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Patient Details


Demographic Details Child's Name: Yash Age: 2 Year 8 Month 7 Days Gender: Male DOB: 2023-07-02 Mother’s age (years): 25 years Mother’s occupation: Homemaker Father’s age (years): 25 years Father’s occupation: Private job Type of family: Joint Number of family members: 5 Number of siblings: 0 Contact: 9165909023 Referred By: Doctor Presenting Concerns Chief concerns: Speech delay, Unable to walk Interaction history: Eye contact: Sustained Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: around 40wk Birth Weight: 2.25Kg Cry at birth: Delayed cry If yes- Duration & Indication: Admitted for refusal to feed, NNHB ( sbil- 19), On DSPT Past history: Hospitalization: Yes Seizures: No Others: 1st episode - at 2year age, tonic clonic seizure in Left UL LL, frothing, uprolling, during sleep, lasted for 15 minutes, admitted for 2 days Past/Current medications: Was discharged on some AED, given for 20 days then discontinued. 2nd episode 3rd march of similar semiology. 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: 9 months (Partial) Roll over: Achieved Age of attainment: 9 months Sitting without support: Achieved Age of attainment: 18 months Standing without support: Achieved Age of attainment: 24 months Walking without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 12 months Unidextrous grasp: Achieved Age of attainment: 14 months Pincer grasp: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 12 months Pointing: Achieved Age of attainment: 24 months Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 5 months Babbling: Achieved Age of attainment: 24 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 5 months Babbling: Achieved Age of attainment: 24 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 9months Waving bye bye: Achieved Age of attainment: 24 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 Type of Play : 3. Onlooker Academic History: Is child enrolled in school: No Diet History: Food allergies: No Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Sleep disturbances: No Daily Screen Time Duration: <30 minutes Type of screen: TV Examination a. Vitals: b. Anthropometry: Weight: 8.5 Kg Height: 80 cm Head circumference: 45 cm c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Bulk of muscles: Wasting Tone: Hypotonia Deep tandon reflexes: DTR- KH 2+/2+, AJ 1+/1+ Oromotor Examination Drooling: Yes Chewing: Proper Swallowing: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: fecolith+ Advice Intervention plan: IDP (+PT) 3/week + PMT 1/month Medications: Continue Syp Epilex (200mg/5ml) 2.5 ml BD. General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Yash
Age: 2 Year 8 Month 7 Days
Gender: Male
DOB: 2023-07-02
Mother’s age (years): 25 years
Mother’s occupation: Homemaker
Father’s age (years): 25 years
Father’s occupation: Private job
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Contact: 9165909023
Referred By: Doctor

Presenting Concerns

Chief concerns: Speech delay, Unable to walk

Interaction history:

Eye contact: Sustained

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: around 40wk
Birth Weight: 2.25Kg
Cry at birth: Delayed cry
If yes- Duration & Indication: Admitted for refusal to feed, NNHB ( sbil- 19), On DSPT

Past history:

Hospitalization: Yes Seizures: No Others: 1st episode - at 2year age, tonic clonic seizure in Left UL LL, frothing, uprolling, during sleep, lasted for 15 minutes, admitted for 2 days

Past/Current medications: Was discharged on some AED, given for 20 days then discontinued. 2nd episode 3rd march of similar semiology. 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: 9 months (Partial)
Roll over: Achieved

Age of attainment: 9 months
Sitting without support: Achieved

Age of attainment: 18 months
Standing without support: Achieved

Age of attainment: 24 months
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 12 months

Unidextrous grasp: Achieved

Age of attainment: 14 months

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 12 months
Pointing: Achieved

Age of attainment: 24 months
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 5 months

Babbling: Achieved

Age of attainment: 24 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 5 months

Babbling: Achieved

Age of attainment: 24 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 9months
Waving bye bye: Achieved

Age of attainment: 24 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

Type of Play : 3. Onlooker Academic History:

Is child enrolled in school: No

Diet History:

Food allergies: No

Sleep History

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

Daily Screen Time

Duration: <30 minutes
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 8.5 Kg Height: 80 cm Head circumference: 45 cm

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Bulk of muscles: Wasting
Tone: Hypotonia
Deep tandon reflexes: DTR- KH 2+/2+, AJ 1+/1+

Oromotor Examination

Drooling: Yes
Chewing: Proper
Swallowing: Improper

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

Advice

Intervention plan: IDP (+PT) 3/week + PMT 1/month
Medications: Continue Syp Epilex (200mg/5ml) 2.5 ml BD.
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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