Create - Child Development Centre

Patient Details


Demographic Details Child's Name: Jayendra Tomar Age: 11 Year 7 Month 4 Days Gender: Male DOB: 2014-08-09 Mother’s age (years): 32 years Mother’s occupation: Homemaker Father’s age (years): 34 years Type of family: Joint Number of family members: 9 Number of siblings: 1 Details of siblings (Age and sex): 1-5 years age Address: Pinto Park Contact: 9131577068 Referred By: Doctor Informant: Paternal uncle, Grandmother Presenting Concerns Chief concerns: Poor age appropriate understanding Duration of symptoms: Realized speech delay at 3 years age, consulted neurologist and RML. Were told child has autism. Interaction history: Eye contact: Suboptimal Quality of Interaction: avoids Behavioral history: Repetitive behaviors (RRBs): Hand flapping when unengaged Patterned behavior or activities: Stubbornness Aggression Sensory Concerns: Details:: Sniffs objects Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Non progression of labor Gestational Age: Late PT Birth Weight: Around 2 kg Cry at birth: Cried after stimulation Resuscitation required: No NICU stay: 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: Yes Others: At 2 years - Hemiparesis in father 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: 10 months Walking without support: Achieved Age of attainment: 14 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 Buttoning / Unbuttoning: Achieved Age of attainment: 5 years Language Receptive:- 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: 3 years 2 word Phrases: Achieved Age of attainment: 4 years Complete sentences: Achieved Age of attainment: 6years Narrates events / stories: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 3 years 2 word Phrases: Achieved Age of attainment: 4 years Complete sentences: Achieved Age of attainment: 6years Narrates events / stories: Not achieved Details:: Sometimes repeats what is asked Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Following commands (gesture + verbal): 1-step Answering Questions:- What Where Who Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: Waving bye bye: Achieved Age of attainment: 12 months Comes when called: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: 5 years Response to Name Call Sitting tolerance- (in minutes) For interaction: Can sit for long intervals For tasks: Can sit for long intervals ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 5. Independent Dressing: 4. Needs minimal assistance Undressing: 4. Needs minimal assistance Details:: Brushing- independent. Doent want to wear shoes Type of Play : 3. Onlooker Details:: Cycling Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Smart Angel Academy Grade: 4 Hours spent in school: 5 hours Board: MP Location: Pinto Park Any change of school: No Additional information: Doesnt involve with teachers and children in school. Completes tasks in school Diet History: Food preferences: Picky eater Junk food intake: Ocassionally- chips and toffee Sleep History Total sleep duration (night): 7-8 hours Afternoon nap: Yes Duration of Afternoon nap: 3-4 hours Daily Screen Time Duration: < 2 hours Examination a. Vitals: b. Anthropometry: Weight: 28.4 Kg Head circumference: 50 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Consciousness: Concious Orientation: Oriented to place and person Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Deep tandon reflexes: Tone normal, DTR- normal Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Others: Sucking - present CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 1/week + PMT 1/week General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

Demographic Details

Child's Name: Jayendra Tomar
Age: 11 Year 7 Month 4 Days
Gender: Male
DOB: 2014-08-09
Mother’s age (years): 32 years
Mother’s occupation: Homemaker
Father’s age (years): 34 years
Type of family: Joint
Number of family members: 9
Number of siblings: 1
Details of siblings (Age and sex): 1-5 years age
Address: Pinto Park
Contact: 9131577068
Referred By: Doctor
Informant: Paternal uncle, Grandmother

Presenting Concerns

Chief concerns: Poor age appropriate understanding
Duration of symptoms: Realized speech delay at 3 years age, consulted neurologist and RML. Were told child has autism.

Interaction history:

Eye contact: Suboptimal
Quality of Interaction: avoids

Behavioral history:

Repetitive behaviors (RRBs): Hand flapping when unengaged Patterned behavior or activities: Stubbornness Aggression
Sensory Concerns:

Details:: Sniffs objects

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Non progression of labor
Gestational Age: Late PT
Birth Weight: Around 2 kg
Cry at birth: Cried after stimulation
Resuscitation required: No
NICU stay: 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: Yes Others: At 2 years - Hemiparesis in father

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: 10 months
Walking without support: Achieved

Age of attainment: 14 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

Buttoning / Unbuttoning: Achieved

Age of attainment: 5 years

Language

Receptive:-

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: 3 years

2 word Phrases: Achieved

Age of attainment: 4 years

Complete sentences: Achieved

Age of attainment: 6years

Narrates events / stories: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 3 years

2 word Phrases: Achieved

Age of attainment: 4 years

Complete sentences: Achieved

Age of attainment: 6years

Narrates events / stories: Not achieved

Details:: Sometimes repeats what is asked

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Following commands (gesture + verbal): 1-step

Answering Questions:-

What Where Who Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment:
Waving bye bye: Achieved

Age of attainment: 12 months
Comes when called: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment: 5 years

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: Can sit for long intervals
For tasks: Can sit for long intervals

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 1. Dependent
Toilet training: 5. Independent
Dressing: 4. Needs minimal assistance
Undressing: 4. Needs minimal assistance

Details:: Brushing- independent. Doent want to wear shoes

Type of Play : 3. Onlooker Details:: Cycling Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Smart Angel Academy
Grade: 4
Hours spent in school: 5 hours
Board: MP
Location: Pinto Park
Any change of school: No
Additional information: Doesnt involve with teachers and children in school. Completes tasks in school

Diet History:

Food preferences: Picky eater
Junk food intake: Ocassionally- chips and toffee

Sleep History

Total sleep duration (night): 7-8 hours
Afternoon nap: Yes
Duration of Afternoon nap: 3-4 hours

Daily Screen Time

Duration: < 2 hours

Examination

a. Vitals:

b. Anthropometry:

Weight: 28.4 Kg Head circumference: 50 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Consciousness: Concious
Orientation: Oriented to place and person

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Deep tandon reflexes: Tone normal, DTR- normal

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Proper
Others: Sucking - present

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

Advice

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

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