Demographic Details
- :
Shivansh Sharma
- :
2 Year 3 Month 2 Days
- :
Male
- :
2023-12-09
- :
32 years
- :
Housewife
- :
31 years
- :
Private job
- :
Nuclear
- :
5
- :
2
- :
1- 10year old female, 2- 7year old female
- :
DD Nagar
- :
8770229171
- :
Doctor
- :
Parents
Presenting Concerns
- :
Delayed milestones
Behavioral history:
Birth & Perinatal History:
Antenatal History
- :
No
- :
Natural
Natal and Postnatal History:
- :
Institutional
- :
NVD
- :
? 34 weeks- 36 weeks
- :
1.7 Kg
- :
Cried after stimulation
- :
No
- :
No
Past history:
:
No
:
No
Investigations done-
:
Not done
:
Not done
Family history:
:
No
Developmental History:
Gross Motor
Fine Motor
:
Achieved
:
18 months
:
Achieved
:
20 months
:
Achieved
:
20 months
Language
Receptive:-
-
:
Achieved
:
16 months
-
:
Achieved
:
18 months
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Not achieved
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Not achieved
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Absent
Answering Questions:-
Social
-
:
Achieved
:
3 months
-
:
Achieved
:
9 months
-
:
Achieved
:
18 months
-
:
Achieved
:
-
:
Not achieved
Response to Name Call
Sitting tolerance- (in minutes)
ADL Skills (Age-appropriate)-
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
Academic History:
- :
No
Diet History:
- :
Mixed diet
Sleep History
- :
6 hours
- :
Yes
- :
1.5 hours
-
:
Daily Screen Time
Examination
a. Vitals:
b. Anthropometry:
:
9 Kg
:
85 cm
:
49 cm
c. General Examination
:
Ab
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
- :
Proper
- :
Proper
:
NAD
:
NAD
:
NAD
Advice
- :
Stop bottlefeeding. (IDP +PT) 1/week + PMT 1/month
- :
Evaluation- Neuromotor assessment 1
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food