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Patient Details


Demographic Details Child's Name: Aayushi kumari Age: 3 Year 2 Month 14 Days Gender: Female DOB: 2023-01-04 Mother’s age (years): 28 years Mother’s occupation: Homemaker Father’s age (years): 33 years Father’s occupation: Private job Type of family: Joint Number of siblings: 1 Details of siblings (Age and sex): 5 year ola male Address: Buxar (Bihar) Contact: 9693056812 Referred By: Doctor Presenting Concerns Chief concerns: Unable to stand Duration of symptoms: Realized delayed motor milestones at 1 years age Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Sensory Concerns: Auditory: Hypersensitive Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: 3 spontaneous abortion (6 weeks) Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Previous LSCS, IUGR Gestational Age: PT Birth Weight: 1.5 Kg Cry at birth: Delayed cry Resuscitation required: Yes If yes- Duration & Indication: NICU stay- 5 days, excessive crying during infancy Past history: Hospitalization: No Seizures: No 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: 12 months Roll over: Achieved Age of attainment: 18 months Sitting without support: Not achieved Standing without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 12 months Unidextrous grasp: Achieved Age of attainment: 18 months Pincer grasp: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 12 months Pointing: Achieved Age of attainment: 12 months Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 15 months Complete sentences: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 15 months Complete sentences: Achieved Age of attainment: Communication & Language Assessment Non-Verbal Communication Grading:- Following commands (gesture + verbal): 1-step Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: 18 months Asking for food and toilet: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 4. Needs minimal assistance Bathing: 3. Needs significant assistance Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Indicates for ADLs Type of Play : 3. Onlooker Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed diet Food allergies: No Sleep History Total sleep duration (night): 10-11 hours Afternoon nap: No Daily Screen Time Duration: <30 minutes Examination a. Vitals: b. Anthropometry: Weight: 9 Kg Height: 82 cm Head circumference: 44.5 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Consciousness: Conscious Orientation: active, alert, playful Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypertonia Deep tandon reflexes: DTR- KJ- exaggerated/exaggerated, AJ- 4+/4+, ankle clonus If present details: Plantar- B/l flexor, scissoring + Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Others: Sucking+ CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Spastic diplegic cerebral palsy with squint Advice Intervention plan: Parents counselled (unable to take sessions here- advised to start Physiotherapy at their native place and follow up) General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Aayushi kumari
Age: 3 Year 2 Month 14 Days
Gender: Female
DOB: 2023-01-04
Mother’s age (years): 28 years
Mother’s occupation: Homemaker
Father’s age (years): 33 years
Father’s occupation: Private job
Type of family: Joint
Number of siblings: 1
Details of siblings (Age and sex): 5 year ola male
Address: Buxar (Bihar)
Contact: 9693056812
Referred By: Doctor

Presenting Concerns

Chief concerns: Unable to stand
Duration of symptoms: Realized delayed motor milestones at 1 years age

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Sensory Concerns:

Auditory: Hypersensitive

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: 3 spontaneous abortion (6 weeks)

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Previous LSCS, IUGR
Gestational Age: PT
Birth Weight: 1.5 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
If yes- Duration & Indication: NICU stay- 5 days, excessive crying during infancy

Past history:

Hospitalization: No Seizures: No

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: 12 months
Roll over: Achieved

Age of attainment: 18 months
Sitting without support: Not achieved
Standing without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 12 months

Unidextrous grasp: Achieved

Age of attainment: 18 months

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 12 months
Pointing: Achieved

Age of attainment: 12 months

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 15 months

Complete sentences: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 15 months

Complete sentences: Achieved

Age of attainment:

Communication & Language Assessment

Non-Verbal Communication Grading:-

Following commands (gesture + verbal): 1-step

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment: 18 months
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 4. Needs minimal assistance
Bathing: 3. Needs significant assistance
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Details:: Indicates for ADLs

Type of Play : 3. Onlooker Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed diet
Food allergies: No

Sleep History

Total sleep duration (night): 10-11 hours
Afternoon nap: No

Daily Screen Time

Duration: <30 minutes

Examination

a. Vitals:

b. Anthropometry:

Weight: 9 Kg Height: 82 cm Head circumference: 44.5 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Consciousness: Conscious
Orientation: active, alert, playful

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypertonia
Deep tandon reflexes: DTR- KJ- exaggerated/exaggerated, AJ- 4+/4+, ankle clonus

If present details: Plantar- B/l flexor, scissoring +

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Proper
Others: Sucking+

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

Impression: Spastic diplegic cerebral palsy with squint

Advice

Intervention plan: Parents counselled (unable to take sessions here- advised to start Physiotherapy at their native place and follow up)
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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