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Patient Details


Demographic Details Child's Name: Mohammed Arhan Khan Age: 1 Year 1 Month 4 Days Gender: Male DOB: 2025-02-23 Mother’s age (years): 25 years Mother’s occupation: Housewife Father’s age (years): 26 years Father’s occupation: Student Type of family: Joint Number of family members: 7 Number of siblings: 0 Address: Tekanpur Contact: 7217730080 Referred By: Doctor Presenting Concerns Duration of symptoms: PT since 20 days Interaction history: Eye contact: Sustained Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Ante partum haemorrhage Others:: ANC USG: cystic lesion Lt side in choroid plexus. Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Indication for LSCS (if applicable): Obstructed labor Gestational Age: Post term Birth Weight: 1.75 Kg Cry at birth: Delayed cry Resuscitation required: Yes Details of Resuscitation: BMV NICU stay: Yes If yes- Duration & Indication: Admitted for 15 days (CPAP, Pneumothorax) Past history: Hospitalization: No Seizures: Yes Others: During Neonatal period. No convulsions noted after thyat Past/Current medications: Currently- Levemix 1 ml BD. Investigations done- Hearing assessment: Not done Vision assessment: Done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Not achieved Roll over: Not achieved Fine Motor Bidextrous grasp: Not achieved Unidextrous grasp: Not achieved Language Expressive:- Cooing: Achieved Age of attainment: 10 months Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 10 months Babbling: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Social smile: Achieved Age of attainment: 6 months Stranger anxiety: Not achieved Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Academic History: Diet History: Food preferences: Predominantly milk diet Sleep History Total sleep duration (night): 6 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 7.4 Kg Height: 71 cm Head circumference: 42 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Consciousness: active alert playful Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypertonia Deep tandon reflexes: KJ 3+/3+, AJ- 2+/2+ Other: Plantar- B/l extensors Oromotor Examination Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. HIE sequelae Advice Intervention plan: IDP (+PT) 3/week Investigations: BERA Medications: Syp Levemex 1 ml BD General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Mohammed Arhan Khan
Age: 1 Year 1 Month 4 Days
Gender: Male
DOB: 2025-02-23
Mother’s age (years): 25 years
Mother’s occupation: Housewife
Father’s age (years): 26 years
Father’s occupation: Student
Type of family: Joint
Number of family members: 7
Number of siblings: 0
Address: Tekanpur
Contact: 7217730080
Referred By: Doctor

Presenting Concerns

Duration of symptoms: PT since 20 days

Interaction history:

Eye contact: Sustained

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Ante partum haemorrhage
Others:: ANC USG: cystic lesion Lt side in choroid plexus.

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Indication for LSCS (if applicable): Obstructed labor
Gestational Age: Post term
Birth Weight: 1.75 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
Details of Resuscitation: BMV
NICU stay: Yes
If yes- Duration & Indication: Admitted for 15 days (CPAP, Pneumothorax)

Past history:

Hospitalization: No Seizures: Yes Others: During Neonatal period. No convulsions noted after thyat

Past/Current medications: Currently- Levemix 1 ml BD. Investigations done-

Hearing assessment: Not done Vision assessment: Done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Not achieved
Roll over: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Unidextrous grasp: Not achieved

Language

Expressive:-

Cooing: Achieved

Age of attainment: 10 months

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 10 months

Babbling: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 6 months
Stranger anxiety: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

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

Academic History:

Diet History:

Food preferences: Predominantly milk diet

Sleep History

Total sleep duration (night): 6 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 7.4 Kg Height: 71 cm Head circumference: 42 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Consciousness: active alert playful

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypertonia
Deep tandon reflexes: KJ 3+/3+, AJ- 2+/2+
Other: Plantar- B/l extensors

Oromotor Examination

Chewing: Improper
Swallowing: Improper
Blowing: Improper
Sucking: Improper

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

Impression: GDD. HIE sequelae

Advice

Intervention plan: IDP (+PT) 3/week
Investigations: BERA
Medications: Syp Levemex 1 ml BD
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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