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Patient Details


Demographic Details Child's Name: Manav Batham Age: 4 Year 6 Month 16 Days Gender: Male DOB: 2021-08-09 Mother’s age (years): 32 years Mother’s occupation: Housewife Father’s age (years): 27 years Father’s occupation: Pvt job Type of family: Nuclear Number of family members: 6 Number of siblings: 1 Contact: 8305887088 Referred By: Doctor Presenting Concerns Chief concerns: Speech delay, poor response Interaction history: Eye contact: Poor Quality of Interaction: avoids Behavioral history: Repetitive behaviors (RRBs): Patterned behavior or activities: Siymming, spinning Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Mouthing of objects Sensory Concerns: Tactile: Hypersensitive Visual: Seeks visuals Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Indication for LSCS (if applicable): Difficult labor, Leaking PV Gestational Age: FT Birth Weight: 2Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: Yes Others: ID in Maternal uncle Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 3 mon Roll over: Achieved Age of attainment: 5mon 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: 14 mon Fine Motor Bidextrous grasp: Achieved Age of attainment: 3 mon Unidextrous grasp: Achieved Age of attainment: 6 mon Pincer grasp: Achieved Age of attainment: 12 mon Scribbling: Not achieved Drinking from cup: Not achieved Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 1.5 years Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 1.5 years Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Drag for needs: Inconsistent Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 mon Stranger anxiety: Achieved Age of attainment: 8 mon Waving bye bye: Not achieved Response to Name Call Sitting tolerance- (in minutes) For interaction: Less than a minute For tasks: Less than a minute ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 2. Isolated Outdoor play duration: Nil Academic History: Is child enrolled in school: No Diet History: Food preferences: Picky eater Junk food intake: Toffy Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: No Sleep disturbances: Yes Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: c. General Examination Dysmorphology: Depressed nasal bridge d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Deep tandon reflexes: DTR- KJ 3+/3+, AJ 2+/2+ Oromotor Examination Chewing: Proper Swallowing: Proper Blowing: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 2/week + PMT 1/week Investigations: CBC, Thyroid profile, Vit D, Vit B12, Ca, Homocysteine (Later) General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Manav Batham
Age: 4 Year 6 Month 16 Days
Gender: Male
DOB: 2021-08-09
Mother’s age (years): 32 years
Mother’s occupation: Housewife
Father’s age (years): 27 years
Father’s occupation: Pvt job
Type of family: Nuclear
Number of family members: 6
Number of siblings: 1
Contact: 8305887088
Referred By: Doctor

Presenting Concerns

Chief concerns: Speech delay, poor response

Interaction history:

Eye contact: Poor
Quality of Interaction: avoids

Behavioral history:

Repetitive behaviors (RRBs): Patterned behavior or activities: Siymming, spinning Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Mouthing of objects
Sensory Concerns:

Tactile: Hypersensitive
Visual: Seeks visuals
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Indication for LSCS (if applicable): Difficult labor, Leaking PV
Gestational Age: FT
Birth Weight: 2Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Nil Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: Yes Others: ID in Maternal uncle

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 3 mon
Roll over: Achieved

Age of attainment: 5mon
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: 14 mon

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 3 mon

Unidextrous grasp: Achieved

Age of attainment: 6 mon

Pincer grasp: Achieved

Age of attainment: 12 mon

Scribbling: Not achieved

Drinking from cup: Not achieved

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 1.5 years

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 1.5 years

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Drag for needs: Inconsistent

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 mon
Stranger anxiety: Achieved

Age of attainment: 8 mon
Waving bye bye: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: Less than a minute
For tasks: Less than a minute

ADL Skills (Age-appropriate)-

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

Type of Play : 2. Isolated Outdoor play duration: Nil Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Picky eater
Junk food intake: Toffy

Sleep History

Total sleep duration (night): 9-10 hours
Afternoon nap: No
Sleep disturbances: Yes

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

Dysmorphology: Depressed nasal bridge

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

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

Oromotor Examination

Chewing: Proper
Swallowing: Proper
Blowing: Improper

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

Advice

Intervention plan: IDP 2/week + PMT 1/week
Investigations: CBC, Thyroid profile, Vit D, Vit B12, Ca, Homocysteine (Later)
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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