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Demographic Details Child's Name: Kunal Goatam Age: 3 Year 9 Month 25 Days Gender: Male DOB: 2022-05-31 Mother’s age (years): 28 years Mother’s occupation: Homemaker Father’s age (years): 30 years Father’s occupation: Private job Type of family: Nuclear Number of family members: 3 Number of siblings: 1 Address: Bilaua Contact: 7970227031 Referred By: Relative Informant: Mother, Paternal aunt (Mami) Presenting Concerns Chief concerns: Delayed development Duration of symptoms: Since birth Interaction history: Eye contact: Sustained Behavioral history: Temper tantrums Stubbornness Aggression Mouthing of objects Sensory Concerns: Auditory: Hypersensitive Details:: Afraid of horns of vehicles Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: H/o Fall from stairs in 2nd trimester Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Indication for LSCS (if applicable): Difficult labor Gestational Age: FT Birth Weight: 2.5 Kg Cry at birth: Delayed cry Details of Resuscitation: No details NICU stay: Yes If yes- Duration & Indication: Wasnt taking feed after birth, H/o seizures. Admitted on day 3 in KRH for 15 days. Past history: Hospitalization: No Seizures: No Others: No seizures post neonatal period Past/Current medications: On discharge fromm NICU- syp Gardenal for 5-6 months, discontinued by themselves 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: 12 months Sitting without support: Achieved Age of attainment: 24 months. (Inconsistent) Fine Motor Bidextrous grasp: Achieved Age of attainment: 24 months Unidextrous grasp: Achieved Age of attainment: 26 months Pincer grasp: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 24 months Pointing: Achieved Age of attainment: 30 months Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 36 months Babbling: Not achieved Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 36 months Babbling: Not achieved Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Joint attention: Consistent Pointing: Consistent meaningful pointing Answering Questions:- Social Social smile: Achieved Age of attainment: 9 months Stranger anxiety: Achieved Age of attainment: 14 months Waving bye bye: Achieved Age of attainment: 38 months Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Indicates toilet needs by gestures Academic History: Is child enrolled in school: No Diet History: Food preferences: Bottlefeeding still there Food allergies: No Junk food intake: Biscuits Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: No Sleep disturbances: Yes Daily Screen Time Duration: > 5 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 11.25Kg Height: 90 cm Head circumference: 47 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypertonia Deep tandon reflexes: KJ-3+/3+, AJ 3+,3+ Meningeal signs: Absent Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper Examination summary: Spasticity + (UL> LL), CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD, CP (? HIE sequelae) Advice Intervention plan: IDP (+PT) 3/week, PMT 1/15 days General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Kunal Goatam
Age: 3 Year 9 Month 25 Days
Gender: Male
DOB: 2022-05-31
Mother’s age (years): 28 years
Mother’s occupation: Homemaker
Father’s age (years): 30 years
Father’s occupation: Private job
Type of family: Nuclear
Number of family members: 3
Number of siblings: 1
Address: Bilaua
Contact: 7970227031
Referred By: Relative
Informant: Mother, Paternal aunt (Mami)

Presenting Concerns

Chief concerns: Delayed development
Duration of symptoms: Since birth

Interaction history:

Eye contact: Sustained

Behavioral history:

Temper tantrums Stubbornness Aggression Mouthing of objects
Sensory Concerns:

Auditory: Hypersensitive

Details:: Afraid of horns of vehicles

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: H/o Fall from stairs in 2nd trimester

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Indication for LSCS (if applicable): Difficult labor
Gestational Age: FT
Birth Weight: 2.5 Kg
Cry at birth: Delayed cry
Details of Resuscitation: No details
NICU stay: Yes
If yes- Duration & Indication: Wasnt taking feed after birth, H/o seizures. Admitted on day 3 in KRH for 15 days.

Past history:

Hospitalization: No Seizures: No Others: No seizures post neonatal period

Past/Current medications: On discharge fromm NICU- syp Gardenal for 5-6 months, discontinued by themselves 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: 12 months
Sitting without support: Achieved

Age of attainment: 24 months. (Inconsistent)

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 24 months

Unidextrous grasp: Achieved

Age of attainment: 26 months

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 24 months
Pointing: Achieved

Age of attainment: 30 months
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 36 months

Babbling: Not achieved

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 36 months

Babbling: Not achieved

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Joint attention: Consistent
Pointing: Consistent meaningful pointing

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 9 months
Stranger anxiety: Achieved

Age of attainment: 14 months
Waving bye bye: Achieved

Age of attainment: 38 months

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

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

Details:: Indicates toilet needs by gestures

Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Bottlefeeding still there
Food allergies: No
Junk food intake: Biscuits

Sleep History

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

Daily Screen Time

Duration: > 5 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 11.25Kg Height: 90 cm Head circumference: 47 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypertonia
Deep tandon reflexes: KJ-3+/3+, AJ 3+,3+

Meningeal signs: Absent

Oromotor Examination

Drooling: Yes
Chewing: Improper
Swallowing: Improper
Blowing: Improper
Sucking: Improper

Examination summary: Spasticity + (UL> LL), CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD, CP (? HIE sequelae)

Advice

Intervention plan: IDP (+PT) 3/week, PMT 1/15 days
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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