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Demographic Details Child's Name: Vedika Kushwaha Age: 1 Year 9 Month 9 Days Gender: Female DOB: 2024-05-08 Mother’s age (years): 23 years Mother’s occupation: Homemaker Father’s age (years): 26 years Father’s occupation: Teacher Type of family: Joint Number of family members: 4 Number of siblings: 0 Address: Kolaras, Shivpuri Contact: 7974731722 Referred By: Doctor Presenting Concerns Chief concerns: Delayed milestones Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Maternal age at conception (years):: 21 Type of conception: Natural High-risk factors in pregnancy: Oligohydramnios Natal and Postnatal History: Place of Birth: Home Mode of Delivery: LSCS Indication for LSCS (if applicable): Oligohydramnios Gestational Age: 8 months (?34 wk) Birth Weight: 2.31 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: SNCU stay for 12 days. H/o neonatal seizures. Gardenal was given for 4 months Past history: Hospitalization: Yes Seizures: Yes Others: H/o seizures (GTCS) till 4 months age. Past/Current medications: On osteon, Calcium, Tab rivotril (0.25mg) 1/4th tab OD, Syp Golderon Investigations done- Hearing assessment: Not done Vision assessment: Done Details: Fundus- Normal Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Not achieved Fine Motor Bidextrous grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 4 month Stranger anxiety: Not achieved Waving bye bye: Not achieved Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Academic History: Diet History: Food preferences: Giving- Dalia, Khichdi. milk (500ml), banana Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Sleep disturbances: Yes Daily Screen Time Duration: <30 minutes Type of screen: TV Examination a. Vitals: b. Anthropometry: Weight: 5.9 Kg Height: 66 cm Head circumference: 38 cm c. General Examination Dysmorphology: Microcephaly, Plagiocephaly Neurocutaneous markers: Ab Others: Skin lesions (Scabies) d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Bulk of muscles: WAsting Tone: Hypertonia Power: Scissoring, decorticate posturing Deep tandon reflexes: DTR- KJ 3+/3+, AJ+/3+ Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper CVS examination: NAD Respiratory System examination: B/l Conducted sounds Per abdomen examination: soft, BS+ Advice Intervention plan: IDP (+PT) 2/week+ PMT 1/15 days Medications: Tab Pacitane (2mg) 1/4th tab OD, Rest same General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Vedika Kushwaha
Age: 1 Year 9 Month 9 Days
Gender: Female
DOB: 2024-05-08
Mother’s age (years): 23 years
Mother’s occupation: Homemaker
Father’s age (years): 26 years
Father’s occupation: Teacher
Type of family: Joint
Number of family members: 4
Number of siblings: 0
Address: Kolaras, Shivpuri
Contact: 7974731722
Referred By: Doctor

Presenting Concerns

Chief concerns: Delayed milestones

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Maternal age at conception (years):: 21
Type of conception: Natural
High-risk factors in pregnancy:
1. Oligohydramnios

Natal and Postnatal History:

Place of Birth: Home
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Oligohydramnios
Gestational Age: 8 months (?34 wk)
Birth Weight: 2.31 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: SNCU stay for 12 days. H/o neonatal seizures. Gardenal was given for 4 months

Past history:

Hospitalization: Yes Seizures: Yes Others: H/o seizures (GTCS) till 4 months age.

Past/Current medications: On osteon, Calcium, Tab rivotril (0.25mg) 1/4th tab OD, Syp Golderon Investigations done-

Hearing assessment: Not done Vision assessment: Done Details: Fundus- Normal

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 4 month
Stranger anxiety: Not achieved
Waving bye bye: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Academic History:

Diet History:

Food preferences: Giving- Dalia, Khichdi. milk (500ml), banana

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Sleep disturbances: Yes

Daily Screen Time

Duration: <30 minutes
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 5.9 Kg Height: 66 cm Head circumference: 38 cm

c. General Examination

Dysmorphology: Microcephaly, Plagiocephaly Neurocutaneous markers: Ab Others: Skin lesions (Scabies)

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Bulk of muscles: WAsting
Tone: Hypertonia
Power: Scissoring, decorticate posturing
Deep tandon reflexes: DTR- KJ 3+/3+, AJ+/3+

Oromotor Examination

Drooling: Yes
Chewing: Improper
Swallowing: Improper

CVS examination: NAD
Respiratory System examination: B/l Conducted sounds
Per abdomen examination: soft, BS+

Advice

Intervention plan: IDP (+PT) 2/week+ PMT 1/15 days
Medications: Tab Pacitane (2mg) 1/4th tab OD, Rest same
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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