OPD :
28-Jul-2026 12:41PM
Demographic Details
- :
Shivansh Rajput
- :
2 Year 10 Month 1 Days
- :
Male
- :
2023-09-27
- :
6005913532
Interaction history:
- :
Sustained
- :
age-appropriate
Behavioral history:
Birth & Perinatal History:
Antenatal History
- :
No
- :
Natural
Natal and Postnatal History:
- :
Institutional
- :
NVD
- :
32 weeks
- :
1.3 Kg
- :
Cried immediately after birth
- :
No
- :
Yes
- :
NICU stay-15 days for PT, VLBW
Past history:
:
No
:
Nil
:
Nil
Investigations done-
:
Done
:
Normal. Reports not there.
:
Done
:
Normal. Reports not there.
Family history:
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
6 mon
-
:
Achieved
:
7 months
-
:
Achieved
:
10 months
-
:
Achieved
:
12 months
-
:
Achieved
:
18 months
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
Fine Motor
:
Achieved
:
6 months
:
Achieved
:
7 month
:
Achieved
:
Not remembered
:
Achieved
:
Language
Receptive:-
-
:
Achieved
:
12 months
-
:
Achieved
:
18 months
- :
1-step
Expressive:-
:
Achieved
:
6 months
:
Achieved
:
12 months
:
Not achieved
Expressive:-
:
Achieved
:
6 months
:
Achieved
:
12 months
:
Not achieved
:
Started speaking a few kinship words and few words like ball, pani
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Consistent
- :
Consistent
- :
Consistent
- :
Inconsistent meaningful pointing
- :
Consistent
- :
1-step
Answering Questions:-
:
Absent
Social
-
:
Achieved
:
2 months
-
:
Achieved
:
10 months
-
:
Achieved
:
12 months
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
Response to Name Call
Sitting tolerance- (in minutes)
- :
age appropriate
- :
age appropriate
ADL Skills (Age-appropriate)-
- :
2. Started attempting
- :
2. Started attempting
- :
2. Started attempting
- :
2. Started attempting
- :
2. Started attempting
Type of Play : 4. Parallel
Academic History:
- :
No
Diet History:
- :
Mixed. Bottlefeeding
- :
No
- :
Nil
Sleep History
- :
10-11 hours
- :
Yes
- :
2-3 hours
Daily Screen Time
-
:
<30 minutes
- :
TV
Examination
a. Vitals:
b. Anthropometry:
c. General Examination
:
Ab
:
Ab
d. CNS:
Higher Mental Functions
- :
Active, alert, playful
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
- :
Proper
- :
Proper
- :
Proper
- :
Proper
:
NAD
:
NAD
:
NAD
:
Growth Faultering (severe stunting, severe underweight). Poor catchup
Advice
- :
Mother counselled. Home strategies adviced. Stop bottlefeeding. Diet adviced.
- :
CBC, LGFT, RFT, Calcium, Vitamin D, Vitamin B12, Calcium, phosphorus, ALP
- :
Growth velocity monitoring
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food
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