Demographic Details
- :
Vishesh Maheshvari
- :
3 year 6 months
- :
Male
- :
2022-11-11
- :
31 years
- :
Homemaker
- :
35 years
- :
Service
- :
15
- :
Nil
- :
Mathura
- :
8871801191
- :
Doctor
- :
Mother, grandmother
Presenting Concerns
- :
Delayed development
- :
Delay in development noticed since 8 months age
Behavioral history:
Sensory Concerns:
- :
Hypersensitive
- :
Hypersensitive
Birth & Perinatal History:
Antenatal History
- :
28
- :
Natural
-
High-risk factors in pregnancy:
- Oligohydramnios
Natal and Postnatal History:
- :
Institutional
- :
LSCS
- :
Olig
- :
37 weeks
- :
2.6
- :
Cried immediately after birth
Past history:
:
No
:
No
:
At 9 months started Physio, OT 7 days/ week.
:
Nil
Investigations done-
:
Done
:
Normal
:
Done
:
Normal
Family history:
:
No
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
2 years age (Partial)
-
:
Achieved
:
1.5 years age
-
:
Achieved
:
2 years age
-
:
Achieved
:
2 years
-
:
Fine Motor
:
Achieved
:
1 year
:
Achieved
:
1.5 year
:
Not achieved
:
Not achieved
Language
Receptive:-
-
:
Achieved
:
After 2 years
-
:
Achieved
:
After 2 years
Expressive:-
:
Achieved
:
3 months
:
Achieved
:
2 years
:
Achieved
:
>2 years
Expressive:-
:
Achieved
:
3 months
:
Achieved
:
2 years
:
Achieved
:
>2 years
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Consistent meaningful pointing
- :
1-step
Answering Questions:-
:
Present
Social
-
:
Achieved
:
9 months
-
:
Achieved
:
2 years
-
:
Achieved
:
after 2 years
-
:
Achieved
:
after 2 years
-
:
Achieved
:
Response to Name Call
Sitting tolerance- (in minutes)
ADL Skills (Age-appropriate)-
- :
2. Started attempting
- :
2. Started attempting
- :
2. Started attempting
- :
2. Started attempting
- :
2. Started attempting
Academic History:
- :
Yes
- :
Regular
- :
Shriji Play school
- :
Playgroup
- :
4.5 hours
- :
Mathura
- :
Doesnt sit in school
Diet History:
- :
Biscuits
Sleep History
- :
8 hours
- :
Yes
-
:
Daily Screen Time
-
:
<30 minutes
- :
Mobile
Examination
a. Vitals:
b. Anthropometry:
:
14 kg
:
100 cm
:
45 cm
c. General Examination
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
- :
Hypotonia
- :
DTR- 2+/2+
- :
Present
Oromotor Examination
- :
Yes
- :
Improper
- :
Improper
- :
Unable to suck
:
NAD
:
NAD
:
NAD
Advice
- :
Evaluations- VSMS, Motor assessment, Speech and language evaluation
- :
Review after evaluation
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food