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OPD : 21-Sep-2026 11:20AM Demographic Details Child's Name: Anmol Age: 1 Year Gender: Male DOB: 2025-09-18 Mother’s age (years): 21 Mother’s occupation: Homemaker Father’s age (years): 24 Father’s occupation: Farmer Type of family: Joint Number of siblings: 0 Address: Jalon Contact: 8957072897 Referred By: Doctor Informant: Mother, grandparents Current concerns: Delayed deevelopment Investigations done: MRI Brain (9mon): periventricular leukomalacia d/t perinatal hypoxic/hypoglycemic insult Presenting Concerns Chief concerns: Developmental delay Interaction history: Eye contact: Suboptimal 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: FT Birth Weight: 1.750 Kg Cry at birth: Delayed cry Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: NICU stay- 11 days for Hypoglycemic seizure, sepsis, neonatal jaundice Past history: Hospitalization: Yes Seizures: Yes Others: At age 2 months started having seizures (? Epileptic spasms), multiple episodes, did not consult anyone. At age 8 months ? meningitis . Past/Current therapies: Nil Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Not achieved Roll over: Not achieved Sitting without support: Not achieved Standing without support: Not achieved Walking without support: Not achieved Fine Motor Bidextrous grasp: Not achieved Unidextrous grasp: Not achieved Pincer grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Not achieved Meaningful words: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Not achieved Meaningful words: Achieved Age of attainment: Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 3 months Stranger anxiety: Not achieved Waving bye bye: Not achieved Comes when called: 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: Diet Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 10-12 hours Afternoon nap: Yes Duration of Afternoon nap: 2 naps. 3 hours 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 Other: AF- closed. Microcephaly Oromotor Examination Drooling: Yes Examination summary: Dystonia+. Pull to sit- head lag+, Prone lying- Lifts head till 90degree with weight on forearms. Doesnt reach for objects. Visual fixation , follows faces and objects till 90 degree. Response to sound- inconsistent CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. Microcephaly. (NHBI) Hopes from the consultation: Parents cant take physical sessions Advice Intervention plan: Home strategies adviced Investigations: BERA/ Pediatric ophthalmologist reference/ EEG Medications: Continue same Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 21-Sep-2026 11:20AM Demographic Details

Child's Name: Anmol
Age: 1 Year
Gender: Male
DOB: 2025-09-18
Mother’s age (years): 21
Mother’s occupation: Homemaker
Father’s age (years): 24
Father’s occupation: Farmer
Type of family: Joint
Number of siblings: 0
Address: Jalon
Contact: 8957072897
Referred By: Doctor
Informant: Mother, grandparents
Current concerns: Delayed deevelopment
Investigations done: MRI Brain (9mon): periventricular leukomalacia d/t perinatal hypoxic/hypoglycemic insult

Presenting Concerns

Chief concerns: Developmental delay

Interaction history:

Eye contact: Suboptimal

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: FT
Birth Weight: 1.750 Kg
Cry at birth: Delayed cry
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: NICU stay- 11 days for Hypoglycemic seizure, sepsis, neonatal jaundice

Past history:

Hospitalization: Yes Seizures: Yes Others: At age 2 months started having seizures (? Epileptic spasms), multiple episodes, did not consult anyone. At age 8 months ? meningitis .

Past/Current therapies: Nil Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

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

Fine Motor

Bidextrous grasp: Not achieved

Unidextrous grasp: Not achieved

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Not achieved

Meaningful words: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Not achieved

Meaningful words: Achieved

Age of attainment:

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 3 months
Stranger anxiety: Not achieved
Waving bye bye: Not achieved
Comes when called: 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: Diet
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 10-12 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 naps. 3 hours

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
Other: AF- closed. Microcephaly

Oromotor Examination

Drooling: Yes

Examination summary: Dystonia+. Pull to sit- head lag+, Prone lying- Lifts head till 90degree with weight on forearms. Doesnt reach for objects. Visual fixation , follows faces and objects till 90 degree. Response to sound- inconsistent CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD. Microcephaly. (NHBI)

Hopes from the consultation: Parents cant take physical sessions
Advice

Intervention plan: Home strategies adviced
Investigations: BERA/ Pediatric ophthalmologist reference/ EEG
Medications: Continue same
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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