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OPD : 07-Oct-2026 09:17AM Demographic Details Child's Name: Shivam Kushwah Age: 11 Month 6 Days Gender: Male DOB: 2025-10-31 Mother’s age (years): 21 years Mother’s occupation: Homemaker Father’s age (years): 22 years Father’s occupation: Private job Type of family: Joint Number of siblings: 0 Address: Gohad Contact: 7828053391 Referred By: Doctor Informant: Parents Investigations done: MRI Brain- Volume loss with multifocal gliosis, thinning of corpus callosum. s/o perinatal insult. Presenting Concerns Chief concerns: Delayed milestones Interaction history: Eye contact: Fleeting Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: Anemia in last trimester Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Gestational Age: FT Birth Weight: 2.6 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: 25 days. Perinatal asphyxia, sepsis Past history: Hospitalization: No Seizures: No 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 Language Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 4 months Stranger anxiety: 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 breastfeed Food allergies: No Junk food intake: Biscuits Sleep History Total sleep duration (night): as per age Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 9.5 Kg Height: 60 cm Head circumference: 37 cm c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypertonia Deep tendon reflexes: KJ-3+/3+, AJ-3+/3+ Superficial reflexes: Plantars- B/l extensors Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper Examination summary: On pull to sit- complete head lag, prone - doesnt lift head, doesnt bear weight on forearm. Doesnt fixate or follow objects, doesnt alerts to sound. AF- closed, microcephaly CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. (HIE sequelae) Advice Intervention plan: IDP + PT 3/week Investigations: BERA. Ophthal examination Medications: Continue as adviced by pediatrician Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 07-Oct-2026 09:17AM Demographic Details

Child's Name: Shivam Kushwah
Age: 11 Month 6 Days
Gender: Male
DOB: 2025-10-31
Mother’s age (years): 21 years
Mother’s occupation: Homemaker
Father’s age (years): 22 years
Father’s occupation: Private job
Type of family: Joint
Number of siblings: 0
Address: Gohad
Contact: 7828053391
Referred By: Doctor
Informant: Parents
Investigations done: MRI Brain- Volume loss with multifocal gliosis, thinning of corpus callosum. s/o perinatal insult.

Presenting Concerns

Chief concerns: Delayed milestones

Interaction history:

Eye contact: Fleeting

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: Anemia in last trimester

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Gestational Age: FT
Birth Weight: 2.6 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: 25 days. Perinatal asphyxia, sepsis

Past history:

Hospitalization: No Seizures: No

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

Language

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 4 months
Stranger anxiety: 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 breastfeed
Food allergies: No
Junk food intake: Biscuits

Sleep History

Total sleep duration (night): as per age

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 9.5 Kg Height: 60 cm Head circumference: 37 cm

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

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

Oromotor Examination

Drooling: Yes
Chewing: Improper
Swallowing: Improper
Blowing: Improper
Sucking: Improper

Examination summary: On pull to sit- complete head lag, prone - doesnt lift head, doesnt bear weight on forearm. Doesnt fixate or follow objects, doesnt alerts to sound. AF- closed, microcephaly CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD. (HIE sequelae)

Advice

Intervention plan: IDP + PT 3/week
Investigations: BERA. Ophthal examination
Medications: Continue as adviced by pediatrician
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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