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Patient Details


Demographic Details Child's Name: Avnish yadav Age: 3 Year Gender: Male DOB: 2023-02-12 Mother’s age (years): 40 years Mother’s occupation: Homemaker Father’s age (years): 47 years Father’s occupation: Government teacher Type of family: Nuclear Number of family members: 4 Number of siblings: 1 Details of siblings (Age and sex): 1- 18 year old female Address: Morar Contact: 6260518537 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay, behavioral issues Interaction history: Eye contact: Fleeting Behavioral history: Repetitive behaviors (RRBs): Stimming, hand flapping Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Sensory Concerns: Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Others:: H/o 1 sibling death (at day 12; ? milk aspiration) Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Malpresentation Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Cried immediately after birth Resuscitation required: No Past history: Hospitalization: No Seizures: No Past/Current medications: Nil 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: 3 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: 12 months Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Achieved Age of attainment: 6 months Pincer grasp: Achieved Age of attainment: 12 months Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: Kinship words Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: Kinship words Communication & Language Assessment Non-Verbal Communication Grading:- Drag for needs: Emerging Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 7 months Waving bye bye: Not achieved Response to Name Call Details: 6/10 Sitting tolerance- (in minutes) For interaction: Less than a minute For tasks: 1-2 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : 2. Isolated Outdoor play duration: 2 hours Academic History: Is child enrolled in school: No Diet History: Food preferences: Doesnt eat fruits Food allergies: No Sleep History Total sleep duration (night): 8-9 hours Afternoon nap: Yes Sleep disturbances: Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 15 Kg Head circumference: 49.5 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Deep tandon reflexes: DTR: KJ-2+/2+, AJ 1+/1+ Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 2/week + PMT1/week Investigations: CBC, S urea, Vitamin D, Vitamin B12, Calcium, Homocysteine Medications: Syp Sizodon (1mg/ml) 0.1ml at evening 7 PM General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

Demographic Details

Child's Name: Avnish yadav
Age: 3 Year
Gender: Male
DOB: 2023-02-12
Mother’s age (years): 40 years
Mother’s occupation: Homemaker
Father’s age (years): 47 years
Father’s occupation: Government teacher
Type of family: Nuclear
Number of family members: 4
Number of siblings: 1
Details of siblings (Age and sex): 1- 18 year old female
Address: Morar
Contact: 6260518537
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay, behavioral issues

Interaction history:

Eye contact: Fleeting

Behavioral history:

Repetitive behaviors (RRBs): Stimming, hand flapping Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness
Sensory Concerns:

Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No
Others:: H/o 1 sibling death (at day 12; ? milk aspiration)

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Malpresentation
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No

Past history:

Hospitalization: No Seizures: No

Past/Current medications: Nil 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: 3 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: 12 months

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp: Achieved

Age of attainment: 6 months

Pincer grasp: Achieved

Age of attainment: 12 months

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: Kinship words

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: Kinship words

Communication & Language Assessment

Non-Verbal Communication Grading:-

Drag for needs: Emerging

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 7 months
Waving bye bye: Not achieved

Response to Name Call

Details: 6/10

Sitting tolerance- (in minutes)

For interaction: Less than a minute
For tasks: 1-2 minutes

ADL Skills (Age-appropriate)-

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

Type of Play : 2. Isolated Outdoor play duration: 2 hours Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Doesnt eat fruits
Food allergies: No

Sleep History

Total sleep duration (night): 8-9 hours
Afternoon nap: Yes
Sleep disturbances:

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 15 Kg Head circumference: 49.5 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Deep tandon reflexes: DTR: KJ-2+/2+, AJ 1+/1+

Oromotor Examination

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

Advice

Intervention plan: IDP 2/week + PMT1/week
Investigations: CBC, S urea, Vitamin D, Vitamin B12, Calcium, Homocysteine
Medications: Syp Sizodon (1mg/ml) 0.1ml at evening 7 PM
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

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