Create - Child Development Centre

Patient Details


Demographic Details Child's Name: Shivansh Prajapati Age: 2 Year 6 Month 13 Days Gender: Male DOB: 2023-08-31 Mother’s age (years): 30 years Mother’s occupation: Homemaker Father’s age (years): 32 years Father’s occupation: Medical represenatative Type of family: Joint Number of family members: 9 Number of siblings: 0 Address: Jiwanjiganj Contact: 8085388346 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay, response to name call Duration of symptoms: Realized speech delay around 2 years Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): opening and closing of behavior Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Sensory Concerns: Auditory: Hypersensitive Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Hypothyroidism Others:: Child's thyroid screening- normal Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: above 2.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: Yes Others: 1 month age- 7 days. Seizures were noticed but EEG, MRI- normal 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: 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: 10 months Walking without support: Achieved Age of attainment: 12 months Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Pincer grasp: Achieved Age of attainment: 12 months Language Receptive:- Joint attention: Not achieved Pointing: Achieved Age of attainment: 2 years (started) Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 2 years Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 2 years Communication & Language Assessment Non-Verbal Communication Grading:- Drag for needs: Consistent Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 2 years Waving bye bye: Not achieved Comes when called: Not achieved Asking for food and toilet: Not achieved Response to Name Call Details: 2/10 Sitting tolerance- (in minutes) For interaction: Less than a minute For tasks: Less than a minute ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Picky eater Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Sleep disturbances: No Daily Screen Time Duration: <30 minutes Type of screen: TV Examination a. Vitals: b. Anthropometry: Head circumference: 49 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypotonia Deep tandon reflexes: DTR- normal If present details: Sit in W position, mild hypotonia Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Improper Others: Sucking- absent CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: M chat score- 10 ( High) Advice Intervention plan: IDP 2/week +PMT 1/week General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Shivansh Prajapati
Age: 2 Year 6 Month 13 Days
Gender: Male
DOB: 2023-08-31
Mother’s age (years): 30 years
Mother’s occupation: Homemaker
Father’s age (years): 32 years
Father’s occupation: Medical represenatative
Type of family: Joint
Number of family members: 9
Number of siblings: 0
Address: Jiwanjiganj
Contact: 8085388346
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay, response to name call
Duration of symptoms: Realized speech delay around 2 years

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): opening and closing of behavior Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness
Sensory Concerns:

Auditory: Hypersensitive
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Hypothyroidism
Others:: Child's thyroid screening- normal

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: above 2.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: Yes Others: 1 month age- 7 days. Seizures were noticed but EEG, MRI- normal

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: 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: 10 months
Walking without support: Achieved

Age of attainment: 12 months

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp:

Pincer grasp: Achieved

Age of attainment: 12 months

Language

Receptive:-

Joint attention: Not achieved
Pointing: Achieved

Age of attainment: 2 years (started)
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 2 years

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 2 years

Communication & Language Assessment

Non-Verbal Communication Grading:-

Drag for needs: Consistent

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 2 years
Waving bye bye: Not achieved
Comes when called: Not achieved
Asking for food and toilet: Not achieved

Response to Name Call

Details: 2/10

Sitting tolerance- (in minutes)

For interaction: Less than a minute
For tasks: Less than a minute

ADL Skills (Age-appropriate)-

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

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Picky eater

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours
Sleep disturbances: No

Daily Screen Time

Duration: <30 minutes
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

Head circumference: 49 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypotonia
Deep tandon reflexes: DTR- normal

If present details: Sit in W position, mild hypotonia

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Improper
Others: Sucking- absent

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

Impression: M chat score- 10 ( High)

Advice

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

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