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Patient Details


Demographic Details Child's Name: Divyangi baghel Age: 3 Year Gender: Female DOB: 2023-02-21 Mother’s age (years): 23 years Mother’s occupation: Homemaker Father’s age (years): 31 years Father’s occupation: MP Police Type of family: Joint Number of family members: 5 Number of siblings: 0 Contact: 9516687340 Referred By: Doctor Presenting Concerns Chief concerns: Delay in speech Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Toe walking Hyperactivity Inattention Impulsivity Object obsession Mouthing of objects Sensory Concerns: Auditory: Hypersensitive Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 2.6 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current medications: Nil Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No 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: 10 months Walking without support: Achieved Age of attainment: 14 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 Language Receptive:- Joint attention: Not achieved Pointing: Achieved Age of attainment: 2 years Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Drag for needs: Emerging Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 6 months 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: better for tasks ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 2. Started attempting Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food allergies: No Sleep History Total sleep duration (night): 9 hours (sleeps at 1 am) Afternoon nap: No Daily Screen Time Duration: < 2 hours Type of screen: TV Examination a. Vitals: b. Anthropometry: Weight: 13.3 Kg Height: 98 cm Head circumference: 48 cm c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Chewing: Proper Swallowing: Proper Blowing: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 2/week + PMT 1/week Investigations: DQ, ISAA, DSM5 ASD (later) General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Divyangi baghel
Age: 3 Year
Gender: Female
DOB: 2023-02-21
Mother’s age (years): 23 years
Mother’s occupation: Homemaker
Father’s age (years): 31 years
Father’s occupation: MP Police
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Contact: 9516687340
Referred By: Doctor

Presenting Concerns

Chief concerns: Delay in speech

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Toe walking Hyperactivity Inattention Impulsivity Object obsession Mouthing of objects
Sensory Concerns:

Auditory: Hypersensitive

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 2.6 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current medications: Nil Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

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: 10 months
Walking without support: Achieved

Age of attainment: 14 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

Language

Receptive:-

Joint attention: Not achieved
Pointing: Achieved

Age of attainment: 2 years

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Drag for needs: Emerging

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 6 months
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: better for tasks

ADL Skills (Age-appropriate)-

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

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food allergies: No

Sleep History

Total sleep duration (night): 9 hours (sleeps at 1 am)
Afternoon nap: No

Daily Screen Time

Duration: < 2 hours
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 13.3 Kg Height: 98 cm Head circumference: 48 cm

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Chewing: Proper
Swallowing: Proper
Blowing: Proper

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

Advice

Intervention plan: IDP 2/week + PMT 1/week
Investigations: DQ, ISAA, DSM5 ASD (later)
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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