Create - Child Development Centre

Patient Details


OPD : 08-Sep-2026 01:20PM Demographic Details Child's Name: Advik Sengar Age: 2 Year 10 Month 9 Days Gender: Male DOB: 2023-10-30 Mother’s age (years): 32 years Mother’s occupation: Homemaker Father’s age (years): 35 years Father’s occupation: Business Number of family members: 11 Number of siblings: 0 Address: Thatipur Contact: 9131348018 Referred By: Doctor Informant: Parents Current medications: Syp Valprol, Zonimid, Clobazam Investigations done: EEG, MRI Brain- asked to review with reports Interaction history: Eye contact: Suboptimal Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Handflapping, stimming Patterned behavior or activities: Hyperactivity Inattention Impulsivity Insisting on sameness Temper tantrums Stubbornness Aggression Sensory Concerns: Auditory: Hyposensitive Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: PIH Natal and Postnatal History: Mode of Delivery: LSCS Indication for LSCS (if applicable): PIH Gestational Age: FT Birth Weight: 3.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Neonatal seizures since day 2 of life (? Hypoglycemia). Admitted for 10 days Past history: Hospitalization: No Seizures: Yes Others: H/o Focal seizures. Last episode 1.5 years back. Past/Current therapies: Discontinued Past/Current medications: Syp Valprol 4ml BD, Zonimid 25 BD, Clobazam- 2ml HS Investigations done- Hearing assessment: Done Details: BERA- normal Vision assessment: Done Details: Squint- improved Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 7 months Roll over: Achieved Age of attainment: 9 months Sitting without support: Achieved Age of attainment: 10 months Standing without support: Achieved Age of attainment: 16 months Walking without support: Achieved Age of attainment: 18 months Fine Motor Bidextrous grasp: Achieved Age of attainment: 18 months Unidextrous grasp: Achieved Age of attainment: 20 months Pincer grasp: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: delayed Pointing: Achieved Age of attainment: Delayed Understanding gestures: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Achieved Age of attainment: 24 months Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Achieved Age of attainment: 24 months Details:: Inconsistent use of 2 word phrases. Patterned. Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent Drag for needs: Inconsistent Joint attention: Inconsistent Pointing: Inconsistent meaningful pointing Understanding gestures: Emerging Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 18 months Waving bye bye: Not achieved Asking for food and toilet: Not achieved Response to Name Call Details: 7/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: Better for tasks ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Doesnt cooperate for haircut Type of Play : 3. Onlooker Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed. Food allergies: No Junk food intake: Biscuits Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours 2 naps Daily Screen Time Duration: < 2 hours Type of screen: TV Examination a. Vitals: b. Anthropometry: Weight: 12 Kg Height: 94 cm Head circumference: 47 cm c. General Examination Dysmorphology: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Tone: Hypotonia Deep tendon reflexes: KJ-2+/2+, AJ-2+/2+ Superficial reflexes: Plantars- B/l flexors Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Improper Examination summary: Mild hypotonia. CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD with epilepsy. Behavioral concerns++. Balance, coordination concerns, fine motor difficulties. Advice Intervention plan: IDP + PT 3/week + PMT 1/week Evaluation: DQ (Later) Medications: Continue same Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 08-Sep-2026 01:20PM Demographic Details

Child's Name: Advik Sengar
Age: 2 Year 10 Month 9 Days
Gender: Male
DOB: 2023-10-30
Mother’s age (years): 32 years
Mother’s occupation: Homemaker
Father’s age (years): 35 years
Father’s occupation: Business
Number of family members: 11
Number of siblings: 0
Address: Thatipur
Contact: 9131348018
Referred By: Doctor
Informant: Parents
Current medications: Syp Valprol, Zonimid, Clobazam
Investigations done: EEG, MRI Brain- asked to review with reports

Interaction history:

Eye contact: Suboptimal
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Handflapping, stimming Patterned behavior or activities: Hyperactivity Inattention Impulsivity Insisting on sameness Temper tantrums Stubbornness Aggression
Sensory Concerns:

Auditory: Hyposensitive
Visual: Seeks visuals
Proprioception: Seeks pressure
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

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

Natal and Postnatal History:

Mode of Delivery: LSCS
Indication for LSCS (if applicable): PIH
Gestational Age: FT
Birth Weight: 3.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Neonatal seizures since day 2 of life (? Hypoglycemia). Admitted for 10 days

Past history:

Hospitalization: No Seizures: Yes Others: H/o Focal seizures. Last episode 1.5 years back.

Past/Current therapies: Discontinued Past/Current medications: Syp Valprol 4ml BD, Zonimid 25 BD, Clobazam- 2ml HS Investigations done-

Hearing assessment: Done Details: BERA- normal Vision assessment: Done Details: Squint- improved

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 7 months
Roll over: Achieved

Age of attainment: 9 months
Sitting without support: Achieved

Age of attainment: 10 months
Standing without support: Achieved

Age of attainment: 16 months
Walking without support: Achieved

Age of attainment: 18 months

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 18 months

Unidextrous grasp: Achieved

Age of attainment: 20 months

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: delayed
Pointing: Achieved

Age of attainment: Delayed
Understanding gestures: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Achieved

Age of attainment: 24 months

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Achieved

Age of attainment: 24 months

Details:: Inconsistent use of 2 word phrases. Patterned.

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Inconsistent
Drag for needs: Inconsistent
Joint attention: Inconsistent
Pointing: Inconsistent meaningful pointing
Understanding gestures: Emerging
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 18 months
Waving bye bye: Not achieved
Asking for food and toilet: Not achieved

Response to Name Call

Details: 7/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: Better for tasks

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Details:: Doesnt cooperate for haircut

Type of Play : 3. Onlooker Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed.
Food allergies: No
Junk food intake: Biscuits

Sleep History

Total sleep duration (night): 9-10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours 2 naps

Daily Screen Time

Duration: < 2 hours
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 12 Kg Height: 94 cm Head circumference: 47 cm

c. General Examination

Dysmorphology: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Tone: Hypotonia
Deep tendon reflexes: KJ-2+/2+, AJ-2+/2+
Superficial reflexes: Plantars- B/l flexors

Oromotor Examination

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

Examination summary: Mild hypotonia. CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD with epilepsy. Behavioral concerns++. Balance, coordination concerns, fine motor difficulties.

Advice

Intervention plan: IDP + PT 3/week + PMT 1/week
Evaluation: DQ (Later)
Medications: Continue same
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

Setting Panel

Select Layout

Light Dark

Sidebar Color

Color Theme

Mini Sidebar

Sticky Header

Patient Details print

Select Layout

Sidebar Color

Color Theme

Patient Details