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Patient Details


Demographic Details Child's Name: Rashi Pal Age: 7 Year 8 Month 28 Days Gender: Female DOB: 2018-05-19 Mother’s age (years): 23 Mother’s occupation: Homemaker Father’s age (years): 24 Father’s occupation: Works in Nagpur Type of family: Joint Number of siblings: 2 Details of siblings (Age and sex): 1- 5 year old female, 2- 2 year old male Address: Lalitpur Contact: 9076966705 Referred By: Doctor Informant: Grandparents Presenting Concerns Chief concerns: Poor understanding, speech delay Interaction history: Eye contact: Fleeting Behavioral history: Mouthing of objects Birth & Perinatal History: Antenatal History Consanguinity: No Maternal age at conception (years):: 16 Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: Not known Cry at birth: Cried immediately after birth NICU stay: No If yes- Duration & Indication: Delivered at the gate of labor room, H/o fall at the time of delivery. Past history: Hospitalization: No Others: 1st episode of abnormal body movements at 2 years age in all 4 limbs lasting for 1-2 minutes, f/b LOC for 1-2 minutes. Multiple episodes since then. Always withdrawal seizures. Last episode of similar semiology 4 days back. On antiepileptics Investigations done- Hearing assessment: Done Details: Reports not there Vision assessment: Done Details: Reports not there Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 months Sitting without support: Achieved Age of attainment: 1 year age Walking without support: Achieved Age of attainment: 2 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: 1 year Buttoning / Unbuttoning: Not achieved Language Expressive:- Cooing: Achieved Age of attainment: 2 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 2 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Not achieved Stranger anxiety: Not achieved Waving bye bye: Not achieved Comes when called: Not achieved Response to Name Call Sitting tolerance- (in 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: Yes Type of school: Regular Name of School: Junior high school Grade: 1 Hours spent in school: 30 minutes to 1 hour Location: Gadiyana, Lalitpur Additional information: Doesnt sit in school. Caregivers accompany child in class Diet History: Food preferences: Picky eating Junk food intake: Daily Sleep History Total sleep duration (night): 10-11 hours , improper sleeping and waking time Afternoon nap: Yes Sleep disturbances: Yes Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 18 Kg Head circumference: 46 cm c. General Examination d. CNS: Higher Mental Functions Consciousness: Awake Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Power: Tone- normal Deep tandon reflexes: DTR- KJ 3+/3+, AJ- 2+/2+ Oromotor Examination Drooling: Yes Chewing: Proper Swallowing: Proper CVS examination: NAD Respiratory System examination: NAd Per abdomen examination: NAD Impression: Intellectual Disability. Epilepsy. Advice Intervention plan: Parents counselled. Investigations: IQ testing, Language and speech evaluation. Medications: Continue antiepileptics . General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Rashi Pal
Age: 7 Year 8 Month 28 Days
Gender: Female
DOB: 2018-05-19
Mother’s age (years): 23
Mother’s occupation: Homemaker
Father’s age (years): 24
Father’s occupation: Works in Nagpur
Type of family: Joint
Number of siblings: 2
Details of siblings (Age and sex): 1- 5 year old female, 2- 2 year old male
Address: Lalitpur
Contact: 9076966705
Referred By: Doctor
Informant: Grandparents

Presenting Concerns

Chief concerns: Poor understanding, speech delay

Interaction history:

Eye contact: Fleeting

Behavioral history:

Mouthing of objects

Birth & Perinatal History: Antenatal History

Consanguinity: No
Maternal age at conception (years):: 16
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: Not known
Cry at birth: Cried immediately after birth
NICU stay: No
If yes- Duration & Indication: Delivered at the gate of labor room, H/o fall at the time of delivery.

Past history:

Hospitalization: No Others: 1st episode of abnormal body movements at 2 years age in all 4 limbs lasting for 1-2 minutes, f/b LOC for 1-2 minutes. Multiple episodes since then. Always withdrawal seizures. Last episode of similar semiology 4 days back. On antiepileptics

Investigations done-

Hearing assessment: Done Details: Reports not there Vision assessment: Done Details: Reports not there

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 months
Sitting without support: Achieved

Age of attainment: 1 year age
Walking without support: Achieved

Age of attainment: 2 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: 1 year

Buttoning / Unbuttoning: Not achieved

Language

Expressive:-

Cooing: Achieved

Age of attainment: 2 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 2 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Not achieved
Stranger anxiety: Not achieved
Waving bye bye: Not achieved
Comes when called: Not achieved

Response to Name Call

Sitting tolerance- (in 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: Yes
Type of school: Regular
Name of School: Junior high school
Grade: 1
Hours spent in school: 30 minutes to 1 hour
Location: Gadiyana, Lalitpur
Additional information: Doesnt sit in school. Caregivers accompany child in class

Diet History:

Food preferences: Picky eating
Junk food intake: Daily

Sleep History

Total sleep duration (night): 10-11 hours , improper sleeping and waking time
Afternoon nap: Yes
Sleep disturbances: Yes

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 18 Kg Head circumference: 46 cm

c. General Examination

d. CNS: Higher Mental Functions

Consciousness: Awake

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

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

Oromotor Examination

Drooling: Yes
Chewing: Proper
Swallowing: Proper

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

Impression: Intellectual Disability. Epilepsy.

Advice

Intervention plan: Parents counselled.
Investigations: IQ testing, Language and speech evaluation.
Medications: Continue antiepileptics .
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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