
Waving bye bye: Not achieved

Response to Name Call

Details: 7/10

Sitting tolerance- (in minutes)

For interaction: Less than a minute
For tasks: More for tasks

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 2. Started attempting
Toilet training: 1. Dependent
Dressing: 2. Started attempting
Undressing: 2. Started attempting

Type of Play : 2. Isolated Outdoor play duration: 2 hours Academic History:

Is child enrolled in school: No
Additional information: School discontinued

Diet History:

Food preferences: Picky eating, likes sweets

Sleep History

Total sleep duration (night): 8 hours
Afternoon nap: Yes
Sleep disturbances:

Daily Screen Time

Duration: <30 minutes
Type of screen: Mobile

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Chewing: Proper
Swallowing: Proper
Blowing: Improper
Others: Sucking ab

CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Advice

Intervention plan: Home based program 1/week
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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