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OPD : 05-Oct-2026 11:17AM Demographic Details Child's Name: Anshika Tomar Age: 1 Year 3 Month 8 Days Gender: Female DOB: 2025-06-27 Mother’s age (years): 21 years Mother’s occupation: Homemaker Father’s age (years): 28 years Father’s occupation: Railway Type of family: Joint Number of family members: 6 Number of siblings: 0 Address: Ambah Contact: 7898475362 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:: H/o 1 spontaneous abortion at 12 weeks prior to this pregnancy Natal and Postnatal History: Place of Birth: Institutional Gestational Age: FT Birth Weight: 1.7 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: No If yes- Duration & Indication: On day 1 admitted for 1 day. Day 3 bluish discoloration, unconsciousness ? hypoglycemia admitted for 1 month Past history: Hospitalization: Yes Seizures: Yes Others: H/o uprolling of eyeball Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: Partial. Roll over: Not achieved Sitting without support: Not achieved Standing without support: Not achieved Walking without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 10 months Unidextrous grasp: Achieved Age of attainment: 12 months Pincer grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Achieved Age of attainment: 11 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Achieved Age of attainment: 11 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: 9 months Stranger anxiety: Not achieved Waving bye bye: 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 milk Food allergies: No Junk food intake: Biscuits Sleep History Total sleep duration (night): 10-11 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 7.5 Kg Height: 72 cm cm Head circumference: 40 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypotonia Oromotor Examination Drooling: No Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper Examination summary: Generalised Hypotonia, DTR- reduced. Plantar- extensor, microcephaly. Pull to sit- partial head lag, prone bears weight on forearm, head lifted to 45 degrees. Inconsistently fixates to objects, alerts to sound present. AF- closed CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. Hypotonia. Advice Intervention plan: Home strategies advised Investigations: EEG. CPK. Thyroid profile Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 05-Oct-2026 11:17AM Demographic Details

Child's Name: Anshika Tomar
Age: 1 Year 3 Month 8 Days
Gender: Female
DOB: 2025-06-27
Mother’s age (years): 21 years
Mother’s occupation: Homemaker
Father’s age (years): 28 years
Father’s occupation: Railway
Type of family: Joint
Number of family members: 6
Number of siblings: 0
Address: Ambah
Contact: 7898475362

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:: H/o 1 spontaneous abortion at 12 weeks prior to this pregnancy

Natal and Postnatal History:

Place of Birth: Institutional
Gestational Age: FT
Birth Weight: 1.7 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: No
If yes- Duration & Indication: On day 1 admitted for 1 day. Day 3 bluish discoloration, unconsciousness ? hypoglycemia admitted for 1 month

Past history:

Hospitalization: Yes Seizures: Yes Others: H/o uprolling of eyeball

Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: Partial.
Roll over: Not achieved
Sitting without support: Not achieved
Standing without support: Not achieved
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 10 months

Unidextrous grasp: Achieved

Age of attainment: 12 months

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Achieved

Age of attainment: 11 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Achieved

Age of attainment: 11 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: 9 months
Stranger anxiety: Not achieved
Waving bye bye: 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 milk
Food allergies: No
Junk food intake: Biscuits

Sleep History

Total sleep duration (night): 10-11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 7.5 Kg Height: 72 cm cm Head circumference: 40 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypotonia

Oromotor Examination

Drooling: No
Chewing: Improper
Swallowing: Improper
Blowing: Improper
Sucking: Improper

Examination summary: Generalised Hypotonia, DTR- reduced. Plantar- extensor, microcephaly. Pull to sit- partial head lag, prone bears weight on forearm, head lifted to 45 degrees. Inconsistently fixates to objects, alerts to sound present. AF- closed CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD. Hypotonia.

Advice

Intervention plan: Home strategies advised
Investigations: EEG. CPK. Thyroid profile
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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