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Patient Details


Demographic Details Child's Name: Sarthak Lodhi Age: 4 Year 8 Month 17 Days Gender: Male DOB: 2021-06-29 Mother’s age (years): 35 years Mother’s occupation: Homemaker Father’s age (years): 34 years Father’s occupation: Farmer Type of family: Nuclear Number of family members: 5 Number of siblings: 3 Details of siblings (Age and sex): 1- 16yr, 2- 14 yr, 3-12 yr (females) Address: Gadhaipura Contact: 8357981567 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay, doesnt follow command Duration of symptoms: Realized around 3 years that child has speech delay Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Looking from lateral side of eye Inattention Stubbornness Aggression Sensory Concerns: Tactile: Hyposensitive Auditory: Hypersensitive Details:: Tactile seeking Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Hypothyroidism Others:: 1 spontaneous abortion at 10 weeks. Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 3.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Investigations done- Hearing assessment: Done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 months Roll over: Achieved Age of attainment: 8 months Sitting without support: Achieved Age of attainment: 8 months Standing without support: Achieved Age of attainment: 12 months Walking without support: Achieved Age of attainment: 14 months Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Achieved Age of attainment: 6 months Pincer grasp: Achieved Age of attainment: 12 months Scribbling: Achieved Age of attainment: 3 years Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 18 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 18 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Not achieved Waving bye bye: Not achieved Asking for food and toilet: Not achieved Response to Name Call Details: 2/10 Sitting tolerance- (in minutes) For interaction: Less than a minute For tasks: Sitting tolerance more for tasks ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 2. Started attempting Details:: Doesnt sit for haircut Type of Play : 2. Isolated Outdoor play duration: Nil Academic History: Is child enrolled in school: No Diet History: Food preferences: vegetarian diet Food allergies: No Junk food intake: 3-4 times/week Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 1 hour Daily Screen Time Duration: > 2 hours Type of screen: TV Examination a. Vitals: b. Anthropometry: Weight: 18.6 Kg Height: 115 cm Head circumference: 50.5 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Chewing: Proper Swallowing: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 2/week + PMT 1/week General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

Demographic Details

Child's Name: Sarthak Lodhi
Age: 4 Year 8 Month 17 Days
Gender: Male
DOB: 2021-06-29
Mother’s age (years): 35 years
Mother’s occupation: Homemaker
Father’s age (years): 34 years
Father’s occupation: Farmer
Type of family: Nuclear
Number of family members: 5
Number of siblings: 3
Details of siblings (Age and sex): 1- 16yr, 2- 14 yr, 3-12 yr (females)
Address: Gadhaipura
Contact: 8357981567
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay, doesnt follow command
Duration of symptoms: Realized around 3 years that child has speech delay

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Looking from lateral side of eye Inattention Stubbornness Aggression
Sensory Concerns:

Tactile: Hyposensitive
Auditory: Hypersensitive

Details:: Tactile seeking

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Hypothyroidism
Others:: 1 spontaneous abortion at 10 weeks.

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 3.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Investigations done-

Hearing assessment: Done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 months
Roll over: Achieved

Age of attainment: 8 months
Sitting without support: Achieved

Age of attainment: 8 months
Standing without support: Achieved

Age of attainment: 12 months
Walking without support: Achieved

Age of attainment: 14 months

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp: Achieved

Age of attainment: 6 months

Pincer grasp: Achieved

Age of attainment: 12 months

Scribbling: Achieved

Age of attainment: 3 years

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

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

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 18 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 18 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Not achieved
Waving bye bye: Not achieved
Asking for food and toilet: Not achieved

Response to Name Call

Details: 2/10

Sitting tolerance- (in minutes)

For interaction: Less than a minute
For tasks: Sitting tolerance more for tasks

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 2. Started attempting
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 2. Started attempting

Details:: Doesnt sit for haircut

Type of Play : 2. Isolated Outdoor play duration: Nil Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: vegetarian diet
Food allergies: No
Junk food intake: 3-4 times/week

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1 hour

Daily Screen Time

Duration: > 2 hours
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 18.6 Kg Height: 115 cm Head circumference: 50.5 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Chewing: Proper
Swallowing: Proper

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

Advice

Intervention plan: IDP 2/week + PMT 1/week
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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