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Demographic Details Child's Name: Om Goyal Age: 12 Year 10 Month 5 Days Gender: Male DOB: 2013-04-22 Mother’s age (years): 40 years Mother’s occupation: Homemaker Father’s age (years): 45 years Father’s occupation: Business Type of family: Joint Number of siblings: 1 Details of siblings (Age and sex): 1-5 year old female Address: Morena Contact: 7000902935 Referred By: Doctor Presenting Concerns Chief concerns: Headache Duration of symptoms: Since 2 months Behavioral history: Stubbornness Aggression School refusal Emotional history: Irritability Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Gestational Age: FT Birth Weight: 1.75 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No If yes- Duration & Indication: NICU stay- 2 days Past history: Hospitalization: No Others: Episodes of screaming and Loss of consciousness. Event triggered when asked to do something. Investigations done- Hearing assessment: Not done Vision assessment: Done Details: Normal Family history: Neuropsychiatric condition: No Others: Grandfather shifted to other house 6 month 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: 7 months Standing without support: Achieved Age of attainment: 9 months Walking without support: Achieved Age of attainment: `10 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 Buttoning / Unbuttoning: Achieved Age of attainment: 3 years Language Receptive:- Joint attention: Achieved Age of attainment: Pointing: Achieved Age of attainment: Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: Babbling: Achieved Age of attainment: Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 18 months Complete sentences: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: Babbling: Achieved Age of attainment: Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 18 months Complete sentences: Achieved Age of attainment: Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 6 months Waving bye bye: Achieved Age of attainment: 9 months Comes when called: Achieved Age of attainment: Copying parents in tasks: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: 5 years Response to Name Call Details: Doesnt want to do his own activities Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 5. Independent Toilet training: 5. Independent Dressing: 5. Independent Undressing: 5. Independent Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Bihari Convent High school Grade: 7 Hours spent in school: 4.5 hours Board: MP Location: Morena Additional information: Not going to school since 6 months. Changed school Diet History: Food preferences: Picky eater Junk food intake: Daily Sleep History Total sleep duration (night): 8 hours Afternoon nap: No Daily Screen Time Duration: > 5 hours Examination a. Vitals: HR: 92/ min RR: 24/min b. Anthropometry: Weight: 52 Kg c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Consciousness: Conscious Orientation: to time, place, person, Memory: Intact Judgement: Intact Insight: Intact Perception: Intact Sensory Examination Touch: Normal Pain: Normal Temperature: Normal 2-point discrimination: Normal Stereognosis: Normal Graphesthesia: Normal Cranial Nerves (1–12) Neuromuscular Concerns Power: Tone - normal, Power 5/5 Deep tandon reflexes: DTR Kj-2+/2+ Other: On observation- apprehensive, insight is intact during episodes. Oromotor Examination Drooling: No CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ? Functional for primary gains Advice Intervention plan: Child councelling 1/week+ PMT 1/week. Counselled to ignore the episodes and avaoid power struggles Investigations: EEG Medications: Continue as advised by pediatrician. To be reviewed after EEG General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

Demographic Details

Child's Name: Om Goyal
Age: 12 Year 10 Month 5 Days
Gender: Male
DOB: 2013-04-22
Mother’s age (years): 40 years
Mother’s occupation: Homemaker
Father’s age (years): 45 years
Father’s occupation: Business
Type of family: Joint
Number of siblings: 1
Details of siblings (Age and sex): 1-5 year old female
Address: Morena
Contact: 7000902935
Referred By: Doctor

Presenting Concerns

Chief concerns: Headache
Duration of symptoms: Since 2 months

Behavioral history:

Stubbornness Aggression School refusal Emotional history:
Irritability

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Gestational Age: FT
Birth Weight: 1.75 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No
If yes- Duration & Indication: NICU stay- 2 days

Past history:

Hospitalization: No Others: Episodes of screaming and Loss of consciousness. Event triggered when asked to do something.

Investigations done-

Hearing assessment: Not done Vision assessment: Done Details: Normal

Family history:

Neuropsychiatric condition: No Others: Grandfather shifted to other house 6 month

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: 7 months
Standing without support: Achieved

Age of attainment: 9 months
Walking without support: Achieved

Age of attainment: `10 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

Buttoning / Unbuttoning: Achieved

Age of attainment: 3 years

Language

Receptive:-

Joint attention: Achieved

Age of attainment:
Pointing: Achieved

Age of attainment:
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment:

Babbling: Achieved

Age of attainment:

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 18 months

Complete sentences: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment:

Babbling: Achieved

Age of attainment:

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 18 months

Complete sentences: Achieved

Age of attainment:

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 6 months
Waving bye bye: Achieved

Age of attainment: 9 months
Comes when called: Achieved

Age of attainment:
Copying parents in tasks: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment: 5 years

Response to Name Call

Details: Doesnt want to do his own activities

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 5. Independent
Bathing: 5. Independent
Toilet training: 5. Independent
Dressing: 5. Independent
Undressing: 5. Independent

Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Bihari Convent High school
Grade: 7
Hours spent in school: 4.5 hours
Board: MP
Location: Morena
Additional information: Not going to school since 6 months. Changed school

Diet History:

Food preferences: Picky eater
Junk food intake: Daily

Sleep History

Total sleep duration (night): 8 hours
Afternoon nap: No

Daily Screen Time

Duration: > 5 hours

Examination

a. Vitals:

HR: 92/ min RR: 24/min

b. Anthropometry:

Weight: 52 Kg

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Consciousness: Conscious
Orientation: to time, place, person,
Memory: Intact
Judgement: Intact
Insight: Intact
Perception: Intact

Sensory Examination

Touch: Normal
Pain: Normal
Temperature: Normal
2-point discrimination: Normal
Stereognosis: Normal
Graphesthesia: Normal

Cranial Nerves (1–12)

Neuromuscular Concerns

Power: Tone - normal, Power 5/5
Deep tandon reflexes: DTR Kj-2+/2+
Other: On observation- apprehensive, insight is intact during episodes.

Oromotor Examination

Drooling: No

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

Impression: ? Functional for primary gains

Advice

Intervention plan: Child councelling 1/week+ PMT 1/week. Counselled to ignore the episodes and avaoid power struggles
Investigations: EEG
Medications: Continue as advised by pediatrician. To be reviewed after EEG
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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