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Patient Details


Demographic Details Child's Name: Anirudh Dixit Age: 2 Year Gender: Male DOB: 2024-02-08 Mother’s age (years): 33 years Mother’s occupation: Homemaker Type of family: Nuclear Number of family members: 3 Number of siblings: 1 Details of siblings (Age and sex): 1- 6 year old female Contact: 9826538873 Presenting Concerns Chief concerns: Delayed Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Previous LSCS Gestational Age: FT Birth Weight: 2.4 Kg Cry at birth: Cried immediately after birth NICU stay: Yes If yes- Duration & Indication: Was in observation in less than 12 hours. On day 11 readmitted for jaundice 12 days. H/o neonatal seizures. Past history: Hospitalization: No Past/Current medications: Was on gardenal till 6 months age. Furoped was given till 1year age. Advised to discontinuee Investigations done- Hearing assessment: Done Details: Normal Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 6 months Roll over: Achieved Age of attainment: 9 months Sitting without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 1 year Unidextrous grasp: Achieved Age of attainment: after 1 year Pincer grasp: Not achieved Language Receptive:- Joint attention: Not achieved Expressive:- Cooing: Not achieved Expressive:- Cooing: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 4 months Stranger anxiety: Achieved Age of attainment: 8 months Comes when called: Achieved Age of attainment: 12 months (by crawling) Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Academic History: Diet History: Food preferences: Wants to drink milk only Food allergies: No Sleep History Total sleep duration (night): Sleeps after 3 am, wakes up at 12 pm. Sleep disturbances: Examination a. Vitals: b. Anthropometry: Height: 73 cm Head circumference: 41 cm c. General Examination Dysmorphology: Plagiocephaly, B/l Multiple pre auricular tags, b/l squint, elongated face, retrognathia Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination CVS examination: Systolic murmur present Respiratory System examination: conducted sounds+ Per abdomen examination: fecolith+ Advice Intervention plan: Home based program Investigations: CBC, RFT, Complete ophthalmological examination, WES Medications: Syp multivitamin 5 ml OD, Syp calcimax 5 ml O General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Anirudh Dixit
Age: 2 Year
Gender: Male
DOB: 2024-02-08
Mother’s age (years): 33 years
Mother’s occupation: Homemaker
Type of family: Nuclear
Number of family members: 3
Number of siblings: 1
Details of siblings (Age and sex): 1- 6 year old female
Contact: 9826538873

Presenting Concerns

Chief concerns: Delayed

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Previous LSCS
Gestational Age: FT
Birth Weight: 2.4 Kg
Cry at birth: Cried immediately after birth
NICU stay: Yes
If yes- Duration & Indication: Was in observation in less than 12 hours. On day 11 readmitted for jaundice 12 days. H/o neonatal seizures.

Past history:

Hospitalization: No

Past/Current medications: Was on gardenal till 6 months age. Furoped was given till 1year age. Advised to discontinuee Investigations done-

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

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 6 months
Roll over: Achieved

Age of attainment: 9 months
Sitting without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 1 year

Unidextrous grasp: Achieved

Age of attainment: after 1 year

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved

Expressive:-

Cooing: Not achieved

Expressive:-

Cooing: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 4 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Comes when called: Achieved

Age of attainment: 12 months (by crawling)

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Academic History:

Diet History:

Food preferences: Wants to drink milk only
Food allergies: No

Sleep History

Total sleep duration (night): Sleeps after 3 am, wakes up at 12 pm.
Sleep disturbances:

Examination

a. Vitals:

b. Anthropometry:

Height: 73 cm Head circumference: 41 cm

c. General Examination

Dysmorphology: Plagiocephaly, B/l Multiple pre auricular tags, b/l squint, elongated face, retrognathia Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

CVS examination: Systolic murmur present
Respiratory System examination: conducted sounds+
Per abdomen examination: fecolith+

Advice

Intervention plan: Home based program
Investigations: CBC, RFT, Complete ophthalmological examination, WES
Medications: Syp multivitamin 5 ml OD, Syp calcimax 5 ml O
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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