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Demographic Details Child's Name: Gourav Tiwari Age: 3 Year 9 Month 4 Days Gender: Male DOB: 2022-06-17 Mother’s age (years): 24 years Mother’s occupation: Homemaker Father’s age (years): 28 years Father’s occupation: Advocate Type of family: Joint Number of family members: 8 Number of siblings: 0 Address: Chhatarpur Contact: 7024528951 Referred By: Doctor Informant: Dadi, chacha Interaction history: Eye contact: Suboptimal Interaction: Wants to play with children Behavioral history: Repetitive behaviors (RRBs): Hand flapping, clapping, looks from corner of eyes Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Emotional history: Irritability 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: NVD Gestational Age: FT Birth Weight: 1.6 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: NICU stay- 47 days, MV for 15 days. HIE 3 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: 12 months Roll over: Achieved Age of attainment: 14 months Sitting without support: Achieved Age of attainment: 14 months Standing without support: Achieved Age of attainment: 3 years Walking without support: Achieved Age of attainment: 4 years Running: Achieved Age of attainment: Climbing upstairs: Achieved Age of attainment: Climbing downstairs: Achieved Age of attainment: Fine Motor Bidextrous grasp: Achieved Age of attainment: 12 months Unidextrous grasp: Achieved Age of attainment: 12 months Pincer grasp: Not achieved Drinking from cup: Not achieved Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: Inconsistent Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 2 years Babbling: Achieved Age of attainment: 3 years Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 2 years Babbling: Achieved Age of attainment: 3 years Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Drag for needs: Emerging Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 24 months Stranger anxiety: Achieved Age of attainment: 24 months Waving bye bye: Not achieved Comes when called: Not achieved Response to Name Call Sitting tolerance- (in minutes) For interaction: Less than 1 minute For tasks: Less than 1 minute ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Details:: At home- goes to toilet himself, but doesnt indicate Type of Play : Outdoor play duration: >2 hours Academic History: Is child enrolled in school: No Diet History: Food allergies: No Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours Sleep disturbances: No Daily Screen Time Duration: < 2 hours Examination a. Vitals: b. Anthropometry: Weight: 12 Kg Height: 97 cm Head circumference: 49 cm c. General Examination Dysmorphology: Long facies, upper lip inverted V shaped, maxillary prominence Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Consciousness: Irritable Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Drooling: Yes Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD (HIE sequelae ?Genetic) Advice Intervention plan: Evaluations: DQ (DST, VSMS), Language and speech evaluation General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Gourav Tiwari
Age: 3 Year 9 Month 4 Days
Gender: Male
DOB: 2022-06-17
Mother’s age (years): 24 years
Mother’s occupation: Homemaker
Father’s age (years): 28 years
Father’s occupation: Advocate
Type of family: Joint
Number of family members: 8
Number of siblings: 0
Address: Chhatarpur
Contact: 7024528951
Referred By: Doctor
Informant: Dadi, chacha

Interaction history:

Eye contact: Suboptimal
Interaction: Wants to play with children

Behavioral history:

Repetitive behaviors (RRBs): Hand flapping, clapping, looks from corner of eyes Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Emotional history:
Irritability
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: NVD
Gestational Age: FT
Birth Weight: 1.6 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: NICU stay- 47 days, MV for 15 days. HIE 3

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: 12 months
Roll over: Achieved

Age of attainment: 14 months
Sitting without support: Achieved

Age of attainment: 14 months
Standing without support: Achieved

Age of attainment: 3 years
Walking without support: Achieved

Age of attainment: 4 years
Running: Achieved

Age of attainment:
Climbing upstairs: Achieved

Age of attainment:
Climbing downstairs: Achieved

Age of attainment:

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 12 months

Unidextrous grasp: Achieved

Age of attainment: 12 months

Pincer grasp: Not achieved

Drinking from cup: Not achieved

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: Inconsistent
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 2 years

Babbling: Achieved

Age of attainment: 3 years

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 2 years

Babbling: Achieved

Age of attainment: 3 years

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Emerging
Drag for needs: Emerging

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 24 months
Stranger anxiety: Achieved

Age of attainment: 24 months
Waving bye bye: Not achieved
Comes when called: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: Less than 1 minute
For tasks: Less than 1 minute

ADL Skills (Age-appropriate)-

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

Details:: At home- goes to toilet himself, but doesnt indicate

Type of Play : Outdoor play duration: >2 hours Academic History:

Is child enrolled in school: No

Diet History:

Food allergies: No

Sleep History

Total sleep duration (night): 9-10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours
Sleep disturbances: No

Daily Screen Time

Duration: < 2 hours

Examination

a. Vitals:

b. Anthropometry:

Weight: 12 Kg Height: 97 cm Head circumference: 49 cm

c. General Examination

Dysmorphology: Long facies, upper lip inverted V shaped, maxillary prominence Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Consciousness: Irritable

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Drooling: Yes
Chewing: Proper
Swallowing: Proper
Blowing: Improper
Sucking: Improper

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

Impression: GDD (HIE sequelae ?Genetic)

Advice

Intervention plan: Evaluations: DQ (DST, VSMS), Language and speech evaluation
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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