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Patient Details


Demographic Details Child's Name: Anaija Shah Gender: Female DOB: 2022-04-10 Type of family: Joint Number of family members: 6 Number of siblings: 1 Details of siblings (Age and sex): 1- 7 year old male Address: Gormi, Bhind Contact: 8871177040 Referred By: Doctor Informant: Father and grandmother Presenting Concerns Chief concerns: Delayed speech and walking Duration of symptoms: Realized delayed milestones since 8 months of age, no intervention done Interaction history: Eye contact: Sustained Behavioral history: Mouthing of objects Habit behaviors Birth & Perinatal History: Antenatal History Consanguinity: No Maternal age at conception (years):: 22 Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: 37 wk Birth Weight: 3 Kg Cry at birth: Delayed cry Resuscitation required: No If yes- Duration & Indication: At DH Bhind SNCU for 8 days Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Investigations done- Hearing assessment: Done Details: BERA (at 1.5 years age)- Normal Vision assessment: Not done Family history: Neuropsychiatric condition: Yes Details (If yes): Similar history in 7 year old sibling. Any recent stressful events in family: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 1.5 years Roll over: Achieved Age of attainment: 2 years Sitting without support: Achieved Age of attainment: 2.5 years Standing without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 2 years Unidextrous grasp: Achieved Age of attainment: 2.5 years Pincer grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: Babbling: Achieved Age of attainment: 2 years Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: Babbling: Achieved Age of attainment: 2 years Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 3 months Stranger anxiety: Not achieved Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 1. Unoccupied Academic History: Is child enrolled in school: No Diet History: Sleep History Total sleep duration (night): 10-11 hours Afternoon nap: Yes Sleep disturbances: No Daily Screen Time Duration: <30 minutes Examination a. Vitals: b. Anthropometry: Weight: 9 kg Height: 85 cm Head circumference: 48 cm c. General Examination Dysmorphology: B/l esotropia, inward slanting of eyes, prominent maxilla, short philtrum, pectus excavatum Neurocutaneous markers: ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Bulk of muscles: Generalized Wasting Deep tandon reflexes: KJ- 3+, AJ-2+/2+ Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 3 /week+ PMT 1/15 days Investigations: Pediatric ophthalmologist reference General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Anaija Shah
Gender: Female
DOB: 2022-04-10
Type of family: Joint
Number of family members: 6
Number of siblings: 1
Details of siblings (Age and sex): 1- 7 year old male
Address: Gormi, Bhind
Contact: 8871177040
Referred By: Doctor
Informant: Father and grandmother

Presenting Concerns

Chief concerns: Delayed speech and walking
Duration of symptoms: Realized delayed milestones since 8 months of age, no intervention done

Interaction history:

Eye contact: Sustained

Behavioral history:

Mouthing of objects Habit behaviors

Birth & Perinatal History: Antenatal History

Consanguinity: No
Maternal age at conception (years):: 22
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: 37 wk
Birth Weight: 3 Kg
Cry at birth: Delayed cry
Resuscitation required: No
If yes- Duration & Indication: At DH Bhind SNCU for 8 days

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Investigations done-

Hearing assessment: Done Details: BERA (at 1.5 years age)- Normal Vision assessment: Not done

Family history:

Neuropsychiatric condition: Yes Details (If yes): Similar history in 7 year old sibling. Any recent stressful events in family: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 1.5 years
Roll over: Achieved

Age of attainment: 2 years
Sitting without support: Achieved

Age of attainment: 2.5 years
Standing without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 2 years

Unidextrous grasp: Achieved

Age of attainment: 2.5 years

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment:

Babbling: Achieved

Age of attainment: 2 years

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment:

Babbling: Achieved

Age of attainment: 2 years

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 3 months
Stranger anxiety: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

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

Type of Play : 1. Unoccupied Academic History:

Is child enrolled in school: No

Diet History:

Sleep History

Total sleep duration (night): 10-11 hours
Afternoon nap: Yes
Sleep disturbances: No

Daily Screen Time

Duration: <30 minutes

Examination

a. Vitals:

b. Anthropometry:

Weight: 9 kg Height: 85 cm Head circumference: 48 cm

c. General Examination

Dysmorphology: B/l esotropia, inward slanting of eyes, prominent maxilla, short philtrum, pectus excavatum Neurocutaneous markers: ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Bulk of muscles: Generalized Wasting
Deep tandon reflexes: KJ- 3+, AJ-2+/2+

Oromotor Examination

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

Advice

Intervention plan: IDP 3 /week+ PMT 1/15 days
Investigations: Pediatric ophthalmologist reference
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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