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OPD : 21-Sep-2026 12:37PM Demographic Details Child's Name: Shivansh Lohpeeta Age: 7 Month 11 Days Gender: Male DOB: 2026-02-10 Mother’s age (years): 21 years Mother’s occupation: Homemaker Father’s age (years): 26 years Father’s occupation: Laborer Type of family: Nuclear Number of siblings: 0 Address: Karaira Contact: 9644377298 Referred By: Doctor Informant: Mother, Mama Investigations done: MRI Brain- Diffuse age inappropriate cerebral neuroparenchymal atrophy. Presenting Concerns Chief concerns: Developmental delay Interaction history: Eye contact: Poor Behavioral history: Emotional history: Irritability Excessive crying episodes Birth & Perinatal History: Antenatal History Consanguinity: No Maternal age at conception (years):: 34 Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 2.5 Kg NICU stay: No If yes- Duration & Indication: ? Delayed cry Past history: Hospitalization: Yes Others: At 2 months- admitted for 3 days for febrile illness. Readmitted at 4 months for febrile illness. Abnormal body movements in the form of tonic posturing, uprolling of eyeballs Past/Current therapies: Nil Investigations done- 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 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 Drag for needs: Absent Joint attention: Absent Answering Questions:- Social Response to Name Call Sitting tolerance- (in minutes) Details:: According to mother , child had social smile at 2 months and had started fixating vision but now regression happened. 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: On breastfeed Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 8-9 hours Afternoon nap: Yes Duration of Afternoon nap: 3-4 hours Sleep disturbances: Yes Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Height: 63 cm Head circumference: 41 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. Hopes from the consultation: Unable to come for physical sessions Advice Intervention plan: Home strategies adviced Investigations: EEG. CBC, Thyroid profile, urea, ammonia, lactate. BERA. Pediatric ohthalmologist reference. Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 21-Sep-2026 12:37PM Demographic Details

Child's Name: Shivansh Lohpeeta
Age: 7 Month 11 Days
Gender: Male
DOB: 2026-02-10
Mother’s age (years): 21 years
Mother’s occupation: Homemaker
Father’s age (years): 26 years
Father’s occupation: Laborer
Type of family: Nuclear
Number of siblings: 0
Address: Karaira
Contact: 9644377298
Referred By: Doctor
Informant: Mother, Mama
Investigations done: MRI Brain- Diffuse age inappropriate cerebral neuroparenchymal atrophy.

Presenting Concerns

Chief concerns: Developmental delay

Interaction history:

Eye contact: Poor

Behavioral history:

Emotional history:
Irritability Excessive crying episodes

Birth & Perinatal History: Antenatal History

Consanguinity: No
Maternal age at conception (years):: 34
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 2.5 Kg
NICU stay: No
If yes- Duration & Indication: ? Delayed cry

Past history:

Hospitalization: Yes Others: At 2 months- admitted for 3 days for febrile illness. Readmitted at 4 months for febrile illness. Abnormal body movements in the form of tonic posturing, uprolling of eyeballs

Past/Current therapies: Nil Investigations done-

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

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
Drag for needs: Absent
Joint attention: Absent

Answering Questions:-

Social

Response to Name Call

Sitting tolerance- (in minutes)

Details:: According to mother , child had social smile at 2 months and had started fixating vision but now regression happened.

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: On breastfeed
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 8-9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 3-4 hours
Sleep disturbances: Yes

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Height: 63 cm Head circumference: 41 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

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

Impression: GDD.

Hopes from the consultation: Unable to come for physical sessions
Advice

Intervention plan: Home strategies adviced
Investigations: EEG. CBC, Thyroid profile, urea, ammonia, lactate. BERA. Pediatric ohthalmologist reference.
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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