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OPD : 26-Sep-2026 01:07PM Demographic Details Child's Name: Ved Gurjar Age: 9 Month 25 Days Gender: Male DOB: 2025-12-01 Mother’s age (years): 26 years Mother’s occupation: Homemaker Father’s age (years): 30 years Father’s occupation: Farmer Type of family: Joint Number of family members: 6 Number of siblings: 2 Details of siblings (Age and sex): 6 years, 4 year old female Address: Shivpuri Contact: 9098033758 Referred By: Doctor Informant: Parents Current medications: Syp Levera 0.6 ml BD Investigations done: MRI Brain- hyperintensities in B/l periventricular regions, asymmetrical prominence of right lateral ventricle Presenting Concerns Chief concerns: Developmental delay Interaction history: Eye contact: Sustained Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: H/o Hyperemesis Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: around 3 Kg If yes- Duration & Indication: ? Delayed cry. Not admitted immediately after birth. At 10 day of life h/o neonatal seizures- admitted for 10 days. No convulsions after discharge Past history: Hospitalization: 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: Partial Roll over: Achieved Age of attainment: Sitting without support: Achieved Age of attainment: 8 months 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: 7 months Language Receptive:- Joint attention: Achieved Age of attainment: Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months 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 Academic History: Is child enrolled in school: No Diet History: Food preferences: Predominantly breastfed Food allergies: No Junk food intake: Nil 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 Tone: Normal Deep tendon reflexes: KJ-3+/3+, AJ-2+/2+ Superficial reflexes: Plantars- B/l extensors Oromotor Examination Drooling: No Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper Examination summary: Pull to sit- Lifts neck in anticipation of picking, Prone- holds weight on hand, started creeping CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: Home startegies adviced Investigations: EEG Medications: Syp Levera 0.6 ml BD Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 26-Sep-2026 01:07PM Demographic Details

Child's Name: Ved Gurjar
Age: 9 Month 25 Days
Gender: Male
DOB: 2025-12-01
Mother’s age (years): 26 years
Mother’s occupation: Homemaker
Father’s age (years): 30 years
Father’s occupation: Farmer
Type of family: Joint
Number of family members: 6
Number of siblings: 2
Details of siblings (Age and sex): 6 years, 4 year old female
Address: Shivpuri
Contact: 9098033758
Referred By: Doctor
Informant: Parents
Current medications: Syp Levera 0.6 ml BD
Investigations done: MRI Brain- hyperintensities in B/l periventricular regions, asymmetrical prominence of right lateral ventricle

Presenting Concerns

Chief concerns: Developmental delay

Interaction history:

Eye contact: Sustained

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: H/o Hyperemesis

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: around 3 Kg
If yes- Duration & Indication: ? Delayed cry. Not admitted immediately after birth. At 10 day of life h/o neonatal seizures- admitted for 10 days. No convulsions after discharge

Past history:

Hospitalization: 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: Partial
Roll over: Achieved

Age of attainment:
Sitting without support: Achieved

Age of attainment: 8 months
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: 7 months

Language

Receptive:-

Joint attention: Achieved

Age of attainment:
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
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

Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Predominantly breastfed
Food allergies: No
Junk food intake: Nil

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

Tone: Normal
Deep tendon reflexes: KJ-3+/3+, AJ-2+/2+
Superficial reflexes: Plantars- B/l extensors

Oromotor Examination

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

Examination summary: Pull to sit- Lifts neck in anticipation of picking, Prone- holds weight on hand, started creeping CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Advice

Intervention plan: Home startegies adviced
Investigations: EEG
Medications: Syp Levera 0.6 ml BD
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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