OPD :
28-Sep-2026 06:56PM
Demographic Details
- :
NISHANK
- :
3 Year 7 Month 13 Days
- :
Male
- :
2023-02-15
- :
2
- :
11 year old female female, 8 year old
- :
7
- :
9981956010
- :
Doctor
- :
Parents
- :
3 yr: CT scan- suspicious hwedge shaped small hypodense areas in left posterior temporal region. MRI brain-Hyperintensities without diffusion in B/l ventricular white matter ? dysmyelination.. EEG- normal
Presenting Concerns
- :
Developmental Delay
Interaction history:
Behavioral history:
Repetitive behaviors (RRBs):
Handflapping
Stubbornness
Mouthing of objects
:
Irrelevant laughing
Sensory Concerns:
- :
Hypersensitive
- :
Seeks movement
Birth & Perinatal History:
Antenatal History
- :
No
- :
Natural
-
High-risk factors in pregnancy:
- Pre-eclampsia
Natal and Postnatal History:
- :
Institutional
- :
NVD
- :
FT
- :
Cried immediately after birth
- :
No
- :
No
Past history:
:
Yes
:
No
:
at age 1 year admitted for pneumonia, parents reported regression in milestones after that. At 2.5 years admitted for severe anemia, received BT, ? ITS
:
Nil
:
Nil
Investigations done-
:
Not done
:
Not done
Family history:
:
Yes
:
Intellectual diability in paternal uncle ( Chacha)
Developmental History:
Gross Motor
-
:
Achieved
:
5 months
-
:
Achieved
:
1 year
-
:
Achieved
:
2 years
-
:
Not achieved
-
:
Not achieved
Fine Motor
:
Achieved
:
1 year
:
Achieved
:
1.5 year
:
Achieved
:
3 years
:
Not achieved
Language
Receptive:-
-
:
Not achieved
-
:
Not achieved
-
:
Not achieved
- :
Not following
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
2 years
:
Not achieved
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
2 years
:
Not achieved
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Absent
- :
Absent
- :
Absent
- :
Absent
- :
Absent
- :
Nil
Answering Questions:-
Social
Response to Name Call
Sitting tolerance- (in minutes)
ADL Skills (Age-appropriate)-
- :
2. Started attempting
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
Type of Play : 1. Unoccupied
Academic History:
- :
No
Diet History:
- :
Mixed
- :
No
- :
Daily
Sleep History
- :
10-11 hours
- :
Yes
- :
1-1.5 hours
Daily Screen Time
Examination
a. Vitals:
b. Anthropometry:
:
46 cm
:
88 cm
c. General Examination
:
1 cafe au lait macule over anterior chest
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
- :
Gross motor and Fine motor
- :
Hypotonia
- :
KJ- 3+/3+, AJ-3+/3+
- :
Plantars- B/l flexors
Oromotor Examination
:
Generalised hypotonia, DTR- Brisk, Plantars- B/l flexors :
NAD
:
NAD
:
NAD
:
GDD. ? Genetic ?IEM
Advice
- :
CBC, Ca, Lactate, Ammonia, Plasma amino acids, Acylcarnitine profile, Urine organic acids, Creatine Kinase, Thyroid profile. WES
- :
As adviced by pediatrician
- :
Review after 15 days
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food
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