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Demographic Details Child's Name: Adhiraj Bhardwaj Age: 4 Year 11 Month 2 Days Gender: Male DOB: 2021-03-24 Mother’s age (years): 34 years Mother’s occupation: Homemaker Father’s age (years): 36 years Father’s occupation: Pvt job (Datia) Type of family: Joint Number of family members: 10 Number of siblings: 1 Details of siblings (Age and sex): 1- 2 year 1 mon Address: Datia Contact: 8770718416 Referred By: Doctor Informant: Parents Presenting Concerns Duration of symptoms: Realized atypical behaviors around 2 years age Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Jumping, toe walking, looks from corner of eyes, stimming Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Sensory Concerns: Auditory: Hypersensitive Visual: Seeks visuals Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: 1 spontaneous abortion at 2.5 months age Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Obstructed labor Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: NICU stay -10 days, On MV for 4 days (TFU- HIE), no AEDs on discharge Past history: Hospitalization: Yes Seizures: No Others: For febrile illness - twice Past/Current medications: Sizodon going on since 2 year age. Currently 5 drops BD Investigations done- Hearing assessment: Done Details: OAE- normal Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 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: 14 months Running: Achieved Age of attainment: 18 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: 12 months Drinking from cup: Not achieved Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: Communication & Language Assessment Non-Verbal Communication Grading:- Drag for needs: Consistent Answering Questions:- Echolalia: Absent Patterned speech: Absent Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 18 months Waving bye bye: Not achieved Response to Name Call Sitting tolerance- (in minutes) For interaction: 1-2 minutes minute For tasks: Better sitting tolerance with objects and tasks ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 2. Isolated Outdoor play duration: 2 hours Academic History: Is child enrolled in school: No Additional information: Didnt sit in school Diet History: Food preferences: Picky eater, prefers semi solid food and sweets. Food allergies: No Junk food intake: Occasionally Sleep History Total sleep duration (night): 7 hours Afternoon nap: No Sleep disturbances: Daily Screen Time Duration: < 2 hours Examination a. Vitals: b. Anthropometry: Weight: 18 Kg Height: 110 cm Head circumference: 51.5 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: 1 hypopigmented macule over anterior abdomen d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Deep tandon reflexes: Tone normal, DTR- KJ3+/3+, AJ 2+/2+ Oromotor Examination Chewing: Proper Swallowing: Proper Blowing: Improper Others: Sucking- improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 2/w+ PMT 1/w Investigations: CBC, S. Urea, Vitamin D, Vitamin B12, S. Homocysteine, S. Lead Medications: Syp Sizodon (1mg/ml) 0.2ml at evening 7 PM General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

Demographic Details

Child's Name: Adhiraj Bhardwaj
Age: 4 Year 11 Month 2 Days
Gender: Male
DOB: 2021-03-24
Mother’s age (years): 34 years
Mother’s occupation: Homemaker
Father’s age (years): 36 years
Father’s occupation: Pvt job (Datia)
Type of family: Joint
Number of family members: 10
Number of siblings: 1
Details of siblings (Age and sex): 1- 2 year 1 mon
Address: Datia
Contact: 8770718416
Referred By: Doctor
Informant: Parents

Presenting Concerns

Duration of symptoms: Realized atypical behaviors around 2 years age

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Jumping, toe walking, looks from corner of eyes, stimming Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects
Sensory Concerns:

Auditory: Hypersensitive
Visual: Seeks visuals
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: 1 spontaneous abortion at 2.5 months age

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Obstructed labor
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: NICU stay -10 days, On MV for 4 days (TFU- HIE), no AEDs on discharge

Past history:

Hospitalization: Yes Seizures: No Others: For febrile illness - twice

Past/Current medications: Sizodon going on since 2 year age. Currently 5 drops BD Investigations done-

Hearing assessment: Done Details: OAE- normal Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 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: 14 months
Running: Achieved

Age of attainment: 18 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: 12 months

Drinking from cup: Not achieved

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

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

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment:

Communication & Language Assessment

Non-Verbal Communication Grading:-

Drag for needs: Consistent

Answering Questions:-

Echolalia: Absent Patterned speech: Absent

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 18 months
Waving bye bye: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: 1-2 minutes minute
For tasks: Better sitting tolerance with objects and tasks

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

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

Is child enrolled in school: No
Additional information: Didnt sit in school

Diet History:

Food preferences: Picky eater, prefers semi solid food and sweets.
Food allergies: No
Junk food intake: Occasionally

Sleep History

Total sleep duration (night): 7 hours
Afternoon nap: No
Sleep disturbances:

Daily Screen Time

Duration: < 2 hours

Examination

a. Vitals:

b. Anthropometry:

Weight: 18 Kg Height: 110 cm Head circumference: 51.5 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: 1 hypopigmented macule over anterior abdomen

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Deep tandon reflexes: Tone normal, DTR- KJ3+/3+, AJ 2+/2+

Oromotor Examination

Chewing: Proper
Swallowing: Proper
Blowing: Improper
Others: Sucking- improper

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

Advice

Intervention plan: IDP 2/w+ PMT 1/w
Investigations: CBC, S. Urea, Vitamin D, Vitamin B12, S. Homocysteine, S. Lead
Medications: Syp Sizodon (1mg/ml) 0.2ml at evening 7 PM
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

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