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Patient Details


Demographic Details Child's Name: Inayat Khan Age: 3 Year 6 Month 0 Days Gender: Female DOB: 2022-08-18 Mother’s age (years): 32 years Mother’s occupation: Housewife Father’s age (years): 35 years Father’s occupation: Business Type of family: Joint Number of family members: 8 Number of siblings: 1 Details of siblings (Age and sex): 1- 5.5 year old female Address: Jhansi (Gudsaray) Contact: 9918107085 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Developmental Delay Interaction history: Eye contact: Sustained Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: Yes If yes Degree: 3 Type of conception: Natural Others:: H/o 1 still birth Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 2.8 Kg Cry at birth: Cried after stimulation Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: At day 3 of life- Fever, Jaundice, excessive crying. Was on ventilator for 11-12 days. Discharged on antiepileptics. Past history: Hospitalization: No Seizures: Yes Others: H/o multiple episodes of GTCS till 1 year of age Past/Current medications: On Syp Valprol (200mg/5ml) 5ml BD- 44mg/kg/day. Syp Cognigrow, Histafer, Becetam Investigations done- Hearing assessment: Not done Vision assessment: Done Details: Follow up advised Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 1.5 years Roll over: Achieved Age of attainment: 2 years Sitting without support: Achieved Age of attainment: 3 years Standing without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 2.5 years Unidextrous grasp: Achieved Age of attainment: 3 years Pincer grasp: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 3 years Pointing: Not achieved 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:- Need-based communication: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 12 months Stranger anxiety: Achieved Age of attainment: 3 years Comes when called: Achieved Age of attainment: After 3 years 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 allergies: No Junk food intake: Once in a while Sleep History Total sleep duration (night): Sleeps at 8 pm, Wakes up by 5 or 7 am (9-10 hours) Afternoon nap: Yes Sleep disturbances: No Daily Screen Time Duration: < 1 hour Type of screen: TV Examination a. Vitals: b. Anthropometry: Weight: 9 kg Head circumference: 42 cm c. General Examination Others: Generalised wasting d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Bulk of muscles: Wasting+ Tone: Hypertonia Oromotor Examination CVS examination: NAD Respiratory System examination: NAd Per abdomen examination: NAD Advice Intervention plan: Home based program. Physiotherapy at nearby place. Stop bottlefeeding. Parents counselled Investigations: EEG Medications: Continue same as advised Follow up plan: review after 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Inayat Khan
Age: 3 Year 6 Month 0 Days
Gender: Female
DOB: 2022-08-18
Mother’s age (years): 32 years
Mother’s occupation: Housewife
Father’s age (years): 35 years
Father’s occupation: Business
Type of family: Joint
Number of family members: 8
Number of siblings: 1
Details of siblings (Age and sex): 1- 5.5 year old female
Address: Jhansi (Gudsaray)
Contact: 9918107085
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Developmental Delay

Interaction history:

Eye contact: Sustained

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: Yes
If yes Degree: 3
Type of conception: Natural
Others:: H/o 1 still birth

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 2.8 Kg
Cry at birth: Cried after stimulation
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: At day 3 of life- Fever, Jaundice, excessive crying. Was on ventilator for 11-12 days. Discharged on antiepileptics.

Past history:

Hospitalization: No Seizures: Yes Others: H/o multiple episodes of GTCS till 1 year of age

Past/Current medications: On Syp Valprol (200mg/5ml) 5ml BD- 44mg/kg/day. Syp Cognigrow, Histafer, Becetam Investigations done-

Hearing assessment: Not done Vision assessment: Done Details: Follow up advised

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 1.5 years
Roll over: Achieved

Age of attainment: 2 years
Sitting without support: Achieved

Age of attainment: 3 years
Standing without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 2.5 years

Unidextrous grasp: Achieved

Age of attainment: 3 years

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 3 years
Pointing: Not achieved

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:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 12 months
Stranger anxiety: Achieved

Age of attainment: 3 years
Comes when called: Achieved

Age of attainment: After 3 years

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 allergies: No
Junk food intake: Once in a while

Sleep History

Total sleep duration (night): Sleeps at 8 pm, Wakes up by 5 or 7 am (9-10 hours)
Afternoon nap: Yes
Sleep disturbances: No

Daily Screen Time

Duration: < 1 hour
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 9 kg Head circumference: 42 cm

c. General Examination

Others: Generalised wasting

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Bulk of muscles: Wasting+
Tone: Hypertonia

Oromotor Examination

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

Advice

Intervention plan: Home based program. Physiotherapy at nearby place. Stop bottlefeeding. Parents counselled
Investigations: EEG
Medications: Continue same as advised
Follow up plan: review after 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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