Create - Child Development Centre

Patient Details


Demographic Details Child's Name: Shivansh Dwivedi Age: 7 Year 2 Month 9 Days Gender: Male DOB: 2018-12-19 Mother’s age (years): 36 years Mother’s occupation: Homemaker Father’s age (years): 37 year Father’s occupation: Service (Airforce) Type of family: Nuclear Number of family members: 3 Number of siblings: 0 Address: DD Nagar Contact: 8285208935 Referred By: Relative Informant: Parents Presenting Concerns Chief concerns: Poor understanding, behavioral issues, speech delay Duration of symptoms: Realized speech delay since 1 year Interaction history: Eye contact: Suboptimal Behavioral history: Repetitive behaviors (RRBs): Patterned behavior or activities: Inattention Impulsivity Object obsession Stubbornness 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: Cried immediately after birth NICU stay: No Past history: Hospitalization: Yes Others: Admitted for AGE 2-3 times Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: Yes Others: Similar history in Cousin Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 months Roll over: Achieved Age of attainment: 5 months Sitting without support: Achieved Age of attainment: 6 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 mon ths Pincer grasp: Achieved Age of attainment: 12 months 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: 4 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Achieved Age of attainment: 6 years Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Achieved Age of attainment: 6 years Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Patterned speech: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 7 monthys Waving bye bye: Achieved Age of attainment: 5 years Asking for food and toilet: Achieved Age of attainment: 3 years Response to Name Call Details: 19/10 Sitting tolerance- (in minutes) For interaction: 2 minutes For tasks: 2 minutes ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 4. Needs minimal assistance Toilet training: 5. Independent Dressing: 4. Needs minimal assistance Undressing: 4. Needs minimal assistance Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Super kidzee School Grade: UKG Hours spent in school: 6 hours Board: CBSE Location: D D nagar Diet History: Food preferences: Picky eater Food allergies: No Sleep History Total sleep duration (night): 7 hours Afternoon nap: No Sleep disturbances: No Daily Screen Time Duration: < 1 hour Type of screen: TV Examination a. Vitals: b. Anthropometry: c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Power: Tone normal Deep tandon reflexes: DTR KJ 2+/2+, AJ 2+/2+ Oromotor Examination Chewing: Proper Swallowing: Proper Blowing: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 2/week + PMT 1/week General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

Demographic Details

Child's Name: Shivansh Dwivedi
Age: 7 Year 2 Month 9 Days
Gender: Male
DOB: 2018-12-19
Mother’s age (years): 36 years
Mother’s occupation: Homemaker
Father’s age (years): 37 year
Father’s occupation: Service (Airforce)
Type of family: Nuclear
Number of family members: 3
Number of siblings: 0
Address: DD Nagar
Contact: 8285208935
Referred By: Relative
Informant: Parents

Presenting Concerns

Chief concerns: Poor understanding, behavioral issues, speech delay
Duration of symptoms: Realized speech delay since 1 year

Interaction history:

Eye contact: Suboptimal

Behavioral history:

Repetitive behaviors (RRBs): Patterned behavior or activities: Inattention Impulsivity Object obsession Stubbornness

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: Cried immediately after birth
NICU stay: No

Past history:

Hospitalization: Yes Others: Admitted for AGE 2-3 times

Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: Yes Others: Similar history in Cousin

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 months
Roll over: Achieved

Age of attainment: 5 months
Sitting without support: Achieved

Age of attainment: 6 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 mon ths

Pincer grasp: Achieved

Age of attainment: 12 months

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: 4 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Achieved

Age of attainment: 6 years

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Achieved

Age of attainment: 6 years

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Patterned speech: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 7 monthys
Waving bye bye: Achieved

Age of attainment: 5 years
Asking for food and toilet: Achieved

Age of attainment: 3 years

Response to Name Call

Details: 19/10

Sitting tolerance- (in minutes)

For interaction: 2 minutes
For tasks: 2 minutes

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 4. Needs minimal assistance
Toilet training: 5. Independent
Dressing: 4. Needs minimal assistance
Undressing: 4. Needs minimal assistance

Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Super kidzee School
Grade: UKG
Hours spent in school: 6 hours
Board: CBSE
Location: D D nagar

Diet History:

Food preferences: Picky eater
Food allergies: No

Sleep History

Total sleep duration (night): 7 hours
Afternoon nap: No
Sleep disturbances: No

Daily Screen Time

Duration: < 1 hour
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Power: Tone normal
Deep tandon reflexes: DTR KJ 2+/2+, AJ 2+/2+

Oromotor Examination

Chewing: Proper
Swallowing: Proper
Blowing: Proper

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

Advice

Intervention plan: IDP 2/week + PMT 1/week
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

Setting Panel

Select Layout

Light Dark

Sidebar Color

Color Theme

Mini Sidebar

Sticky Header

Patient Details print

Select Layout

Sidebar Color

Color Theme

Patient Details