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OPD : 14-Sep-2026 01:21PM Demographic Details Child's Name: Aada Khan Age: 10 Month 0 Days Gender: Male DOB: 2025-11-14 Mother’s age (years): 30 years Mother’s occupation: Homemaker Father’s age (years): 31 years Father’s occupation: Private Type of family: Joint Number of family members: 4 Number of siblings: 0 Address: Shivpuri Contact: 6268922801 Referred By: Doctor Informant: Parents Investigations done: MRI brain- mild volume loss with gliosis in B/l fronto parietal lobes. ? Old insult (Hypglycemia/ischemia). EEG- normal Presenting Concerns Chief concerns: Developmental delay Interaction history: Eye contact: Sustained Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: PIH Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): PIH Gestational Age: 34 weeks Birth Weight: 2.2 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: On day 2 admitted for neonatal seizures. Admitted for 20 days? meningitis. Discharged on gardenal, given for 4 months. Past history: Hospitalization: Yes Seizures: Yes Others: At 8 months- abnormal body movement, admitted for 5 days, preceded by fever. Past/Current therapies: Nil Past/Current medications: Syp gardenal for 4 months 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: Partial Roll over: Not achieved Sitting without support: Not achieved Standing without support: Not achieved Walking without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 10 months Unidextrous grasp: Not achieved Pincer grasp: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 8 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 8 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Drag for needs: Absent Joint attention: Absent Pointing: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Not achieved Waving bye bye: Not achieved Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 1. Unoccupied Academic History: Diet History: Food preferences: Mixed diet Food allergies: No Junk food intake: Biscuits Sleep History Total sleep duration (night): 11 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 7.6 Kg Head circumference: 40 cm c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper Examination summary: Af closed. Pull to sit- Partial head lag, curved back. On prone- lifts head to 30 degree. Reaches for objects. Visual fixation +, alerts to sound+, social interaction+ CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD Advice Intervention plan: IDP + PT 1/week . Home strategies. Investigations: CBC, Vitamin D, Vitamin B12, thyroid profile, Calcium Medications: BERA. Follow up plan: Every month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 14-Sep-2026 01:21PM Demographic Details

Child's Name: Aada Khan
Age: 10 Month 0 Days
Gender: Male
DOB: 2025-11-14
Mother’s age (years): 30 years
Mother’s occupation: Homemaker
Father’s age (years): 31 years
Father’s occupation: Private
Type of family: Joint
Number of family members: 4
Number of siblings: 0
Address: Shivpuri
Contact: 6268922801
Referred By: Doctor
Informant: Parents
Investigations done: MRI brain- mild volume loss with gliosis in B/l fronto parietal lobes. ? Old insult (Hypglycemia/ischemia). EEG- normal

Presenting Concerns

Chief concerns: Developmental delay

Interaction history:

Eye contact: Sustained

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. PIH

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): PIH
Gestational Age: 34 weeks
Birth Weight: 2.2 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: On day 2 admitted for neonatal seizures. Admitted for 20 days? meningitis. Discharged on gardenal, given for 4 months.

Past history:

Hospitalization: Yes Seizures: Yes Others: At 8 months- abnormal body movement, admitted for 5 days, preceded by fever.

Past/Current therapies: Nil Past/Current medications: Syp gardenal for 4 months 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: Partial
Roll over: Not achieved
Sitting without support: Not achieved
Standing without support: Not achieved
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 10 months

Unidextrous grasp: Not achieved

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment:
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 8 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 8 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Not achieved
Waving bye bye: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Type of Play : 1. Unoccupied Academic History:

Diet History:

Food preferences: Mixed diet
Food allergies: No
Junk food intake: Biscuits

Sleep History

Total sleep duration (night): 11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 7.6 Kg Head circumference: 40 cm

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

Drooling: No
Chewing: Improper
Swallowing: Improper
Blowing: Improper
Sucking: Improper

Examination summary: Af closed. Pull to sit- Partial head lag, curved back. On prone- lifts head to 30 degree. Reaches for objects. Visual fixation +, alerts to sound+, social interaction+ CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD

Advice

Intervention plan: IDP + PT 1/week . Home strategies.
Investigations: CBC, Vitamin D, Vitamin B12, thyroid profile, Calcium
Medications: BERA.
Follow up plan: Every month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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