General Clinics

Demographic Details

Name : NeenadAge : 2 years 8 monthsGender : maleDate of birth :5th February 2013Religion: HinduPlace : MangaloreDate of admission: 10th October 2015

Informant : motherReliability : good

Chief Complaint

- Developmental delayCurrently admitted for second round of physiotherapy.

Birth History

Antenatal History- Birth order : first child- Mother was 27 years old when she was

pregnant with the child.First trimester- Mother conceived spontaneously.- She was a booked case.- Folic acid tablets were taken.- No history of fever with rash.- No history of drug intake or radiation

exposure.

Second trimester- Quickening felt at 5th month of gestation.- Regular antenatal check-ups were attended.- Iron and calcium supplementation taken.- Two doses of tetanus toxoid injections taken.- No h/s/o Pre-eclampsia,GDM,Anemia- No h/o Bleeding PV

Third trimester- Regular antenatal check-ups attended.- Fetal movements were well appreciated.- Mother was diagnosed to have hypertension during one

of her antenatal check-ups and she received medication for the same.

- No h/o GDM,Burning micturition, Suprapubic pain,Bleeding PV.

Natal History- Labour was induced at 34 weeks of gestation due

to uncontrolled hypertension in the mother at Government Lady Goschen Hospital on 5th February 2013.

- Normal vaginal delivery.- No history of instrumentation or prolonged

labour.- Baby did not cry immediately after birth.- Baby was shifted to NICU soon after birth, airway

was stabilised and mother’s breast milk was withheld.

- Birth weight is 2.125kg.

Postnatal History- Baby was transferred from Government Lady

Goschen Hospital NICU to KMC Hospital Attavar NICU on the 4th postnatal day.

- Baby remained in NICU for 1 month.- Expressed breast milk from the mother was

introduced at the end of first week, given as pallada feeds.

- Breastfeeding started at the end of 4th week.- No history of poor feeding and occasional

regurgitation of milk.- Baby was discharged after a total duration of 1.5

months of stay at KMC Hospital Attavar.

Developmental HistoryDomains of

developmentMilestones Age of

attainmentExpected age of

attainmentDevelopmental quotient (DQ)

Gross Motor Head controlRolling over

--

3 months5 months

(0 months/32 months) x 100%

= 0%

Fine Motor Immature pincer grasp

2 years 9 months (9 months/32 months) x 100%=28%

Personal and Social

Asks for food when hungry

2 years 8 months

2 years (24 months/32 months) x 100%

= 75%

Speech Monosyllables 1.5 years 6 months (6 months/32 months) x 100%= 19%

- Mother complains that child never attained head control, is unable to get up or even turn about in bed.

- Child’s first active movements were noticed by mother around 1.5 years of age. Child would move both upper limbs, more so in the left upper limb, with both palms closed in a fist.

- By the end of 2 years, child was actively moving the left arm, reaching out to objects with his fingers, right hand still held firm with the palm closed in a fist.

- Child recognises the mother, maintains eye contact with her, laughs out loud when happy.

- Child could say ‘ma,ba’ at the end of 1.5 years.- He could convey that he is hungry.- Child is dry by day.- Feeding the child has been difficult because

child’s appetite is less, after 3-4 mouthfuls, he refuses further feeding.

- No history of occasional nasal regurgitation, coughing during feeding or spillage from either angles of the mouth.

Two months back, when the mother was feeding him in the morning, she noticed deviation of the left angle of the mouth, lasting for about 5 seconds. No history of loss of consciousness. Mother took the child to RAPCC on the same day. Child was admitted and started on medications.

Mother was informed about the developmental delay and was told to start physiotherapy for her child. Child was discharged and was given syrup for the seizures to be taken once daily at night.

One month later, child developed another similar episode and was brought to RAPCC. The child’s seizure medication was changed and physiotherapy was given. The child was discharged and was adviced to come back after 1 month for physiotherapy and review of medication.

No history of any regression of milestones, projectile vomiting, altered sensorium, cranial nerve involvement, bowel and bladder incontinence, constipation, lethargy, fever or generalised seizures.

Immunization History

- Child is immunised up to date.- BCG scar is seen on the left upper arm.- Last immunization was at the age of 1.5 years.

Diet HistoryChild was exclusively breastfed until 4 months of age and

complementary feeding was started thereafter with ragiTime Food Energy (Kcal) Protein ( grams)

8.30 am ½ glass milk ½ dosa

33.561

1.651.55

10.00 am ½ glass milk1 banana

33.546

1.650.48

12.00 pm ½ cup sambhar½ cup boiled rice

6888

3.251.7

4.00 pm ½ glass milk3 rusk

33.550

1.650.5

8.00 pm ½ cup sambhar ½ cup boiled rice

6888

3.251.7

Total 569.5 17.38

RDA 1150 18.2

Deficit 580.5 0.82

2 years 8 months

29 years33 years

Family history Child is born out of a non-consanguinous marriage No history of similar complaints in the family