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OPD : 12-Oct-2026 11:59AM Demographic Details Child's Name: Mohammad Khan Age: 8 Month 8 Days Gender: Male DOB: 2026-02-04 Mother’s age (years): 30 years Mother’s occupation: Homemaker Father’s age (years): 40 years Father’s occupation: Driver Type of family: Joint Number of siblings: 2 Details of siblings (Age and sex): 1- 9 year old female, 2- 3 year old female Address: Joura Contact: 7610117970 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Delayed milestones Interaction history: Eye contact: Suboptimal Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: 1 history of spontaneous abortion Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Prev LSCS Gestational Age: 34 weeks Birth Weight: 2 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No If yes- Duration & Indication: Kept in NICU for 1 hour for observation Past history: Hospitalization: No Seizures: No Others: K/c/o CHD. Recurrent LRTIs 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 Fine Motor Bidextrous grasp: Not achieved Unidextrous grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 8 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 8 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: 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: On breastfeeding + bottlefeeding 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: Weight: 5.5 Kg Height: 64 cm Head circumference: 41 cm c. General Examination Dysmorphology: Downs phenotype Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Bulk of muscles: Wasting Tone: Hypotonia Deep tendon reflexes: KJ- 1+/1+, AJ- 1+/1+ Oromotor Examination Examination summary: Generalised hypotonia. Complete head lag on pull to sit, back rounded/. Doesnt Lift head on prone position. AF- wide, open. CVS examination: Tachycardia+ Respiratory System examination: B/l conducted sounds Per abdomen examination: NAD Impression: GDD (Down syndrome ) Advice Intervention plan: Home based strategies. Stop bottlfeeding. Initiate complimentary feeding as adviced with supported sitting, safely. PT activities at home. Investigations: To review with all reports Medications: Continue as adviced by pediatrician Follow up plan: After 15 days General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 12-Oct-2026 11:59AM Demographic Details

Child's Name: Mohammad Khan
Age: 8 Month 8 Days
Gender: Male
DOB: 2026-02-04
Mother’s age (years): 30 years
Mother’s occupation: Homemaker
Father’s age (years): 40 years
Father’s occupation: Driver
Type of family: Joint
Number of siblings: 2
Details of siblings (Age and sex): 1- 9 year old female, 2- 3 year old female
Address: Joura
Contact: 7610117970
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Delayed milestones

Interaction history:

Eye contact: Suboptimal

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: 1 history of spontaneous abortion

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Prev LSCS
Gestational Age: 34 weeks
Birth Weight: 2 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No
If yes- Duration & Indication: Kept in NICU for 1 hour for observation

Past history:

Hospitalization: No Seizures: No Others: K/c/o CHD. Recurrent LRTIs

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

Fine Motor

Bidextrous grasp: Not achieved

Unidextrous grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 8 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 8 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: 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: On breastfeeding + bottlefeeding
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:

Weight: 5.5 Kg Height: 64 cm Head circumference: 41 cm

c. General Examination

Dysmorphology: Downs phenotype Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Bulk of muscles: Wasting
Tone: Hypotonia
Deep tendon reflexes: KJ- 1+/1+, AJ- 1+/1+

Oromotor Examination

Examination summary: Generalised hypotonia. Complete head lag on pull to sit, back rounded/. Doesnt Lift head on prone position. AF- wide, open. CVS examination: Tachycardia+
Respiratory System examination: B/l conducted sounds
Per abdomen examination: NAD

Impression: GDD (Down syndrome )

Advice

Intervention plan: Home based strategies. Stop bottlfeeding. Initiate complimentary feeding as adviced with supported sitting, safely. PT activities at home.
Investigations: To review with all reports
Medications: Continue as adviced by pediatrician
Follow up plan: After 15 days
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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