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Patient Details


Demographic Details Child's Name: Yuvaan Patel Age: 2 Year 3 Month 15 Days Gender: Male DOB: 2023-11-23 Mother’s age (years): 26 years Mother’s occupation: Homemaker Father’s age (years): 26 years Father’s occupation: Job Type of family: Nuclear Number of family members: 5 Number of siblings: 0 Address: Kampoo Contact: 7000835883 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay, poor eye contact Duration of symptoms: Noted since 22 months age Interaction history: Eye contact: Poor Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Hand flapping, spinning, jumping Patterned behavior or activities: Hyperactivity Inattention Impulsivity Defiance Object obsession Temper tantrums Stubbornness Sensory Concerns: Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Generalised swelling Gestational Age: FT Birth Weight: 3.7 Kg Cry at birth: Cried immediately after birth NICU stay: No Past history: Hospitalization: No Seizures: No 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: 4 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: 9 months Walking without support: Achieved Age of attainment: 10 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 Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 8 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 8 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Drag for needs: Emerging Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 7 months Waving bye bye: Not achieved Response to Name Call Details: 1/10 Sitting tolerance- (in minutes) For interaction: Less than a minute For tasks: Less than a minute ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Parents understand by cues about toilet needs Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food allergies: No Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 2-2.5 hours Daily Screen Time Duration: < 1 hour Examination a. Vitals: b. Anthropometry: c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Other: Sits in W position Oromotor Examination Chewing: Proper Swallowing: Proper Blowing: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: Stop bottlefeeding. IDP 2/week +PMT 1/week General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Yuvaan Patel
Age: 2 Year 3 Month 15 Days
Gender: Male
DOB: 2023-11-23
Mother’s age (years): 26 years
Mother’s occupation: Homemaker
Father’s age (years): 26 years
Father’s occupation: Job
Type of family: Nuclear
Number of family members: 5
Number of siblings: 0
Address: Kampoo
Contact: 7000835883
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay, poor eye contact
Duration of symptoms: Noted since 22 months age

Interaction history:

Eye contact: Poor
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Hand flapping, spinning, jumping Patterned behavior or activities: Hyperactivity Inattention Impulsivity Defiance Object obsession Temper tantrums Stubbornness
Sensory Concerns:

Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Generalised swelling
Gestational Age: FT
Birth Weight: 3.7 Kg
Cry at birth: Cried immediately after birth
NICU stay: No

Past history:

Hospitalization: No Seizures: No

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: 4 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: 9 months
Walking without support: Achieved

Age of attainment: 10 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

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 8 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 8 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Drag for needs: Emerging

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 7 months
Waving bye bye: Not achieved

Response to Name Call

Details: 1/10

Sitting tolerance- (in minutes)

For interaction: Less than a minute
For tasks: Less than a minute

ADL Skills (Age-appropriate)-

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

Details:: Parents understand by cues about toilet needs

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food allergies: No

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-2.5 hours

Daily Screen Time

Duration: < 1 hour

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Other: Sits in W position

Oromotor Examination

Chewing: Proper
Swallowing: Proper
Blowing: Proper

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

Advice

Intervention plan: Stop bottlefeeding. IDP 2/week +PMT 1/week
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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