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OPD : 23-Oct-2026 02:24PM Demographic Details Child's Name: Shriya Chauhan Age: 4 Month 19 Days Gender: Female DOB: 2026-06-04 Mother’s age (years): 24 years Mother’s occupation: Homemaker Father’s age (years): 24 years Father’s occupation: Private job Type of family: Joint Number of family members: 3 Number of siblings: 0 Contact: 7355482050 Referred By: Doctor Informant: Parents Investigations done: MRI Brain- WNL, TSH-2.3 Presenting Concerns Chief concerns: 3 Behavioral history: 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: 34 weeks Birth Weight: 2.5 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: 11 days. HIE2. RDS Past history: Hospitalization: No Others: ? Anormal body movements since 2 days Past/Current medications: Syp Gardenal given for 1 month Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Language Receptive:- Joint attention: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Expressive:- Cooing: Achieved Age of attainment: 4 months Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Drag for needs: Absent Joint attention: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Academic History: Diet History: Food preferences: On formula feed. topfeed Food allergies: Yes Junk food intake: ?Cow milk protein allergy Sleep History Total sleep duration (night): as per age Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 5.4 Kg Height: 60 cm Head circumference: 37.5 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination Drooling: No Examination summary: Tone normal, KJ-3+/3+, AJ-2+/2+, plantar- B/l withdrawal, AF- at level. Pull to sit- attempts to holds head in plane of body, prone- lifts head to 30 degrees. ALert to sound- inconsistent. Visual fixation+, following inconsistent CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: Early stimulation adviced Investigations: BERA, EEG. Calcium, Magnesium. Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 23-Oct-2026 02:24PM Demographic Details

Child's Name: Shriya Chauhan
Age: 4 Month 19 Days
Gender: Female
DOB: 2026-06-04
Mother’s age (years): 24 years
Mother’s occupation: Homemaker
Father’s age (years): 24 years
Father’s occupation: Private job
Type of family: Joint
Number of family members: 3
Number of siblings: 0
Contact: 7355482050
Referred By: Doctor
Informant: Parents
Investigations done: MRI Brain- WNL, TSH-2.3

Presenting Concerns

Chief concerns: 3

Behavioral history:

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: 34 weeks
Birth Weight: 2.5 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: 11 days. HIE2. RDS

Past history:

Hospitalization: No Others: ? Anormal body movements since 2 days

Past/Current medications: Syp Gardenal given for 1 month Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Language

Receptive:-

Joint attention: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent
Drag for needs: Absent
Joint attention: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Academic History:

Diet History:

Food preferences: On formula feed. topfeed
Food allergies: Yes
Junk food intake: ?Cow milk protein allergy

Sleep History

Total sleep duration (night): as per age

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 5.4 Kg Height: 60 cm Head circumference: 37.5 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

Drooling: No

Examination summary: Tone normal, KJ-3+/3+, AJ-2+/2+, plantar- B/l withdrawal, AF- at level. Pull to sit- attempts to holds head in plane of body, prone- lifts head to 30 degrees. ALert to sound- inconsistent. Visual fixation+, following inconsistent CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Advice

Intervention plan: Early stimulation adviced
Investigations: BERA, EEG. Calcium, Magnesium.
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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