Demographic Details
- :
Shivansh Batham
- :
3 Year
- :
Male
- :
2023-02-20
- :
Joint
- :
9
- :
1
- :
2 months
- :
9669328851
- :
Doctor
- :
Parents
Presenting Concerns
- :
Delayed milestones
Interaction history:
Behavioral history:
Birth & Perinatal History:
Antenatal History
- :
No
- :
Natural
Natal and Postnatal History:
- :
Institutional
- :
NVD
- :
FT
- :
2.8 Kg
- :
Delayed cry
- :
Yes
- :
Yes
- :
22 days- HIE2
Past history:
:
Yes
:
Yes
:
5 mon- abnormal body movements after waking up from sleep, multiple episodes ?myoclonic jerks
:
Nil
:
Syp Valance 4ml BD, Syp Levera 1ml BD
Investigations done-
:
Not done
:
Not done
Family history:
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
-
:
Not achieved
-
:
Not achieved
Fine Motor
:
Not achieved
:
Not achieved
Language
Receptive:-
-
:
Not achieved
-
:
Not achieved
Expressive:-
:
Achieved
:
6 months
:
Not achieved
Expressive:-
:
Achieved
:
6 months
:
Not achieved
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Absent
Answering Questions:-
Social
Response to Name Call
Sitting tolerance- (in minutes)
ADL Skills (Age-appropriate)-
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
Type of Play : 1. Unoccupied
Academic History:
- :
No
Diet History:
- :
accepts food in liquid form
- :
No
- :
no
Sleep History
- :
10 hours ( 9pm to 7 am)
- :
Yes
- :
1-1.5 hours
Daily Screen Time
Examination
a. Vitals:
b. Anthropometry:
c. General Examination
:
Ab
:
Ab
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
- :
Wasting
- :
Hypertonia
- :
DTR- KJ- 4+/4+, AJ- 3+/3+
- :
Scissoring, foot developing equinovarus
Oromotor Examination
- :
Yes
- :
Improper
- :
Improper
:
NAD
:
NAD
:
NAD
Advice
- :
IDP (+ PT) 5/week + PMT 1/m
- :
Continue AEDs
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food