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OPD : 09-Sep-2026 11:33AM Demographic Details Child's Name: Dev Yadav Age: 1 Year Gender: Male DOB: 2025-08-12 Mother’s age (years): 28 years Mother’s occupation: Homemaker Father’s age (years): 30 years Father’s occupation: Business Type of family: Joint Number of siblings: 1 Details of siblings (Age and sex): 5 year old female Address: Chhatarpur Contact: 8871377757 Referred By: Doctor Informant: Parents Investigations done: MRI Brain- Perinatal hypoxic ischemic insult. Presenting Concerns Chief concerns: Developmental delay Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: H/o 1 spontaneous abortion and 1 still birth in mother Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 2.7 Kg Cry at birth: Cried after stimulation Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Investigations done- Hearing assessment: Done Details: OAE- B/l Pass. BERA- normal Vision assessment: Done Details: Were told concerns in vision Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 6 months Roll over: Achieved Age of attainment: 7 months Sitting without support: Not achieved Standing without support: Not achieved Walking 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 Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 11 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 11 months Meaningful words: Not achieved Details:: Partial neck control+. On prone- lifts head upto 65degree, from supine to sitting- lifts head in body plane 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: Achieved Age of attainment: 3 months Stranger anxiety: Not achieved 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 Type of Play : 1. Unoccupied Academic History: Diet History: Food preferences: Predominantly bottlefeeding. Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 11 hours Afternoon nap: Yes Duration of Afternoon nap: 3-4 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 7.7 Kg Height: 70 cm Head circumference: 41 cm c. General Examination Neurocutaneous markers: Ab Others: B/l squint+. d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypotonia Deep tendon reflexes: Kj-3+/3+, AJ-2+/2+ Superficial reflexes: Plantars- B/l extensors Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Examination summary: Generalised hypotonia, AF - closed, DTR- brisk, plantar extensors. GDD. Visual fixation absent, alerts to sound but doesnt turn to sound. CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD with central hypotonia with microcephaly with squint Advice Intervention plan: Home startegies adviced Evaluation: Neuromotor assessment Investigations: EEG, Pediatric ophthalmologist opinion Medications: Continue Follow up plan: After investigations General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 09-Sep-2026 11:33AM Demographic Details

Child's Name: Dev Yadav
Age: 1 Year
Gender: Male
DOB: 2025-08-12
Mother’s age (years): 28 years
Mother’s occupation: Homemaker
Father’s age (years): 30 years
Father’s occupation: Business
Type of family: Joint
Number of siblings: 1
Details of siblings (Age and sex): 5 year old female
Address: Chhatarpur
Contact: 8871377757
Referred By: Doctor
Informant: Parents
Investigations done: MRI Brain- Perinatal hypoxic ischemic insult.

Presenting Concerns

Chief concerns: Developmental delay

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: H/o 1 spontaneous abortion and 1 still birth in mother

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 2.7 Kg
Cry at birth: Cried after stimulation
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Investigations done-

Hearing assessment: Done Details: OAE- B/l Pass. BERA- normal Vision assessment: Done Details: Were told concerns in vision

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 6 months
Roll over: Achieved

Age of attainment: 7 months
Sitting without support: Not achieved
Standing without support: Not achieved
Walking 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
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 11 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 11 months

Meaningful words: Not achieved

Details:: Partial neck control+. On prone- lifts head upto 65degree, from supine to sitting- lifts head in body plane

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: Achieved

Age of attainment: 3 months
Stranger anxiety: Not achieved
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

Type of Play : 1. Unoccupied Academic History:

Diet History:

Food preferences: Predominantly bottlefeeding.
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 3-4 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 7.7 Kg Height: 70 cm Head circumference: 41 cm

c. General Examination

Neurocutaneous markers: Ab Others: B/l squint+.

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypotonia
Deep tendon reflexes: Kj-3+/3+, AJ-2+/2+
Superficial reflexes: Plantars- B/l extensors

Oromotor Examination

Drooling: Yes
Chewing: Improper
Swallowing: Improper

Examination summary: Generalised hypotonia, AF - closed, DTR- brisk, plantar extensors. GDD. Visual fixation absent, alerts to sound but doesnt turn to sound. CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD with central hypotonia with microcephaly with squint

Advice

Intervention plan: Home startegies adviced
Evaluation: Neuromotor assessment
Investigations: EEG, Pediatric ophthalmologist opinion
Medications: Continue
Follow up plan: After investigations
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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