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Patient Details


Demographic Details Child's Name: Manvik Age: 3 Year 4 Month 21 Days Gender: Male DOB: 2022-10-21 Mother’s age (years): 29 years Mother’s occupation: Homemaker Father’s age (years): 33 years Father’s occupation: Govt job Type of family: Joint Number of family members: 4 Number of siblings: 0 Address: Darpan Contact: 9660622484 Referred By: Doctor Presenting Concerns Chief concerns: Speech delay Duration of symptoms: Noticed 2.5 years Interaction history: Eye contact: Suboptimal Interaction: wants to engage with children Behavioral history: Hyperactivity Inattention Impulsivity Object obsession Stubbornness Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Ante partum haemorrhage Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): APH Gestational Age: 32 wk Birth Weight: 1.9 kg Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: No Past/Current medications: NO 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 m onths Sitting without support: Achieved Age of attainment: 9 months Standing without support: Achieved Age of attainment: 13 months Walking without support: Achieved Age of attainment: 14 months Fine Motor Bidextrous grasp: Achieved Age of attainment: 3 months Unidextrous grasp: Achieved Age of attainment: 4 months Pincer grasp: Achieved Age of attainment: 12 months Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 18 months Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 18 months Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 18 months Details:: Started speaking kinship words Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Joint attention: Consistent Pointing: Consistent meaningful pointing Understanding gestures: Emerging Answering Questions:- Social Social smile: Achieved Age of attainment: 4 months Stranger anxiety: Achieved Age of attainment: 7 months Waving bye bye: Achieved Age of attainment: Comes when called: Achieved Age of attainment: Copying parents in tasks: Not achieved Response to Name Call Sitting tolerance- (in minutes) For interaction: Doesnt sit for interaction For tasks: Better for tasks ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Eats finger foods, and by spoon Type of Play : 4. Parallel Outdoor play duration: 2-3 hours Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Avengers Playschool Grade: Play group Hours spent in school: 3 hours Location: Darpan colony Additional information: Follows commands in school Diet History: Food preferences: No Sleep History Total sleep duration (night): 8 hours Afternoon nap: Yes Duration of Afternoon nap: 3 hours Sleep disturbances: No Daily Screen Time Duration: < 2 hours 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 Oromotor Examination Chewing: Proper Swallowing: Proper Blowing: Proper Others: Sucking- proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: Stop bottlefeeding. Investigations: ISAA, DSM5 ASD, DSM5 ADHD Follow up plan: Review with report General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Manvik
Age: 3 Year 4 Month 21 Days
Gender: Male
DOB: 2022-10-21
Mother’s age (years): 29 years
Mother’s occupation: Homemaker
Father’s age (years): 33 years
Father’s occupation: Govt job
Type of family: Joint
Number of family members: 4
Number of siblings: 0
Address: Darpan
Contact: 9660622484
Referred By: Doctor

Presenting Concerns

Chief concerns: Speech delay
Duration of symptoms: Noticed 2.5 years

Interaction history:

Eye contact: Suboptimal
Interaction: wants to engage with children

Behavioral history:

Hyperactivity Inattention Impulsivity Object obsession Stubbornness

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Ante partum haemorrhage

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): APH
Gestational Age: 32 wk
Birth Weight: 1.9 kg
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: No Past/Current medications: NO 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 m onths
Sitting without support: Achieved

Age of attainment: 9 months
Standing without support: Achieved

Age of attainment: 13 months
Walking without support: Achieved

Age of attainment: 14 months

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 3 months

Unidextrous grasp: Achieved

Age of attainment: 4 months

Pincer grasp: Achieved

Age of attainment: 12 months

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 18 months
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 18 months

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 18 months

Details:: Started speaking kinship words

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Joint attention: Consistent
Pointing: Consistent meaningful pointing
Understanding gestures: Emerging

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 4 months
Stranger anxiety: Achieved

Age of attainment: 7 months
Waving bye bye: Achieved

Age of attainment:
Comes when called: Achieved

Age of attainment:
Copying parents in tasks: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: Doesnt sit for interaction
For tasks: Better for tasks

ADL Skills (Age-appropriate)-

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

Details:: Eats finger foods, and by spoon

Type of Play : 4. Parallel Outdoor play duration: 2-3 hours Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Avengers Playschool
Grade: Play group
Hours spent in school: 3 hours
Location: Darpan colony
Additional information: Follows commands in school

Diet History:

Food preferences: No

Sleep History

Total sleep duration (night): 8 hours
Afternoon nap: Yes
Duration of Afternoon nap: 3 hours
Sleep disturbances: No

Daily Screen Time

Duration: < 2 hours
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

Oromotor Examination

Chewing: Proper
Swallowing: Proper
Blowing: Proper
Others: Sucking- proper

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

Advice

Intervention plan: Stop bottlefeeding.
Investigations: ISAA, DSM5 ASD, DSM5 ADHD
Follow up plan: Review with report
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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