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Demographic Details Child's Name: Udbhav Pathak Age: 4 Year 4 Month 11 Days Gender: Male DOB: 2021-10-28 Mother’s age (years): 39 years Mother’s occupation: Homemaker Father’s age (years): 43 years Father’s occupation: Real estate Type of family: Joint Number of family members: 5 Number of siblings: 0 Contact: 8109739947 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay Duration of symptoms: Speech therapy 20 sessions attended Interaction history: Eye contact: Fleeting Behavioral history: Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Stubbornness Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: IVF Others:: Conceived after 8 years of message Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Gestational Age: Late PT Birth Weight: 2.4 Kg Cry at birth: Cried immediately after birth Resuscitation required: No 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: 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: 9 months Walking without support: Achieved Age of attainment: ``12 months Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Achieved Age of attainment: 9 months Pincer grasp: Achieved Age of attainment: 12 months Language Receptive:- Joint attention: Achieved Age of attainment: 7 months Pointing: Achieved Age of attainment: 24 months Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 13 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 13 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Drag for needs: Consistent Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: Waving bye bye: Achieved Age of attainment: 3 years Comes when called: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : Outdoor play duration: Irregular Academic History: Is child enrolled in school: Yes Name of School: ITM Global school Grade: Nursery Hours spent in school: 4 hours Location: Madhavnagar Diet History: Food preferences: Picky eater Food allergies: No Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 1 hour Daily Screen Time Duration: < 2 hours Examination a. Vitals: b. Anthropometry: Weight: 15 Kg Head circumference: 49 cm c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Deep tandon reflexes: Tone normal, DTR- Kj 3+/3+, AJ-2 +/2+ Oromotor Examination Chewing: Proper Swallowing: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: Parents counselled General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

Demographic Details

Child's Name: Udbhav Pathak
Age: 4 Year 4 Month 11 Days
Gender: Male
DOB: 2021-10-28
Mother’s age (years): 39 years
Mother’s occupation: Homemaker
Father’s age (years): 43 years
Father’s occupation: Real estate
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Contact: 8109739947
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay
Duration of symptoms: Speech therapy 20 sessions attended

Interaction history:

Eye contact: Fleeting

Behavioral history:

Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Stubbornness

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: IVF
Others:: Conceived after 8 years of message

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Gestational Age: Late PT
Birth Weight: 2.4 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
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: 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: 9 months
Walking without support: Achieved

Age of attainment: ``12 months

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp: Achieved

Age of attainment: 9 months

Pincer grasp: Achieved

Age of attainment: 12 months

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 7 months
Pointing: Achieved

Age of attainment: 24 months
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 13 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 13 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Drag for needs: Consistent

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment:
Waving bye bye: Achieved

Age of attainment: 3 years
Comes when called: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

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

Type of Play : Outdoor play duration: Irregular Academic History:

Is child enrolled in school: Yes
Name of School: ITM Global school
Grade: Nursery
Hours spent in school: 4 hours
Location: Madhavnagar

Diet History:

Food preferences: Picky eater
Food allergies: No

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1 hour

Daily Screen Time

Duration: < 2 hours

Examination

a. Vitals:

b. Anthropometry:

Weight: 15 Kg Head circumference: 49 cm

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Deep tandon reflexes: Tone normal, DTR- Kj 3+/3+, AJ-2 +/2+

Oromotor Examination

Chewing: Proper
Swallowing: Proper

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

Advice

Intervention plan: Parents counselled
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

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