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Patient Details


Demographic Details Child's Name: kartik Age: 2 Year 3 Month 13 Days Gender: Male DOB: 2023-12-01 Mother’s age (years): 33 years Mother’s occupation: Homemaker Father’s age (years): 36 years Father’s occupation: Air force (Udhampur) Type of family: Joint Number of siblings: 2 Details of siblings (Age and sex): Twins - 7 year (male,female) Address: Tansen nagar Contact: 7987004412 Referred By: Doctor Informant: 10 Interaction history: Eye contact: Poor Quality of Interaction: limited Behavioral history: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Mouthing of objects Sensory Concerns: Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Hypothyroidism Others:: Thyroid screening at birth- normal Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Gestational Age: 38 wk Birth Weight: 2.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: No Past/Current medications: No Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Walking without support: Achieved Age of attainment: 12 months Fine Motor 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: 4 months Babbling: Achieved Age of attainment: 7 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 7 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 6 months Stranger anxiety: Achieved Age of attainment: 7 months Waving bye bye: Not achieved Asking for food and toilet: Not achieved Response to Name Call Details: 1/10 Sitting tolerance- (in minutes) For interaction: less than a minute For tasks: Less than minute Details:: Can sit if one is speaking rhymes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 2. Isolated Academic History: Is child enrolled in school: No 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- 3 hours Daily Screen Time Duration: > 5 hours Examination a. Vitals: b. Anthropometry: Weight: 11.4 Height: 90 cm Head circumference: 48 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: 1 cafe au lait macule over back 2.5*2 cm d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Chewing: Improper Swallowing: Improper Blowing: Improper Impression: M chat R score- 15 (High risk) Advice Intervention plan: IDP 2 week +PMT 1/week General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: kartik
Age: 2 Year 3 Month 13 Days
Gender: Male
DOB: 2023-12-01
Mother’s age (years): 33 years
Mother’s occupation: Homemaker
Father’s age (years): 36 years
Father’s occupation: Air force (Udhampur)
Type of family: Joint
Number of siblings: 2
Details of siblings (Age and sex): Twins - 7 year (male,female)
Address: Tansen nagar
Contact: 7987004412
Referred By: Doctor
Informant: 10

Interaction history:

Eye contact: Poor
Quality of Interaction: limited

Behavioral history:

Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Mouthing of objects
Sensory Concerns:

Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Hypothyroidism
Others:: Thyroid screening at birth- normal

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Gestational Age: 38 wk
Birth Weight: 2.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: No Past/Current medications: No Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Walking without support: Achieved

Age of attainment: 12 months

Fine Motor

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: 4 months

Babbling: Achieved

Age of attainment: 7 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 7 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 6 months
Stranger anxiety: Achieved

Age of attainment: 7 months
Waving bye bye: Not achieved
Asking for food and toilet: Not achieved

Response to Name Call

Details: 1/10

Sitting tolerance- (in minutes)

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

Details:: Can sit if one is speaking rhymes

ADL Skills (Age-appropriate)-

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

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

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- 3 hours

Daily Screen Time

Duration: > 5 hours

Examination

a. Vitals:

b. Anthropometry:

Weight: 11.4 Height: 90 cm Head circumference: 48 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: 1 cafe au lait macule over back 2.5*2 cm

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Chewing: Improper
Swallowing: Improper
Blowing: Improper

Impression: M chat R score- 15 (High risk)

Advice

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

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