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Demographic Details Child's Name: Aaradhya Jagtap Age: 12 Year 4 Month 6 Days Gender: Female DOB: 2013-11-06 Mother’s age (years): 33 years Mother’s occupation: Teacher Father’s age (years): 39 years Father’s occupation: Business Type of family: Joint Number of family members: 4 Number of siblings: 1 Details of siblings (Age and sex): 1- 3 year old female Address: Kampoo Contact: 8827500618 Referred By: Doctor Informant: Mother, maternal uncles Presenting Concerns Chief concerns: Irritability, Crying Behavioral history: Stubbornness Aggression 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: 3.5 Kg Cry at birth: Delayed cry Resuscitation required: Yes Details of Resuscitation: Details not known NICU stay: Yes If yes- Duration & Indication: Admitted immediately after birth for 15 days, HIE , neonatal seizures, discharged on AEDs, given for 5 months then discontinued Past history: Hospitalization: Yes Seizures: Yes Others: Recurrent cough and cold . At 8 years of age admitted for Status epilepticus for 10 days. Multiple episodes since then. Last episode 2 months back. Past/Current medications: On Levera 3ml BD, earlier was on phenytoin and va;proate. 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: 15 months. Partial Roll over: Achieved Age of attainment: 4 years Sitting without support: Not achieved Standing without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 years Language Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Achieved Age of attainment: 16 months Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Achieved Age of attainment: 16 months Details:: Neck holding is partial. Unable to roll over now Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Answering Questions:- Social Social smile: Achieved Age of attainment: 3 months Stranger anxiety: Achieved Age of attainment: 24 months Waving bye bye: Not achieved Copying parents in tasks: Not achieved Response to Name Call Details: Gives cues for her needs Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Academic History: Is child enrolled in school: No Diet History: Food preferences: Eats mashed food Sleep History Total sleep duration (night): 8 hours Afternoon nap: No Duration of Afternoon nap: Sometimes takes afternoon naps Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 24 Kg Head circumference: 49 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypertonia Other: Squint Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Blowing: Improper Others: Sucking started Impression: Spastic Cerebral Palsy with epilepsy (HIE sequelae) Advice Intervention plan: IDP (+PT ) 3/eeek +PMT 1/week Investigations: Neuromotor assessment 1; Blood investigations- CBC, Calcium, Vitamin D, Vitamin B12; Orthopedic opinion Medications: Continue Syp Levera (100mg/ml) 3ml BD advised General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Aaradhya Jagtap
Age: 12 Year 4 Month 6 Days
Gender: Female
DOB: 2013-11-06
Mother’s age (years): 33 years
Mother’s occupation: Teacher
Father’s age (years): 39 years
Father’s occupation: Business
Type of family: Joint
Number of family members: 4
Number of siblings: 1
Details of siblings (Age and sex): 1- 3 year old female
Address: Kampoo
Contact: 8827500618
Referred By: Doctor
Informant: Mother, maternal uncles

Presenting Concerns

Chief concerns: Irritability, Crying

Behavioral history:

Stubbornness Aggression

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: 3.5 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
Details of Resuscitation: Details not known
NICU stay: Yes
If yes- Duration & Indication: Admitted immediately after birth for 15 days, HIE , neonatal seizures, discharged on AEDs, given for 5 months then discontinued

Past history:

Hospitalization: Yes Seizures: Yes Others: Recurrent cough and cold . At 8 years of age admitted for Status epilepticus for 10 days. Multiple episodes since then. Last episode 2 months back.

Past/Current medications: On Levera 3ml BD, earlier was on phenytoin and va;proate. 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: 15 months. Partial
Roll over: Achieved

Age of attainment: 4 years
Sitting without support: Not achieved
Standing without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 years

Language

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Achieved

Age of attainment: 16 months

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Achieved

Age of attainment: 16 months

Details:: Neck holding is partial. Unable to roll over now

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Emerging

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 3 months
Stranger anxiety: Achieved

Age of attainment: 24 months
Waving bye bye: Not achieved
Copying parents in tasks: Not achieved

Response to Name Call

Details: Gives cues for her needs

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

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

Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Eats mashed food

Sleep History

Total sleep duration (night): 8 hours
Afternoon nap: No
Duration of Afternoon nap: Sometimes takes afternoon naps

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 24 Kg Head circumference: 49 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypertonia
Other: Squint

Oromotor Examination

Drooling: Yes
Chewing: Improper
Swallowing: Improper
Blowing: Improper
Others: Sucking started

Impression: Spastic Cerebral Palsy with epilepsy (HIE sequelae)

Advice

Intervention plan: IDP (+PT ) 3/eeek +PMT 1/week
Investigations: Neuromotor assessment 1; Blood investigations- CBC, Calcium, Vitamin D, Vitamin B12; Orthopedic opinion
Medications: Continue Syp Levera (100mg/ml) 3ml BD advised
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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