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Patient Details


Demographic Details Child's Name: Shivam Mittal Age: 8 Month 6 Days Gender: Male DOB: 2025-06-13 Mother’s age (years): 23 years Mother’s occupation: Homemaker Father’s age (years): 29 years Type of family: Joint Number of family members: 5 Number of siblings: 0 Contact: 7828262942 Referred By: Doctor Presenting Concerns Chief concerns: Delayed milestones Interaction history: Eye contact: Poor Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Gestational Age: FT Birth Weight: 2.6 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: H/o neonatal seizure. MAS Past history: Hospitalization: No Seizures: Yes Others: No episodes after NICU stay Investigations done- Hearing assessment: Done Details: BERA- Right ear- moderate hearing loss, Left ear- moderately severe hearing loss Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Not achieved Fine Motor Bidextrous grasp: Not achieved Language Receptive:- Joint attention: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 months Expressive:- Cooing: Achieved Age of attainment: 3 months Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Social smile: Achieved Age of attainment: 5 months 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: On milk and Cerelac. Frequent regurgitations Sleep History Total sleep duration (night): As per age Daily Screen Time Duration: <30 minutes Examination a. Vitals: b. Anthropometry: Weight: 7 Kg Height: 64 cm Head circumference: 41 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypertonia Deep tandon reflexes: DTR- KJ 3+/3+, AJ- 2+/2+, Plantar- extensor/extensor If present details: Spasticity+, Scissoring, On pull to sit- not sitting, stands directly. Af- admitting 1 fingertip Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP (+PT) 6/week Investigations: Thyroid profile, ABBR General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Shivam Mittal
Age: 8 Month 6 Days
Gender: Male
DOB: 2025-06-13
Mother’s age (years): 23 years
Mother’s occupation: Homemaker
Father’s age (years): 29 years
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Contact: 7828262942
Referred By: Doctor

Presenting Concerns

Chief concerns: Delayed milestones

Interaction history:

Eye contact: Poor

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Gestational Age: FT
Birth Weight: 2.6 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: H/o neonatal seizure. MAS

Past history:

Hospitalization: No Seizures: Yes Others: No episodes after NICU stay

Investigations done-

Hearing assessment: Done Details: BERA- Right ear- moderate hearing loss, Left ear- moderately severe hearing loss Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 5 months

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: On milk and Cerelac. Frequent regurgitations

Sleep History

Total sleep duration (night): As per age

Daily Screen Time

Duration: <30 minutes

Examination

a. Vitals:

b. Anthropometry:

Weight: 7 Kg Height: 64 cm Head circumference: 41 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypertonia
Deep tandon reflexes: DTR- KJ 3+/3+, AJ- 2+/2+, Plantar- extensor/extensor

If present details: Spasticity+, Scissoring, On pull to sit- not sitting, stands directly. Af- admitting 1 fingertip

Oromotor Examination

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

Advice

Intervention plan: IDP (+PT) 6/week
Investigations: Thyroid profile, ABBR
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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