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Patient Details


Demographic Details Child's Name: Sangeeta Jatav Age: 4 Year Gender: Female DOB: 2022-02-04 Mother’s age (years): 20 years Mother’s occupation: Housewife Father’s age (years): 23 years Father’s occupation: Pvt job Type of family: Joint Number of family members: 15 Number of siblings: 1 Address: Ghas mandi Contact: 7970130188 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Poor understanding, Speech delay Duration of symptoms: Since birth Behavioral history: 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): Obstructed labor Gestational Age: FT Birth Weight: Not known NICU stay: Yes If yes- Duration & Indication: ? Delayed cry. On day 2 H/o top feeding f/b seizures, aspiration. Nicu stay- 8 days Past history: Hospitalization: No Seizures: Yes Others: Paroxysmal events (atonic seizures) f/b LOC lasting for 2-3 minutes started at 3 years age, last episode 5 months back Past/Current therapies: Nil Past/Current medications: On Syp valproate, cognizest since 3 months Investigations done- Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 7 mon Roll over: Achieved Age of attainment: 7 mon Sitting without support: Achieved Age of attainment: 12 mon Standing without support: Achieved Age of attainment: 17 mon Walking without support: Achieved Age of attainment: 18 mon Climbing upstairs: Achieved Age of attainment: 2.5 years Climbing downstairs: Achieved Age of attainment: 3 years 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: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 3 years Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 3 months Meaningful words: Achieved Age of attainment: Kinship words (4yrs) Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 3 months Meaningful words: Achieved Age of attainment: Kinship words (4yrs) Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Social smile: Achieved Age of attainment: 2 mon Stranger anxiety: Achieved Age of attainment: 7 mon Waving bye bye: Achieved Age of attainment: 3 yrs Asking for food and toilet: Not achieved Response to Name Call Sitting tolerance- (in minutes) For interaction: Less than one minute For tasks: 1 to 2 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Academic History: Is child enrolled in school: No Diet History: Food allergies: No Sleep History Total sleep duration (night): 7-8 hours Afternoon nap: Yes Sleep disturbances: Daily Screen Time Duration: <30 minutes Examination a. Vitals: b. Anthropometry: Weight: 12.3Kg Height: 93 cm Head circumference: 43 cm (Microcephaly) c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypertonia Deep tandon reflexes: DTR- KJ 3+/3+, AJ-2+/2+ Oromotor Examination Drooling: No Chewing: Improper Swallowing: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 1/week, PMT 1/mon General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Sangeeta Jatav
Age: 4 Year
Gender: Female
DOB: 2022-02-04
Mother’s age (years): 20 years
Mother’s occupation: Housewife
Father’s age (years): 23 years
Father’s occupation: Pvt job
Type of family: Joint
Number of family members: 15
Number of siblings: 1
Address: Ghas mandi
Contact: 7970130188
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Poor understanding, Speech delay
Duration of symptoms: Since birth

Behavioral history:

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): Obstructed labor
Gestational Age: FT
Birth Weight: Not known
NICU stay: Yes
If yes- Duration & Indication: ? Delayed cry. On day 2 H/o top feeding f/b seizures, aspiration. Nicu stay- 8 days

Past history:

Hospitalization: No Seizures: Yes Others: Paroxysmal events (atonic seizures) f/b LOC lasting for 2-3 minutes started at 3 years age, last episode 5 months back

Past/Current therapies: Nil Past/Current medications: On Syp valproate, cognizest since 3 months Investigations done-

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 7 mon
Roll over: Achieved

Age of attainment: 7 mon
Sitting without support: Achieved

Age of attainment: 12 mon
Standing without support: Achieved

Age of attainment: 17 mon
Walking without support: Achieved

Age of attainment: 18 mon
Climbing upstairs: Achieved

Age of attainment: 2.5 years
Climbing downstairs: Achieved

Age of attainment: 3 years

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: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 3 years

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 3 months

Meaningful words: Achieved

Age of attainment: Kinship words (4yrs)

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 3 months

Meaningful words: Achieved

Age of attainment: Kinship words (4yrs)

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 mon
Stranger anxiety: Achieved

Age of attainment: 7 mon
Waving bye bye: Achieved

Age of attainment: 3 yrs
Asking for food and toilet: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: Less than one minute
For tasks: 1 to 2 minutes

ADL Skills (Age-appropriate)-

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

Academic History:

Is child enrolled in school: No

Diet History:

Food allergies: No

Sleep History

Total sleep duration (night): 7-8 hours
Afternoon nap: Yes
Sleep disturbances:

Daily Screen Time

Duration: <30 minutes

Examination

a. Vitals:

b. Anthropometry:

Weight: 12.3Kg Height: 93 cm Head circumference: 43 cm (Microcephaly)

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypertonia
Deep tandon reflexes: DTR- KJ 3+/3+, AJ-2+/2+

Oromotor Examination

Drooling: No
Chewing: Improper
Swallowing: Improper

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

Advice

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

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