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OPD : 18-Aug-2026 09:47AM Demographic Details Child's Name: Aahan sagar Age: 8 Month 16 Days Gender: Male DOB: 2025-12-02 Mother’s age (years): 22 years Mother’s occupation: Homemaker Father’s age (years): 32 years Father’s occupation: Farmer Type of family: Joint Number of family members: 14 Number of siblings: 1 Details of siblings (Age and sex): 3 year old female Address: Pichor Contact: 9098057920 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Delayed milestones, seizures Interaction history: Eye contact: Poor Interaction: Doesnt interact Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Oligohydramnios, MSL Gestational Age: FT Birth Weight: 1.5 Kg If yes- Duration & Indication: 5 Days- for Perinatal asphyxia, MAS, hypocalcemia, NNHB Past history: Hospitalization: Yes Seizures: Yes Others: Seizures since 1 month age, in clusters, immediately after waking up, not asso. fever ? Infantile spasms 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 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: 3 months Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: 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: Not achieved Stranger anxiety: Not achieved Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Type of Play : 1. Unoccupied Academic History: Is child enrolled in school: No Diet History: Food preferences: Predominantly bottle-feeding+ breastfeeding. Food allergies: No Junk food intake: Biscuits Sleep History Total sleep duration (night): as per age Afternoon nap: Yes Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 7 Kg Height: 68 cm Head circumference: 40.5 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypotonia Deep tendon reflexes: KJ-2+/2+. AJ-2+/2+ Superficial reflexes: Plantar- B/l extensors Oromotor Examination Chewing: Improper Swallowing: Improper Examination summary: AF- admitting fingertip; Visual fixation- absent; alerts to sound CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD with ? West syndrome. Advice Intervention plan: IDP + PT Investigations: EEG, MRI Brain Medications: Continue as adviced by pediatrician Follow up plan: Review with reports General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 18-Aug-2026 09:47AM Demographic Details

Child's Name: Aahan sagar
Age: 8 Month 16 Days
Gender: Male
DOB: 2025-12-02
Mother’s age (years): 22 years
Mother’s occupation: Homemaker
Father’s age (years): 32 years
Father’s occupation: Farmer
Type of family: Joint
Number of family members: 14
Number of siblings: 1
Details of siblings (Age and sex): 3 year old female
Address: Pichor
Contact: 9098057920
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Delayed milestones, seizures

Interaction history:

Eye contact: Poor
Interaction: Doesnt interact

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Oligohydramnios, MSL
Gestational Age: FT
Birth Weight: 1.5 Kg
If yes- Duration & Indication: 5 Days- for Perinatal asphyxia, MAS, hypocalcemia, NNHB

Past history:

Hospitalization: Yes Seizures: Yes Others: Seizures since 1 month age, in clusters, immediately after waking up, not asso. fever ? Infantile spasms

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

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: 3 months

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: 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: Not achieved
Stranger anxiety: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Type of Play : 1. Unoccupied Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Predominantly bottle-feeding+ breastfeeding.
Food allergies: No
Junk food intake: Biscuits

Sleep History

Total sleep duration (night): as per age
Afternoon nap: Yes

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 7 Kg Height: 68 cm Head circumference: 40.5 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypotonia
Deep tendon reflexes: KJ-2+/2+. AJ-2+/2+
Superficial reflexes: Plantar- B/l extensors

Oromotor Examination

Chewing: Improper
Swallowing: Improper

Examination summary: AF- admitting fingertip; Visual fixation- absent; alerts to sound CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD with ? West syndrome.

Advice

Intervention plan: IDP + PT
Investigations: EEG, MRI Brain
Medications: Continue as adviced by pediatrician
Follow up plan: Review with reports
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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