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Patient Details


Demographic Details Child's Name: Amit jatab Age: 13 Year 6 Month 7 Days Gender: Male DOB: 2012-08-05 Mother’s age (years): 32 years Mother’s occupation: Homemaker Father’s age (years): 34 years Father’s occupation: Private job Type of family: Joint Number of siblings: 1 Details of siblings (Age and sex): 11 year old male Address: Bawripur Contact: 9372053449 Referred By: Doctor Informant: Grandfather, father Interaction history: Eye contact: Sustained Behavioral history: Stubbornness Aggression Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: 37 weeks Birth Weight: Not known Cry at birth: Delayed cry NICU stay: Yes If yes- Duration & Indication: 3 days Past history: Hospitalization: No Seizures: Yes Others: 1st episode- last year. 2nd episode- December 2026. GTCS lasting for 10-15 minutes, f/b LOC. Not preceded by feve.r Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 8 months Sitting without support: Achieved Age of attainment: 9 months Walking without support: Achieved Age of attainment: 24 months Running: Achieved Age of attainment: Climbing upstairs: Achieved Age of attainment: Climbing downstairs: Achieved Age of attainment: Hopping: Achieved Age of attainment: Fine Motor Bidextrous grasp: Achieved Age of attainment: 1 year Unidextrous grasp: Achieved Age of attainment: after 1 year Pincer grasp: Achieved Age of attainment: Delayed (Age not known) Scribbling: Achieved Age of attainment: Delayed (Age not known) Drinking from cup: Achieved Age of attainment: Delayed (Age not known) Buttoning / Unbuttoning: Not achieved Language Expressive:- Meaningful words: Achieved Age of attainment: 3 years 2 word Phrases: Achieved Age of attainment: Delayed (Age not known) Complete sentences: Achieved Age of attainment: Delayed (Age not known) Expressive:- Meaningful words: Achieved Age of attainment: 3 years 2 word Phrases: Achieved Age of attainment: Delayed (Age not known) Complete sentences: Achieved Age of attainment: Delayed (Age not known) Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- What Where Who Social Social smile: Achieved Age of attainment: Stranger anxiety: Achieved Age of attainment: Waving bye bye: Achieved Age of attainment: Comes when called: Achieved Age of attainment: Copying parents in tasks: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 3. Needs significant assistance Bathing: 3. Needs significant assistance Toilet training: 5. Independent Dressing: 3. Needs significant assistance Undressing: 3. Needs significant assistance Type of Play : 5. Associative Outdoor play duration: Plays marbles Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: shaskiya madhyamik vidyalaya Grade: 8 Hours spent in school: Irregulary goes to school for few hours Board: MP Location: Bawripur Diet History: Sleep History Total sleep duration (night): 10-11 hours Afternoon nap: No Sleep disturbances: No Daily Screen Time Duration: > 5 hours Type of screen: Mobile Examination a. Vitals: HR: 94/min RR: 24/min Temperature: afebrile b. Anthropometry: Weight: 28.9 kg Head circumference: 47.5 cm c. General Examination Dysmorphology: Microcephaly d. CNS: Higher Mental Functions Consciousness: Conscious Orientation: Oriented to place and person Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Fine Power: Tone normal Deep tandon reflexes: KJ- 3+/3+, AJ- 3+/3+ Cerebellar examination: Poor coordination, squint+ Oromotor Examination Drooling: Yes Chewing: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 2/ week Investigations: Pediatric surgeon reference, Ophthal reference, EEG General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Amit jatab
Age: 13 Year 6 Month 7 Days
Gender: Male
DOB: 2012-08-05
Mother’s age (years): 32 years
Mother’s occupation: Homemaker
Father’s age (years): 34 years
Father’s occupation: Private job
Type of family: Joint
Number of siblings: 1
Details of siblings (Age and sex): 11 year old male
Address: Bawripur
Contact: 9372053449
Referred By: Doctor
Informant: Grandfather, father

Interaction history:

Eye contact: Sustained

Behavioral history:

Stubbornness Aggression

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: 37 weeks
Birth Weight: Not known
Cry at birth: Delayed cry
NICU stay: Yes
If yes- Duration & Indication: 3 days

Past history:

Hospitalization: No Seizures: Yes Others: 1st episode- last year. 2nd episode- December 2026. GTCS lasting for 10-15 minutes, f/b LOC. Not preceded by feve.r

Past/Current therapies: Nil Past/Current medications: Nil Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 8 months
Sitting without support: Achieved

Age of attainment: 9 months
Walking without support: Achieved

Age of attainment: 24 months
Running: Achieved

Age of attainment:
Climbing upstairs: Achieved

Age of attainment:
Climbing downstairs: Achieved

Age of attainment:
Hopping: Achieved

Age of attainment:

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 1 year

Unidextrous grasp: Achieved

Age of attainment: after 1 year

Pincer grasp: Achieved

Age of attainment: Delayed (Age not known)

Scribbling: Achieved

Age of attainment: Delayed (Age not known)

Drinking from cup: Achieved

Age of attainment: Delayed (Age not known)

Buttoning / Unbuttoning: Not achieved

Language

Expressive:-

Meaningful words: Achieved

Age of attainment: 3 years

2 word Phrases: Achieved

Age of attainment: Delayed (Age not known)

Complete sentences: Achieved

Age of attainment: Delayed (Age not known)

Expressive:-

Meaningful words: Achieved

Age of attainment: 3 years

2 word Phrases: Achieved

Age of attainment: Delayed (Age not known)

Complete sentences: Achieved

Age of attainment: Delayed (Age not known)

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

What Where Who

Social

Social smile: Achieved

Age of attainment:
Stranger anxiety: Achieved

Age of attainment:
Waving bye bye: Achieved

Age of attainment:
Comes when called: Achieved

Age of attainment:
Copying parents in tasks: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 3. Needs significant assistance
Bathing: 3. Needs significant assistance
Toilet training: 5. Independent
Dressing: 3. Needs significant assistance
Undressing: 3. Needs significant assistance

Type of Play : 5. Associative Outdoor play duration: Plays marbles Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: shaskiya madhyamik vidyalaya
Grade: 8
Hours spent in school: Irregulary goes to school for few hours
Board: MP
Location: Bawripur

Diet History:

Sleep History

Total sleep duration (night): 10-11 hours
Afternoon nap: No
Sleep disturbances: No

Daily Screen Time

Duration: > 5 hours
Type of screen: Mobile

Examination

a. Vitals:

HR: 94/min RR: 24/min Temperature: afebrile

b. Anthropometry:

Weight: 28.9 kg Head circumference: 47.5 cm

c. General Examination

Dysmorphology: Microcephaly

d. CNS: Higher Mental Functions

Consciousness: Conscious
Orientation: Oriented to place and person

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Fine
Power: Tone normal
Deep tandon reflexes: KJ- 3+/3+, AJ- 3+/3+

Cerebellar examination: Poor coordination, squint+
Oromotor Examination

Drooling: Yes
Chewing: Proper

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

Advice

Intervention plan: IDP 2/ week
Investigations: Pediatric surgeon reference, Ophthal reference, EEG
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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