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Demographic Details Child's Name: Divyansh Sahu Age: 2 Year 8 Month 18 Days Gender: Male DOB: 2023-06-08 Mother’s age (years): 24 years Mother’s occupation: Homemaker Father’s age (years): 28 years Father’s occupation: Self employed Type of family: Joint Number of family members: 25 Number of siblings: 0 Contact: 9589529106 Referred By: Doctor Informant: Parents Behavioral history: 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: 2.5 Kg Cry at birth: Cried immediately after birth NICU stay: Yes If yes- Duration & Indication: Bluish discoloration on day 3- admitted for 15d,H/o neonatal seizures, Not discharged on AED Ventilated for 13d. Readmitted on 26d for refusal to feed Past history: Hospitalization: No Seizures: Yes Others: Abnormal body movements- 1st episode at 8 mon age in the form of head drop attacks multiple episodes, immediately after waking up , Presently 20-15 episodes of head drop or fall during walking, not asso. with LOC, not asso with fever. Started consulting after 2 years, no significant improvement with AED Past/Current medications: Syp Levilex 20 drops BD, supplements Investigations done- Hearing assessment: Not done Vision assessment: Done Details: Reports not there 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: 9 months Walking without support: Achieved Age of attainment: 2 years 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 Drinking from cup: Achieved Age of attainment: 2 years Language Receptive:- Joint attention: Achieved Age of attainment: 7 months Pointing: Achieved Age of attainment: 12 months Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 24 months Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 24 months Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Joint attention: Consistent Pointing: Consistent meaningful pointing Understanding gestures: Consistent Following commands (gesture + verbal): 1-step Answering Questions:- Social Social smile: Achieved Age of attainment: 3 months Stranger anxiety: Achieved Age of attainment: 7 months Waving bye bye: Achieved Age of attainment: 9 months Comes when called: Achieved Age of attainment: Copying parents in tasks: 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: 2. Started attempting Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 1. Dependent Undressing: 2. Started attempting Type of Play : 4. Parallel Academic History: Is child enrolled in school: No Diet History: Food allergies: No Junk food intake: Daily (chips) Sleep History Total sleep duration (night): 9 hours Afternoon nap: No Sleep disturbances: No Daily Screen Time Duration: <30 minutes Examination a. Vitals: b. Anthropometry: Weight: 10 Kg Head circumference: 45 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: 3 cafe au lait macules over right side of back (approx 2.5*2 cm) Others: Lt eye squint d. CNS: Higher Mental Functions Consciousness: Conscious, alert, playful Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Deep tandon reflexes: DTR: KJ-3+/3+, AJ-2+/2+ Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: Parents counselled. Investigations: Ophthalmologist opinion, Neurologist opinion Medications: Continue Syp Levilex as advised General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Divyansh Sahu
Age: 2 Year 8 Month 18 Days
Gender: Male
DOB: 2023-06-08
Mother’s age (years): 24 years
Mother’s occupation: Homemaker
Father’s age (years): 28 years
Father’s occupation: Self employed
Type of family: Joint
Number of family members: 25
Number of siblings: 0
Contact: 9589529106
Referred By: Doctor
Informant: Parents

Behavioral history:

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: 2.5 Kg
Cry at birth: Cried immediately after birth
NICU stay: Yes
If yes- Duration & Indication: Bluish discoloration on day 3- admitted for 15d,H/o neonatal seizures, Not discharged on AED Ventilated for 13d. Readmitted on 26d for refusal to feed

Past history:

Hospitalization: No Seizures: Yes Others: Abnormal body movements- 1st episode at 8 mon age in the form of head drop attacks multiple episodes, immediately after waking up , Presently 20-15 episodes of head drop or fall during walking, not asso. with LOC, not asso with fever. Started consulting after 2 years, no significant improvement with AED

Past/Current medications: Syp Levilex 20 drops BD, supplements Investigations done-

Hearing assessment: Not done Vision assessment: Done Details: Reports not there

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: 9 months
Walking without support: Achieved

Age of attainment: 2 years

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

Drinking from cup: Achieved

Age of attainment: 2 years

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 7 months
Pointing: Achieved

Age of attainment: 12 months
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 24 months

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 24 months

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Joint attention: Consistent
Pointing: Consistent meaningful pointing
Understanding gestures: Consistent
Following commands (gesture + verbal): 1-step

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 3 months
Stranger anxiety: Achieved

Age of attainment: 7 months
Waving bye bye: Achieved

Age of attainment: 9 months
Comes when called: Achieved

Age of attainment:
Copying parents in tasks: 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: 2. Started attempting
Bathing: 2. Started attempting
Toilet training: 2. Started attempting
Dressing: 1. Dependent
Undressing: 2. Started attempting

Type of Play : 4. Parallel Academic History:

Is child enrolled in school: No

Diet History:

Food allergies: No
Junk food intake: Daily (chips)

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: No
Sleep disturbances: No

Daily Screen Time

Duration: <30 minutes

Examination

a. Vitals:

b. Anthropometry:

Weight: 10 Kg Head circumference: 45 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: 3 cafe au lait macules over right side of back (approx 2.5*2 cm) Others: Lt eye squint

d. CNS: Higher Mental Functions

Consciousness: Conscious, alert, playful

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Deep tandon reflexes: DTR: KJ-3+/3+, AJ-2+/2+

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Proper

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

Advice

Intervention plan: Parents counselled.
Investigations: Ophthalmologist opinion, Neurologist opinion
Medications: Continue Syp Levilex as advised
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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