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Patient Details


Demographic Details Child's Name: Aasma Jatav Age: 6 Year 3 Month 27 Days Gender: Female DOB: 2019-11-17 Mother’s age (years): 31 years Mother’s occupation: Homemaker Father’s age (years): 29 years Father’s occupation: Private job Type of family: Joint Number of family members: 5 Number of siblings: 2 Details of siblings (Age and sex): 1- 4.5 year female, 2- 3 year male Address: Sabalgarh Contact: 9993491372 Referred By: Doctor Presenting Concerns Chief concerns: Poor understanding, stubborness Duration of symptoms: Concerns since early childhood Interaction history: Eye contact: Sustained Behavioral history: Temper tantrums Stubbornness Aggression Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: PIH Others:: 1 spontaneous abortion after Aasma's delivery Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Delayed cry Resuscitation required: Yes Details of Resuscitation: Details not available NICU stay: Yes If yes- Duration & Indication: NICU stay for 1 month (RDS + ?HIE) Past history: Hospitalization: Yes Seizures: Yes Others: At 3 months- 1st episode of abnormal body movements, admitted for 15 days (Deatils not available) Past/Current medications: Sizodon 5 drops OD 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: 6 months Roll over: Achieved Age of attainment: 6 months Sitting without support: Achieved Age of attainment: 7 months Standing without support: Achieved Age of attainment: 10 months Walking without support: Achieved Age of attainment: 12 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: 3 years Drinking from cup: Not achieved Buttoning / Unbuttoning: Achieved Age of attainment: 6 years (unbuttoning) Language Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 2 years 2 word Phrases: Achieved Age of attainment: 3 years Complete sentences: Achieved Age of attainment: 4 years Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 2 years 2 word Phrases: Achieved Age of attainment: 3 years Complete sentences: Achieved Age of attainment: 4 years Communication & Language Assessment Non-Verbal Communication Grading:- Following commands (gesture + verbal): 1-step Answering Questions:- What Where Who Echolalia: Absent Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 7 months Asking for food and toilet: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) For interaction: 4-5 minutes For tasks: 4-5 minutes ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 4. Needs minimal assistance Toilet training: 5. Independent Dressing: 3. Needs significant assistance Undressing: 4. Needs minimal assistance Type of Play : 4. Parallel Academic History: Is child enrolled in school: Yes Additional information: Doesnt want to go to present school- says she wants to go bigger school Diet History: Sleep History Total sleep duration (night): 11- 12 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Sleep disturbances: Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 17.5 Kg Height: 111 cm Head circumference: 46 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Consciousness: Conscious Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Power: Tone normal Deep tandon reflexes: DTR- KJ 2+/2+, AJ 2+/2+ Oromotor Examination Chewing: Proper Swallowing: Proper Blowing: Proper Others: Sucking- present CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IQ evaluation. Session to be planned accordingly General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

Demographic Details

Child's Name: Aasma Jatav
Age: 6 Year 3 Month 27 Days
Gender: Female
DOB: 2019-11-17
Mother’s age (years): 31 years
Mother’s occupation: Homemaker
Father’s age (years): 29 years
Father’s occupation: Private job
Type of family: Joint
Number of family members: 5
Number of siblings: 2
Details of siblings (Age and sex): 1- 4.5 year female, 2- 3 year male
Address: Sabalgarh
Contact: 9993491372
Referred By: Doctor

Presenting Concerns

Chief concerns: Poor understanding, stubborness
Duration of symptoms: Concerns since early childhood

Interaction history:

Eye contact: Sustained

Behavioral history:

Temper tantrums Stubbornness Aggression

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. PIH
Others:: 1 spontaneous abortion after Aasma's delivery

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
Details of Resuscitation: Details not available
NICU stay: Yes
If yes- Duration & Indication: NICU stay for 1 month (RDS + ?HIE)

Past history:

Hospitalization: Yes Seizures: Yes Others: At 3 months- 1st episode of abnormal body movements, admitted for 15 days (Deatils not available)

Past/Current medications: Sizodon 5 drops OD 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: 6 months
Roll over: Achieved

Age of attainment: 6 months
Sitting without support: Achieved

Age of attainment: 7 months
Standing without support: Achieved

Age of attainment: 10 months
Walking without support: Achieved

Age of attainment: 12 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: 3 years

Drinking from cup: Not achieved

Buttoning / Unbuttoning: Achieved

Age of attainment: 6 years (unbuttoning)

Language

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 2 years

2 word Phrases: Achieved

Age of attainment: 3 years

Complete sentences: Achieved

Age of attainment: 4 years

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 2 years

2 word Phrases: Achieved

Age of attainment: 3 years

Complete sentences: Achieved

Age of attainment: 4 years

Communication & Language Assessment

Non-Verbal Communication Grading:-

Following commands (gesture + verbal): 1-step

Answering Questions:-

What Where Who Echolalia: Absent

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 7 months
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: 4-5 minutes
For tasks: 4-5 minutes

ADL Skills (Age-appropriate)-

Eating: 5. Independent
Bathing: 4. Needs minimal assistance
Toilet training: 5. Independent
Dressing: 3. Needs significant assistance
Undressing: 4. Needs minimal assistance

Type of Play : 4. Parallel Academic History:

Is child enrolled in school: Yes
Additional information: Doesnt want to go to present school- says she wants to go bigger school

Diet History:

Sleep History

Total sleep duration (night): 11- 12 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours
Sleep disturbances:

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 17.5 Kg Height: 111 cm Head circumference: 46 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Consciousness: Conscious

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Power: Tone normal
Deep tandon reflexes: DTR- KJ 2+/2+, AJ 2+/2+

Oromotor Examination

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

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

Advice

Intervention plan: IQ evaluation. Session to be planned accordingly
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

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