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Patient Details


Demographic Details Child's Name: Arnav Shrivastab Age: 7 Year 5 Month 7 Days Gender: Male DOB: 2018-09-02 Mother’s age (years): 39 Mother’s education: 12th Mother’s occupation: Homemaker Father’s age (years): 44 Father’s education: Graduate Father’s occupation: Private job Type of family: Nuclear Number of family members: 3 Number of siblings: 0 Address: Sirol Road Contact: 8878326105 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Poor understanding Duration of symptoms: Realized speech delay when child was 2.5 years old. Consulted multiple doctors. Intervention going on Roshani since 2 years Interaction history: Eye contact: Poor Interaction: Interaction is better with known people Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Chewing clothes Patterned behavior or activities: Blowing Hyperactivity Aggression Mouthing of objects Sensory Concerns: Auditory: Hypersensitive Birth & Perinatal History: Antenatal History Consanguinity: No Maternal age at conception (years):: 33 Type of conception: Natural Others:: H/o 1 spontaneous abortion Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Malpresentation Gestational Age: 37 week Birth Weight: 2.25 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: Intervention going on Roshani since 2 years (2 hours for 3 days, 1 hour for 1 day) Investigations done- Hearing assessment: Done Vision assessment: Not done Family history: Others: H/o CHD in previous sibling. Certified during surgery at 2.5 years age. Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 months Roll over: Achieved Age of attainment: 5 mon Sitting without support: Achieved Age of attainment: 6 mon Standing without support: Achieved Age of attainment: 10 mon Walking without support: Achieved Age of attainment: 12 mo Running: Achieved Age of attainment: 16 mon Climbing upstairs: Achieved Age of attainment: Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Achieved Age of attainment: 6 mo Pincer grasp: Not achieved Drinking from cup: Achieved Age of attainment: Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 2 years Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 2 years Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Drag for needs: Inconsistent Answering Questions:- Social Social smile: Achieved Age of attainment: Stranger anxiety: Not achieved Waving bye bye: Not achieved Response to Name Call Details: Comes when called 3-4 times Sitting tolerance- (in minutes) For interaction: Doesnt sit even for 1-2 minutes For tasks: Sits for 1-2 minutes ADL Skills (Age-appropriate)- Eating: 3. Needs significant assistance Bathing: 1. Dependent Toilet training: 2. Started attempting Dressing: 1. Dependent Undressing: 2. Started attempting Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Junk food intake: Infrequent- Bicuits and mixture Sleep History Total sleep duration (night): 8 hours Afternoon nap: No Sleep disturbances: Daily Screen Time Duration: <30 minutes Type of screen: TV Examination a. Vitals: b. Anthropometry: Weight: 24 Kg Height: 123 cm Head circumference: 49 cm c. General Examination Dysmorphology: Depressed nasal bridge, predominantly open mouth Neurocutaneous markers: 1 cafe au lait over left anterior side of chest 21.5 cm, 1 nevus over left arm 52.5 cm d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Deep tandon reflexes: KJ- 3+/3+, AJ- 2+/2+ Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 2/week +PMT 1/week Medications: Continue L thyroxine as advised by pediatrician and endocrinologist. General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

Demographic Details

Child's Name: Arnav Shrivastab
Age: 7 Year 5 Month 7 Days
Gender: Male
DOB: 2018-09-02
Mother’s age (years): 39
Mother’s education: 12th
Mother’s occupation: Homemaker
Father’s age (years): 44
Father’s education: Graduate
Father’s occupation: Private job
Type of family: Nuclear
Number of family members: 3
Number of siblings: 0
Address: Sirol Road
Contact: 8878326105
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Poor understanding
Duration of symptoms: Realized speech delay when child was 2.5 years old. Consulted multiple doctors. Intervention going on Roshani since 2 years

Interaction history:

Eye contact: Poor
Interaction: Interaction is better with known people
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Chewing clothes Patterned behavior or activities: Blowing Hyperactivity Aggression Mouthing of objects
Sensory Concerns:

Auditory: Hypersensitive

Birth & Perinatal History: Antenatal History

Consanguinity: No
Maternal age at conception (years):: 33
Type of conception: Natural
Others:: H/o 1 spontaneous abortion

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Malpresentation
Gestational Age: 37 week
Birth Weight: 2.25 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Intervention going on Roshani since 2 years (2 hours for 3 days, 1 hour for 1 day) Investigations done-

Hearing assessment: Done Vision assessment: Not done

Family history:

Others: H/o CHD in previous sibling. Certified during surgery at 2.5 years age.

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 months
Roll over: Achieved

Age of attainment: 5 mon
Sitting without support: Achieved

Age of attainment: 6 mon
Standing without support: Achieved

Age of attainment: 10 mon
Walking without support: Achieved

Age of attainment: 12 mo
Running: Achieved

Age of attainment: 16 mon
Climbing upstairs: Achieved

Age of attainment:

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp: Achieved

Age of attainment: 6 mo

Pincer grasp: Not achieved

Drinking from cup: Achieved

Age of attainment:

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 2 years

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 2 years

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Drag for needs: Inconsistent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment:
Stranger anxiety: Not achieved
Waving bye bye: Not achieved

Response to Name Call

Details: Comes when called 3-4 times

Sitting tolerance- (in minutes)

For interaction: Doesnt sit even for 1-2 minutes
For tasks: Sits for 1-2 minutes

ADL Skills (Age-appropriate)-

Eating: 3. Needs significant assistance
Bathing: 1. Dependent
Toilet training: 2. Started attempting
Dressing: 1. Dependent
Undressing: 2. Started attempting

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Junk food intake: Infrequent- Bicuits and mixture

Sleep History

Total sleep duration (night): 8 hours
Afternoon nap: No
Sleep disturbances:

Daily Screen Time

Duration: <30 minutes
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 24 Kg Height: 123 cm Head circumference: 49 cm

c. General Examination

Dysmorphology: Depressed nasal bridge, predominantly open mouth Neurocutaneous markers: 1 cafe au lait over left anterior side of chest 2*1.5 cm, 1 nevus over left arm 5*2.5 cm

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

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

Oromotor Examination

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

Advice

Intervention plan: IDP 2/week +PMT 1/week
Medications: Continue L thyroxine as advised by pediatrician and endocrinologist.
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

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