Demographic Details
- :
Harshal Sharma
- :
2 Year 3 Month 2 Days
- :
Male
- :
2023-12-01
- :
33 years
- :
Homemaker
- :
35 years
- :
Nuclear
- :
3
- :
1
- :
1- 7 year old female
- :
9575329999
- :
Relative
Presenting Concerns
- :
Speech delay
Interaction history:
Behavioral history:
Hyperactivity
Inattention
Impulsivity
Birth & Perinatal History:
Antenatal History
- :
No
- :
Natural
-
High-risk factors in pregnancy:
- Hypothyroidism
- :
H/o 1 spontaneous abortion at 4 weeks.
Natal and Postnatal History:
- :
Institutional
- :
LSCS
- :
Polyhydramnios
- :
3.050 Kg
- :
Cried immediately after birth
- :
No
- :
No
Past history:
:
No
:
No
:
Nil
Investigations done-
:
Not done
:
Not done
Family history:
:
Yes
:
ASD in cousin
Developmental History:
Gross Motor
-
:
Achieved
:
4 months
-
:
Achieved
:
5 months
-
:
Achieved
:
6 months
-
:
Achieved
:
9 months
-
:
Achieved
:
18 months
Fine Motor
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
12 months
:
Not achieved
:
Not achieved
Language
Receptive:-
-
:
Not achieved
-
:
Not achieved
- :
Not following
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
12 months
:
Not achieved
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
12 months
:
Not achieved
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Emerging
Answering Questions:-
:
Present
Social
Response to Name Call
Sitting tolerance- (in minutes)
- :
Better for tasks and objects
ADL Skills (Age-appropriate)-
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
Type of Play :
:
Nil
Academic History:
- :
No
Diet History:
- :
Picky eating
- :
No
Sleep History
- :
10-11 hours
- :
Yes
-
:
Yes
Daily Screen Time
Examination
a. Vitals:
b. Anthropometry:
:
11 Kg
:
46 cm
c. General Examination
:
Ab
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
:
NAD
:
NAD
:
NAD
Advice
- :
Review after 1 month
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food