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OPD : 07-Oct-2026 04:40PM Demographic Details Child's Name: Himanshi Kushwah Age: 6 Month 10 Days Gender: Female DOB: 2026-03-27 Mother’s age (years): 23 years Mother’s occupation: Homemaker Father’s age (years): 26 years Father’s occupation: Private job Type of family: Joint Number of family members: 6 Number of siblings: 0 Address: Datia Contact: 9713278819 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Delayed milestones Interaction history: Eye contact: Poor Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): cord around neck, obstructed labor Gestational Age: FT Birth Weight: 2.7 Kg Cry at birth: Delayed cry Resuscitation required: Yes Details of Resuscitation: Intubated NICU stay: Yes If yes- Duration & Indication: 20 days. 10 days on MV. HIE3. Discharged on Syp gardenal Past history: Hospitalization: No Seizures: Yes Past/Current therapies: Nil Past/Current medications: Syp Gardenal 2.5 ml BD Investigations done- Hearing assessment: Done Details: B/l Pass in OAE Vision assessment: Done Details: Squint Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Not achieved Roll over: Not achieved Sitting without support: Not achieved Fine Motor Bidextrous grasp: Not achieved Unidextrous grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Expressive:- Cooing: Not achieved Babbling: Not achieved Expressive:- Cooing: Not achieved Babbling: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Not achieved Stranger anxiety: 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: Is child enrolled in school: No Diet History: Food preferences: On cowmilk Food allergies: No Junk food intake: Biscuits Sleep History Total sleep duration (night): as per age Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Deep tendon reflexes: KJ-3+/3+, AJ-2+/2+ Superficial reflexes: Plantars- B/l extensors Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Examination summary: Seizures noted during examination. GTCS in all 4 limbs lasted for 4-5 seconds, not followed by LOC. AF- closed, sutural over riding, microcephaly. Doesnt fixate to objects. Alerts to sound CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. Epilepsy. Post HIE Advice Intervention plan: Physiotherapy as adviced. Diet as adviced Medications: Continue as adviced by pediatrician Follow up plan: After 15 days General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 07-Oct-2026 04:40PM Demographic Details

Child's Name: Himanshi Kushwah
Age: 6 Month 10 Days
Gender: Female
DOB: 2026-03-27
Mother’s age (years): 23 years
Mother’s occupation: Homemaker
Father’s age (years): 26 years
Father’s occupation: Private job
Type of family: Joint
Number of family members: 6
Number of siblings: 0
Address: Datia
Contact: 9713278819
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Delayed milestones

Interaction history:

Eye contact: Poor

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): cord around neck, obstructed labor
Gestational Age: FT
Birth Weight: 2.7 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
Details of Resuscitation: Intubated
NICU stay: Yes
If yes- Duration & Indication: 20 days. 10 days on MV. HIE3. Discharged on Syp gardenal

Past history:

Hospitalization: No Seizures: Yes

Past/Current therapies: Nil Past/Current medications: Syp Gardenal 2.5 ml BD Investigations done-

Hearing assessment: Done Details: B/l Pass in OAE Vision assessment: Done Details: Squint

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Not achieved
Roll over: Not achieved
Sitting without support: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Unidextrous grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved

Expressive:-

Cooing: Not achieved

Babbling: Not achieved

Expressive:-

Cooing: Not achieved

Babbling: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Not achieved
Stranger anxiety: 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:

Is child enrolled in school: No

Diet History:

Food preferences: On cowmilk
Food allergies: No
Junk food intake: Biscuits

Sleep History

Total sleep duration (night): as per age

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Deep tendon reflexes: KJ-3+/3+, AJ-2+/2+
Superficial reflexes: Plantars- B/l extensors

Oromotor Examination

Drooling: Yes
Chewing: Improper
Swallowing: Improper

Examination summary: Seizures noted during examination. GTCS in all 4 limbs lasted for 4-5 seconds, not followed by LOC. AF- closed, sutural over riding, microcephaly. Doesnt fixate to objects. Alerts to sound CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD. Epilepsy. Post HIE

Advice

Intervention plan: Physiotherapy as adviced. Diet as adviced
Medications: Continue as adviced by pediatrician
Follow up plan: After 15 days
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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