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Patient Details


Demographic Details Child's Name: Yuvraj Age: 1 Year 11 Month 26 Days Gender: Male DOB: 2024-02-12 Mother’s age (years): 23 Mother’s education: Post Graduate Mother’s occupation: jknjn Father’s age (years): jjnjknjnjnjk Father’s occupation: jknjknjk9090909 Type of family: Nuclear Number of family members: 909 Number of siblings: 9090 Details of siblings (Age and sex): 90 Address: 8 Contact: 8908 Informant: 908908908908 Presenting Concerns Chief concerns: 90890809809 Duration of symptoms: 908908908908908 Concerns noticed by school (if any): 90890808908 Strengths of child: 9089080809890 Interaction history: Interaction: 9089089890 Quality of Interaction: age-appropriate Behavioral history: Others Emotional History Details: nj Academic Concerns: Difficulty understanding word problems Sensory Concerns: Tactile: Hyposensitive Auditory: Hypersensitive Visual: Avoids visuals Proprioception: Seeks pressure Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: Yes If yes Degree: 1 High-risk factors in pregnancy: Chronic hypertension Eclampsia Hypothyroidism Others:: jdnfjn jksnfjsdnfjsdnf jksnf jksdnfjk sdfnjksd nkj Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Indication for LSCS (if applicable): jn Gestational Age: j Birth Weight: nj Cry at birth: Cried immediately after birth Resuscitation required: No Details of Resuscitation: njn If yes- Duration & Indication: jknjnjkn Past history: Others: jknjnjk Past/Current therapies: jnjnjk Past/Current medications: jnj Investigations done- Details: njknjknjk Details: njkjknjk Family history: Neuropsychiatric condition: No Details (If yes): jknjk Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 89d fjngjfngjfn Roll over: Achieved Age of attainment: jkn 888 Fine Motor Bidextrous grasp: Not achieved Language Expressive:- Cooing: Achieved Age of attainment: 90 hdbfhdbf hdfbdhbjh Expressive:- Cooing: Achieved Age of attainment: 90 hdbfhdbf hdfbdhbjh Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent Drag for needs: Absent Joint attention: Consistent Pointing: Inconsistent meaningful pointing Understanding gestures: Emerging Following commands (gesture + verbal): 3-step Answering Questions:- Able to answer questions: No What Echolalia: Present Patterned speech: Absent Social Social smile: Not achieved Response to Name Call Sitting tolerance- (in minutes) For interaction: fkjnjfnkj ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 3. Needs significant assistance Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 1. Unoccupied Outdoor play duration: jknjknjk Academic History: Is child enrolled in school: No Name of School: knjk Grade: njknjknjknjk Hours spent in school: jkn Location: njk Any change of school: No Repetition of grade: No Additional information: njk Diet History: Food preferences: njkn Junk food intake: jkn Calorie intake: jkn Protein intake: jkn Sleep History Total sleep duration (night): jkn Sleep disturbances: Daily Screen Time Duration: Type of screen: Mobile Examination a. Vitals: HR: jnnj RR: kjn Temperature: n BP: jkjn b. Anthropometry: Weight: jkn Height: kjnjk Head circumference: njkn BMI: jk c. General Examination Dysmorphology: nj Neurocutaneous markers: nkj Others: njk d. CNS: Higher Mental Functions Consciousness: nj Orientation: nj Memory: nj Repetition: jkn Naming: jk Voice: nj Judgement: nj Insight: nj Perception: j Sensory Examination Touch: n Pain: jn Temperature: jkn 2-point discrimination: jkn Stereognosis: jn Graphesthesia: jk Proprioception: njk Cranial Nerves (1–12) Olfactory nerve: njk Optic Nerve: nj cculomotor, Trochlear, Abducent: nj Trigeminal Nerve: knjk Facial Nerve: njk Vestibulocochlear Nerve: njnjk Glossopharyngeal Nerve: njk Vagus Nerve: njknjknjn Spinal Accessory: jknjknjknjn Hypoglossal Nerve: jknjknjknj Neuromuscular Concerns Bulk of muscles: fjgnj njksfgn fjkng jfkgn jfdk gnjdfkg ndfjn Tone: Hypertonia Power: djkknfjdks njksdfn sjnfs kjs Deep tandon reflexes: grfngfjn jdn jkgn jdn jkgndjk Gait issues: slfnsj njk Posture issues: jnjfndjfknsjkfnjsknjk Other: kjsfnjnfjnfjn Cerebellar examination: kjfnjksfjkfgfn kjfnjfkngkjs Meningeal signs: Absent If present details: sdkjfnjsdnfjsdnfsjnk Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Others: jsfnj jsn jksfn jksnf jksnjk CVS examination: sdjfnjsfnjsf ls jnsjk njng jsd ngdjknjk Respiratory System examination: skjfnjksf njksn jkn gjksgn jksng kjsn jksn Per abdomen examination: kfjsn kjfnsjk nj nskj njkgsng kjdng jk Impression: kjdngjkfd njkd njkd njk n jkndkj ndkj ndjk gnjkd ngjk Hopes from the consultation: kjdfng jkdn kjd nkjd nkjd nkjdf ngjkd ndkj ndjk Advice Intervention plan: skjfn sjk Investigations: kjn Medications: jkn Follow up plan: jknj

Demographic Details

Child's Name: Yuvraj
Age: 1 Year 11 Month 26 Days
Gender: Male
DOB: 2024-02-12
Mother’s age (years): 23
Mother’s education: Post Graduate
Mother’s occupation: jknjn
Father’s age (years): jjnjknjnjnjk
Father’s occupation: jknjknjk9090909
Type of family: Nuclear
Number of family members: 909
Number of siblings: 9090
Details of siblings (Age and sex): 90
Address: 8
Contact: 8908
Informant: 908908908908

Presenting Concerns

Chief concerns: 90890809809
Duration of symptoms: 908908908908908
Concerns noticed by school (if any): 90890808908

Strengths of child: 9089080809890

Interaction history:

Interaction: 9089089890
Quality of Interaction: age-appropriate

Behavioral history:

Others Emotional History Details: nj Academic Concerns:
Difficulty understanding word problems
Sensory Concerns:

Tactile: Hyposensitive
Auditory: Hypersensitive
Visual: Avoids visuals
Proprioception: Seeks pressure
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: Yes
If yes Degree: 1
High-risk factors in pregnancy:
1. Chronic hypertension
2. Eclampsia
3. Hypothyroidism
Others:: jdnfjn jksnfjsdnfjsdnf jksnf jksdnfjk sdfnjksd nkj

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Indication for LSCS (if applicable): jn
Gestational Age: j
Birth Weight: nj
Cry at birth: Cried immediately after birth
Resuscitation required: No
Details of Resuscitation: njn
If yes- Duration & Indication: jknjnjkn

Past history:

Others: jknjnjk

Past/Current therapies: jnjnjk Past/Current medications: jnj Investigations done-

Details: njknjknjk Details: njkjknjk

Family history:

Neuropsychiatric condition: No Details (If yes): jknjk

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 89d fjngjfngjfn
Roll over: Achieved

Age of attainment: jkn 888

Fine Motor

Bidextrous grasp: Not achieved

Language

Expressive:-

Cooing: Achieved

Age of attainment: 90 hdbfhdbf hdfbdhbjh

Expressive:-

Cooing: Achieved

Age of attainment: 90 hdbfhdbf hdfbdhbjh

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Inconsistent
Drag for needs: Absent
Joint attention: Consistent
Pointing: Inconsistent meaningful pointing
Understanding gestures: Emerging
Following commands (gesture + verbal): 3-step

Answering Questions:-

Able to answer questions: No What Echolalia: Present Patterned speech: Absent

Social

Social smile: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: fkjnjfnkj

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 3. Needs significant assistance
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Type of Play : 1. Unoccupied Outdoor play duration: jknjknjk Academic History:

Is child enrolled in school: No
Name of School: knjk
Grade: njknjknjknjk
Hours spent in school: jkn
Location: njk
Any change of school: No
Repetition of grade: No
Additional information: njk

Diet History:

Food preferences: njkn
Junk food intake: jkn
Calorie intake: jkn
Protein intake: jkn

Sleep History

Total sleep duration (night): jkn
Sleep disturbances:

Daily Screen Time

Duration:
Type of screen: Mobile

Examination

a. Vitals:

HR: jnnj RR: kjn Temperature: n BP: jkjn

b. Anthropometry:

Weight: jkn Height: kjnjk Head circumference: njkn BMI: jk

c. General Examination

Dysmorphology: nj Neurocutaneous markers: nkj Others: njk

d. CNS: Higher Mental Functions

Consciousness: nj
Orientation: nj
Memory: nj
Repetition: jkn
Naming: jk
Voice: nj
Judgement: nj
Insight: nj
Perception: j

Sensory Examination

Touch: n
Pain: jn
Temperature: jkn
2-point discrimination: jkn
Stereognosis: jn
Graphesthesia: jk
Proprioception: njk

Cranial Nerves (1–12)

Olfactory nerve: njk
Optic Nerve: nj
cculomotor, Trochlear, Abducent: nj
Trigeminal Nerve: knjk
Facial Nerve: njk
Vestibulocochlear Nerve: njnjk
Glossopharyngeal Nerve: njk
Vagus Nerve: njknjknjn
Spinal Accessory: jknjknjknjn
Hypoglossal Nerve: jknjknjknj

Neuromuscular Concerns

Bulk of muscles: fjgnj njksfgn fjkng jfkgn jfdk gnjdfkg ndfjn
Tone: Hypertonia
Power: djkknfjdks njksdfn sjnfs kjs
Deep tandon reflexes: grfngfjn jdn jkgn jdn jkgndjk
Gait issues: slfnsj njk
Posture issues: jnjfndjfknsjkfnjsknjk
Other: kjsfnjnfjnfjn

Cerebellar examination: kjfnjksfjkfgfn kjfnjfkngkjs
Meningeal signs: Absent

If present details: sdkjfnjsdnfjsdnfsjnk

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Proper
Others: jsfnj jsn jksfn jksnf jksnjk

CVS examination: sdjfnjsfnjsf ls jnsjk njng jsd ngdjknjk
Respiratory System examination: skjfnjksf njksn jkn gjksgn jksng kjsn jksn
Per abdomen examination: kfjsn kjfnsjk nj nskj njkgsng kjdng jk

Impression: kjdngjkfd njkd njkd njk n jkndkj ndkj ndjk gnjkd ngjk

Hopes from the consultation: kjdfng jkdn kjd nkjd nkjd nkjdf ngjkd ndkj ndjk
Advice

Intervention plan: skjfn sjk
Investigations: kjn
Medications: jkn
Follow up plan: jknj

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