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Demographic Details Child's Name: Aditya Singh Age: 7 Year 6 Month 27 Days Gender: Male DOB: 2018-07-20 Mother’s age (years): 30 years Mother’s occupation: Homemaker Father’s age (years): 34 years Father’s occupation: Pvt job (Works in Gujarat) Type of family: Joint Number of family members: 8 Number of siblings: 1 Details of siblings (Age and sex): 1- 3 year old female Address: Shatapdiburam Contact: 7069558704 Referred By: Doctor Informant: Parents Presenting Concerns Duration of symptoms: Abnormal body movements from 2.5 years age. Regression of milestones were noticed after that Interaction history: Eye contact: Suboptimal Behavioral history: Hyperactivity Inattention Impulsivity Stubbornness Aggression Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Oligohydramnios Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): No labor pains, oligohydramnios Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Cried immediately after birth NICU stay: No Past history: Hospitalization: Yes Seizures: Yes Others: H/o ? atonic seizures. 1st episode at 2.5 years f/b LOC . 2nd episode of similar semiology 1 year back. Past/Current therapies: Took some therapies for 1 year then discontinued Past/Current medications: On antiepileptics since 2.5 years age (treatment going on in AIIMS) Investigations done- Hearing assessment: Done Vision assessment: Done Family history: Neuropsychiatric condition: No 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: 9 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: 12 months Buttoning / Unbuttoning: Achieved Age of attainment: Language Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 24 months Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 24 months Communication & Language Assessment Non-Verbal Communication Grading:- Joint attention: Consistent Pointing: Consistent meaningful pointing Understanding gestures: 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: 7 months Waving bye bye: Achieved Age of attainment: 9 months Comes when called: Achieved Age of attainment: Copying parents in tasks: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) For interaction: 1-2 minutes For tasks: 1-2 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 3. Needs significant assistance Toilet training: 5. Independent Dressing: 3. Needs significant assistance Undressing: 3. Needs significant assistance Type of Play : Outdoor play duration: Absent Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Elite school Grade: UKg Hours spent in school: 5 hours Location: Shatabpdipuram Diet History: Junk food intake: 1-2 times/ week Sleep History Total sleep duration (night): 11 hours (sleeps at 7 pm, wakes up at 6 am) Afternoon nap: Yes Sleep disturbances: No Daily Screen Time Duration: < 2 hours Type of screen: TV Examination a. Vitals: b. Anthropometry: Weight: 26 Kg Height: 126 cm Head circumference: 51 cm c. General Examination d. CNS: Higher Mental Functions Consciousness: Conscious Orientation: Orineted to place and person Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypotonia Deep tandon reflexes: KJ 1+/1+, AJ 1+/1+ Gait issues: Present Meningeal signs: Absent Oromotor Examination Drooling: Yes CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 2/week +PMT1/week Medications: Continue medications as advised in AIIMS General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

Demographic Details

Child's Name: Aditya Singh
Age: 7 Year 6 Month 27 Days
Gender: Male
DOB: 2018-07-20
Mother’s age (years): 30 years
Mother’s occupation: Homemaker
Father’s age (years): 34 years
Father’s occupation: Pvt job (Works in Gujarat)
Type of family: Joint
Number of family members: 8
Number of siblings: 1
Details of siblings (Age and sex): 1- 3 year old female
Address: Shatapdiburam
Contact: 7069558704
Referred By: Doctor
Informant: Parents

Presenting Concerns

Duration of symptoms: Abnormal body movements from 2.5 years age. Regression of milestones were noticed after that

Interaction history:

Eye contact: Suboptimal

Behavioral history:

Hyperactivity Inattention Impulsivity Stubbornness Aggression

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Oligohydramnios

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): No labor pains, oligohydramnios
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Cried immediately after birth
NICU stay: No

Past history:

Hospitalization: Yes Seizures: Yes Others: H/o ? atonic seizures. 1st episode at 2.5 years f/b LOC . 2nd episode of similar semiology 1 year back.

Past/Current therapies: Took some therapies for 1 year then discontinued Past/Current medications: On antiepileptics since 2.5 years age (treatment going on in AIIMS) Investigations done-

Hearing assessment: Done Vision assessment: Done

Family history:

Neuropsychiatric condition: No

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: 9 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: 12 months

Buttoning / Unbuttoning: Achieved

Age of attainment:

Language

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 24 months

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 24 months

Communication & Language Assessment

Non-Verbal Communication Grading:-

Joint attention: Consistent
Pointing: Consistent meaningful pointing
Understanding gestures: 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: 7 months
Waving bye bye: Achieved

Age of attainment: 9 months
Comes when called: Achieved

Age of attainment:
Copying parents in tasks: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: 1-2 minutes
For tasks: 1-2 minutes

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 3. Needs significant assistance
Toilet training: 5. Independent
Dressing: 3. Needs significant assistance
Undressing: 3. Needs significant assistance

Type of Play : Outdoor play duration: Absent Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Elite school
Grade: UKg
Hours spent in school: 5 hours
Location: Shatabpdipuram

Diet History:

Junk food intake: 1-2 times/ week

Sleep History

Total sleep duration (night): 11 hours (sleeps at 7 pm, wakes up at 6 am)
Afternoon nap: Yes
Sleep disturbances: No

Daily Screen Time

Duration: < 2 hours
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 26 Kg Height: 126 cm Head circumference: 51 cm

c. General Examination

d. CNS: Higher Mental Functions

Consciousness: Conscious
Orientation: Orineted to place and person

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypotonia
Deep tandon reflexes: KJ 1+/1+, AJ 1+/1+
Gait issues: Present

Meningeal signs: Absent

Oromotor Examination

Drooling: Yes

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

Advice

Intervention plan: IDP 2/week +PMT1/week
Medications: Continue medications as advised in AIIMS
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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