Create - Child Development Centre

Patient Details


Demographic Details Child's Name: Uzaif Khan Age: 6 years Gender: Male DOB: 2020-01-30 Mother’s age (years): 27 years Mother’s occupation: Homemaker Father’s age (years): 31 years Father’s occupation: Job Type of family: Joint Number of family members: 15 Number of siblings: 1 Details of siblings (Age and sex): 1- 3 year old female Address: Shivpuri Contact: 9131006431 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Hyperactivity, Delayed speech Interaction history: Eye contact: Fleeting Quality of Interaction: avoids Behavioral history: Repetitive behaviors (RRBs): Stymming, handfalpping Patterned behavior or activities: Hyperactivity Inattention Insisting on sameness Stubbornness Sensory Concerns: Tactile: Hypersensitive Birth & Perinatal History: Antenatal History Consanguinity: Yes If yes Degree: 3 Type of conception: Natural Others:: h/o 1 sibling death at 3 years age (due to CHD) Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 3.25 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current medications: Some medications going on. Not brought prescriptions. 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: 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: 10 months Walking without support: Achieved Age of attainment: 1 year 8 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: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: Pointing: Not achieved Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Drag for needs: Consistent Answering Questions:- Echolalia: Present Patterned speech: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 2.5 years Waving bye bye: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) For interaction: less than a minute For tasks: 1-2 minutes ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : 2. Isolated Outdoor play duration: Inconsistent Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: BP Convent school Grade: Nursery Hours spent in school: 5 hours Location: Shivpuri Diet History: Food allergies: No Sleep History Total sleep duration (night): 11 hours Afternoon nap: No Sleep disturbances: No Daily Screen Time Duration: < 2 hours Examination a. Vitals: b. Anthropometry: Weight: 17 kg Height: 114 cm Head circumference: 50 cm c. General Examination Neurocutaneous markers: Absent d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: Home based Program Investigations: DQ, ISAA, DSM5 ASD (Later) Follow up plan: F/u OPD every month General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Uzaif Khan
Age: 6 years
Gender: Male
DOB: 2020-01-30
Mother’s age (years): 27 years
Mother’s occupation: Homemaker
Father’s age (years): 31 years
Father’s occupation: Job
Type of family: Joint
Number of family members: 15
Number of siblings: 1
Details of siblings (Age and sex): 1- 3 year old female
Address: Shivpuri
Contact: 9131006431
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Hyperactivity, Delayed speech

Interaction history:

Eye contact: Fleeting
Quality of Interaction: avoids

Behavioral history:

Repetitive behaviors (RRBs): Stymming, handfalpping Patterned behavior or activities: Hyperactivity Inattention Insisting on sameness Stubbornness
Sensory Concerns:

Tactile: Hypersensitive

Birth & Perinatal History: Antenatal History

Consanguinity: Yes
If yes Degree: 3
Type of conception: Natural
Others:: h/o 1 sibling death at 3 years age (due to CHD)

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 3.25 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current medications: Some medications going on. Not brought prescriptions. 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: 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: 10 months
Walking without support: Achieved

Age of attainment: 1 year 8 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: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment:
Pointing: Not achieved
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Drag for needs: Consistent

Answering Questions:-

Echolalia: Present Patterned speech: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 2.5 years
Waving bye bye: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: less than a minute
For tasks: 1-2 minutes

ADL Skills (Age-appropriate)-

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

Type of Play : 2. Isolated Outdoor play duration: Inconsistent Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: BP Convent school
Grade: Nursery
Hours spent in school: 5 hours
Location: Shivpuri

Diet History:

Food allergies: No

Sleep History

Total sleep duration (night): 11 hours
Afternoon nap: No
Sleep disturbances: No

Daily Screen Time

Duration: < 2 hours

Examination

a. Vitals:

b. Anthropometry:

Weight: 17 kg Height: 114 cm Head circumference: 50 cm

c. General Examination

Neurocutaneous markers: Absent

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

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

Advice

Intervention plan: Home based Program
Investigations: DQ, ISAA, DSM5 ASD (Later)
Follow up plan: F/u OPD every month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

Setting Panel

Select Layout

Light Dark

Sidebar Color

Color Theme

Mini Sidebar

Sticky Header

Patient Details print

Select Layout

Sidebar Color

Color Theme

Patient Details