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Patient Details


Demographic Details Child's Name: Love Age: 1 Year 7 Month 15 Days Gender: Male DOB: 2024-07-09 Mother’s age (years): 23 Mother’s occupation: Homemaker Father’s age (years): 26 years Father’s occupation: Farmily Type of family: Joint Number of family members: 5 Number of siblings: 0 Address: Rampura, Jalon Contact: 7881185822 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Delayed milestones, decreased Lt hand movements Duration of symptoms: Since birth Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: Conceived after 6 yrs of marriage. Natal and Postnatal History: Past history: Hospitalization: Yes Seizures: Yes Others: At 1.5 mon- admitted for abn body movements in form of tonic posturing Past/Current therapies: Nil Past/Current medications: Syp Levilex, Phenobarb 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: Partial (8 mon) Roll over: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 8 mon Unidextrous grasp: Not achieved Pincer grasp: Not achieved Language Receptive:- Joint attention: Not achieved Expressive:- Cooing: Achieved Age of attainment: 9 mon Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 9 mon Babbling: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 9 mon Stranger anxiety: Not achieved Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Academic History: Diet History: Food preferences: Mil+Biscuits Sleep History Total sleep duration (night): !3-14 hours divided in to 2 naps in day Afternoon nap: Yes Daily Screen Time Duration: < 2 hours Examination a. Vitals: b. Anthropometry: Weight: 8 kg Height: 72 cm Head circumference: 40.5 cm (Microcephaly) c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Consciousness: awake, playful Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypertonia Deep tandon reflexes: KJ- 3+/3+, AJ 2+/2+ Other: Spacticity (UL>LL), restricted movements of Lt arm Oromotor Examination Others: Pull to sit- Head lag, back curved, prone - uplift head above ground >45degree CVS examination: NAD Respiratory System examination: NAD Advice Intervention plan: IDP(+PT) 2/week. Parents counselled. Dietary advice given Investigations: EEG, BERA, Complete ophthalmological examination Medications: Continue medications as adviced General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Love
Age: 1 Year 7 Month 15 Days
Gender: Male
DOB: 2024-07-09
Mother’s age (years): 23
Mother’s occupation: Homemaker
Father’s age (years): 26 years
Father’s occupation: Farmily
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Address: Rampura, Jalon
Contact: 7881185822
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Delayed milestones, decreased Lt hand movements
Duration of symptoms: Since birth

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: Conceived after 6 yrs of marriage.

Natal and Postnatal History:

Past history:

Hospitalization: Yes Seizures: Yes Others: At 1.5 mon- admitted for abn body movements in form of tonic posturing

Past/Current therapies: Nil Past/Current medications: Syp Levilex, Phenobarb 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: Partial (8 mon)
Roll over: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 8 mon

Unidextrous grasp: Not achieved

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 9 mon

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 9 mon

Babbling: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 9 mon
Stranger anxiety: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Academic History:

Diet History:

Food preferences: Mil+Biscuits

Sleep History

Total sleep duration (night): !3-14 hours divided in to 2 naps in day
Afternoon nap: Yes

Daily Screen Time

Duration: < 2 hours

Examination

a. Vitals:

b. Anthropometry:

Weight: 8 kg Height: 72 cm Head circumference: 40.5 cm (Microcephaly)

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Consciousness: awake, playful

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypertonia
Deep tandon reflexes: KJ- 3+/3+, AJ 2+/2+
Other: Spacticity (UL>LL), restricted movements of Lt arm

Oromotor Examination

Others: Pull to sit- Head lag, back curved, prone - uplift head above ground >45degree

CVS examination: NAD
Respiratory System examination: NAD

Advice

Intervention plan: IDP(+PT) 2/week. Parents counselled. Dietary advice given
Investigations: EEG, BERA, Complete ophthalmological examination
Medications: Continue medications as adviced
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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