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OPD : 03-Oct-2026 11:26AM Demographic Details Child's Name: Nandita Gautam Age: 1 Year 6 Month 3 Days Gender: Female DOB: 2025-03-30 Mother’s age (years): 31 years Mother’s occupation: Homemaker Father’s age (years): 35 years Father’s occupation: Private job Type of family: Nuclear Number of family members: 3 Number of siblings: 1 Details of siblings (Age and sex): 2.5 year old female Address: Etawah Contact: 7906005036 Referred By: Doctor Informant: Mother, paternal uncle Presenting Concerns Chief concerns: Developmental delay Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Anaemia Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: around 2.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No If yes- Duration & Indication: H/o excessive cry, irritability at 1st month Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Nil 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: 6 months Roll over: Achieved Age of attainment: 1.5 years Sitting without support: Not achieved Standing without support: Not achieved Walking without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 6 months Unidextrous grasp: Achieved Age of attainment: 8 months Pincer grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: Babbling: Not achieved Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: Babbling: Not achieved Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Drag for needs: Absent Joint attention: Absent Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Social Social smile: Achieved Age of attainment: 12 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: Is child enrolled in school: No Diet History: Food preferences: Predominantlt milk Examination a. Vitals: b. Anthropometry: Weight: 8 Kg Height: 42.5 cm Head circumference: 71 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Deep tendon reflexes: KJ_2+/2+, AJ-1+/1+ Superficial reflexes: B/l flexors Oromotor Examination Drooling: No Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper Examination summary: knuckle hyper pigmentation, Mild hypotonia, predominantly mouth open, tongue protruded. Lifts head while pull to sit, prone- bears weight on forearm, lifts head above 60 degrees. Squint+ CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD ? Nutritional Hopes from the consultation: unable to take physical sessions Advice Intervention plan: Home strategies adviced Investigations: CBC, Vitamin D, Vitamin B12, TSH, free T3, free T4. BERA. Medications: Syp Bifolate 2.5 ml OD. Rest same Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 03-Oct-2026 11:26AM Demographic Details

Child's Name: Nandita Gautam
Age: 1 Year 6 Month 3 Days
Gender: Female
DOB: 2025-03-30
Mother’s age (years): 31 years
Mother’s occupation: Homemaker
Father’s age (years): 35 years
Father’s occupation: Private job
Type of family: Nuclear
Number of family members: 3
Number of siblings: 1
Details of siblings (Age and sex): 2.5 year old female
Address: Etawah
Contact: 7906005036
Referred By: Doctor
Informant: Mother, paternal uncle

Presenting Concerns

Chief concerns: Developmental delay

Behavioral history:

Birth & Perinatal History: Antenatal History

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

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: around 2.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No
If yes- Duration & Indication: H/o excessive cry, irritability at 1st month

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Nil 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: 6 months
Roll over: Achieved

Age of attainment: 1.5 years
Sitting without support: Not achieved
Standing without support: Not achieved
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 6 months

Unidextrous grasp: Achieved

Age of attainment: 8 months

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment:

Babbling: Not achieved

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment:

Babbling: Not achieved

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent
Drag for needs: Absent
Joint attention: Absent
Pointing: Absent
Understanding gestures: Absent
Following commands (gesture + verbal): Nil

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 12 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:

Is child enrolled in school: No

Diet History:

Food preferences: Predominantlt milk

Examination

a. Vitals:

b. Anthropometry:

Weight: 8 Kg Height: 42.5 cm Head circumference: 71 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Deep tendon reflexes: KJ_2+/2+, AJ-1+/1+
Superficial reflexes: B/l flexors

Oromotor Examination

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

Examination summary: knuckle hyper pigmentation, Mild hypotonia, predominantly mouth open, tongue protruded. Lifts head while pull to sit, prone- bears weight on forearm, lifts head above 60 degrees. Squint+ CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD ? Nutritional

Hopes from the consultation: unable to take physical sessions
Advice

Intervention plan: Home strategies adviced
Investigations: CBC, Vitamin D, Vitamin B12, TSH, free T3, free T4. BERA.
Medications: Syp Bifolate 2.5 ml OD. Rest same
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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