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Patient Details


Demographic Details Child's Name: Angad Kansana Age: 3 Year 6 Month 4 Days Gender: Male DOB: 2022-08-20 Mother’s age (years): 42 years Father’s age (years): 48 years Father’s occupation: Business Number of siblings: 3 Details of siblings (Age and sex): 1- 22y f, 2- 17y f, 3- 5y m Address: Madhavnagar Contact: 9301250174 Referred By: Doctor Informant: Mother Presenting Concerns Chief concerns: Clarity of speech Behavioral history: Hyperactivity Inattention Object obsession Stubbornness Aggression Birth & Perinatal History: Antenatal History Consanguinity: No Maternal age at conception (years):: 37 Type of conception: Natural High-risk factors in pregnancy: Chronic hypertension Pre-eclampsia Hypothyroidism Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Chronic hypertension Gestational Age: FT Birth Weight: 3.7 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: On day 3 admitted for NNHB under PT for 24 hours Past history: Hospitalization: No Seizures: 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: 3 mon Roll over: Achieved Age of attainment: 5 mon Sitting without support: Achieved Age of attainment: 6 mon Standing without support: Achieved Age of attainment: 9 mon Walking without support: Achieved Age of attainment: 11 mon Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 mon Unidextrous grasp: Achieved Age of attainment: 6 mon Pincer grasp: Achieved Age of attainment: 12 mon Language Receptive:- Joint attention: Achieved Age of attainment: Not remembered Pointing: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 3 `mon Babbling: Achieved Age of attainment: 6 mon Meaningful words: Achieved Age of attainment: 2 years Expressive:- Cooing: Achieved Age of attainment: 3 `mon Babbling: Achieved Age of attainment: 6 mon Meaningful words: Achieved Age of attainment: 2 years Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Answering Questions:- Echolalia: Present Patterned speech: Present Social Social smile: Achieved Age of attainment: 2 mon Stranger anxiety: Achieved Age of attainment: 7 mon Waving bye bye: Achieved Age of attainment: 9 mon Response to Name Call Sitting tolerance- (in minutes) For interaction: 2-4 minutes For tasks: sits while eating, or with objects ADL Skills (Age-appropriate)- Eating: 4. Needs minimal assistance Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : Outdoor play duration: 2 hours Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Little Angels Grade: Playgroup Hours spent in school: 4.5 hours Diet History: Food preferences: Picky eating Food allergies: No Sleep History Total sleep duration (night): 10 hours Afternoon nap: No Daily Screen Time Duration: > 2 hours Examination a. Vitals: b. Anthropometry: Weight: 17 Kg Height: 102 cm Head circumference: 49.5 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Deep tandon reflexes: DTR- KJ1+/1+, AJ2+/2+ Oromotor Examination Drooling: No Chewing: Improper Swallowing: Proper Blowing: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: VSMS, ISAA, DSM5 ASD General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Angad Kansana
Age: 3 Year 6 Month 4 Days
Gender: Male
DOB: 2022-08-20
Mother’s age (years): 42 years
Father’s age (years): 48 years
Father’s occupation: Business
Number of siblings: 3
Details of siblings (Age and sex): 1- 22y f, 2- 17y f, 3- 5y m
Address: Madhavnagar
Contact: 9301250174
Referred By: Doctor
Informant: Mother

Presenting Concerns

Chief concerns: Clarity of speech

Behavioral history:

Hyperactivity Inattention Object obsession Stubbornness Aggression

Birth & Perinatal History: Antenatal History

Consanguinity: No
Maternal age at conception (years):: 37
Type of conception: Natural
High-risk factors in pregnancy:
1. Chronic hypertension
2. Pre-eclampsia
3. Hypothyroidism

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Chronic hypertension
Gestational Age: FT
Birth Weight: 3.7 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: On day 3 admitted for NNHB under PT for 24 hours

Past history:

Hospitalization: No Seizures: 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: 3 mon
Roll over: Achieved

Age of attainment: 5 mon
Sitting without support: Achieved

Age of attainment: 6 mon
Standing without support: Achieved

Age of attainment: 9 mon
Walking without support: Achieved

Age of attainment: 11 mon

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 mon

Unidextrous grasp: Achieved

Age of attainment: 6 mon

Pincer grasp: Achieved

Age of attainment: 12 mon

Language

Receptive:-

Joint attention: Achieved

Age of attainment: Not remembered
Pointing:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 3 `mon

Babbling: Achieved

Age of attainment: 6 mon

Meaningful words: Achieved

Age of attainment: 2 years

Expressive:-

Cooing: Achieved

Age of attainment: 3 `mon

Babbling: Achieved

Age of attainment: 6 mon

Meaningful words: Achieved

Age of attainment: 2 years

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent

Answering Questions:-

Echolalia: Present Patterned speech: Present

Social

Social smile: Achieved

Age of attainment: 2 mon
Stranger anxiety: Achieved

Age of attainment: 7 mon
Waving bye bye: Achieved

Age of attainment: 9 mon

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: 2-4 minutes
For tasks: sits while eating, or with objects

ADL Skills (Age-appropriate)-

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

Type of Play : Outdoor play duration: 2 hours Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Little Angels
Grade: Playgroup
Hours spent in school: 4.5 hours

Diet History:

Food preferences: Picky eating
Food allergies: No

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: No

Daily Screen Time

Duration: > 2 hours

Examination

a. Vitals:

b. Anthropometry:

Weight: 17 Kg Height: 102 cm Head circumference: 49.5 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Deep tandon reflexes: DTR- KJ1+/1+, AJ2+/2+

Oromotor Examination

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

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

Advice

Intervention plan: VSMS, ISAA, DSM5 ASD
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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