Create - Child Development Centre

Patient Details


OPD : 13-Jun-2026 10:53AM Demographic Details Child's Name: Ved Sullere Age: 1 Year 9 Month 15 Days Gender: Male DOB: 2024-08-29 Mother’s age (years): 26 years Mother’s occupation: Homemaker Father’s age (years): 28 years Father’s occupation: Indian railways Type of family: Joint Number of family members: 12 Number of siblings: 0 Address: Chhatarpur Contact: 7024726138 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Delayed Milestones Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: Late PT Birth Weight: 2 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Kept in NICU for 24 hrs for LBW Past history: Hospitalization: No Seizures: No Others: Breatholding spells from 7 months age. Frequent vomitings after food. Past/Current medications: Syp Carbamazepine started from 1 year age. currently 2.5 ml BD Investigations done- Hearing assessment: Done Details: Normal. Details not there 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 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 Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Drag for needs: Absent Joint attention: Absent Pointing: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months 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 : 3. Onlooker Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours Daily Screen Time Duration: <30 minutes Type of screen: TV Examination a. Vitals: b. Anthropometry: Weight: 8.6 Kg Height: 77 cm Head circumference: 47.5 cm c. General Examination Dysmorphology: Low set ears, mild depression of nasal bridge Neurocutaneous markers: Ab. Mongolian spot over back. d. CNS: Higher Mental Functions Consciousness: irritable Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Bulk of muscles: Wasting+ Tone: Hypotonia Deep tendon reflexes: KJ-1+/1+, AJ 1+/1+ Superficial reflexes: Plantars- flexors/flexors Oromotor Examination Drooling: Yes Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper Others: Frequent choking. Needs force feeding. CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD ? Genetic Advice Intervention plan: Intervention strategies adviced for home Evaluation: Neuromotor assessment 1 Investigations: CBC, Iron profile, CPK, EEG, Whole Exome Sequencing, Complete ophthalmological Examination. Follow up plan: After investigations General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 13-Jun-2026 10:53AM Demographic Details

Child's Name: Ved Sullere
Age: 1 Year 9 Month 15 Days
Gender: Male
DOB: 2024-08-29
Mother’s age (years): 26 years
Mother’s occupation: Homemaker
Father’s age (years): 28 years
Father’s occupation: Indian railways
Type of family: Joint
Number of family members: 12
Number of siblings: 0
Address: Chhatarpur
Contact: 7024726138
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Delayed Milestones

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: Late PT
Birth Weight: 2 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Kept in NICU for 24 hrs for LBW

Past history:

Hospitalization: No Seizures: No Others: Breatholding spells from 7 months age. Frequent vomitings after food.

Past/Current medications: Syp Carbamazepine started from 1 year age. currently 2.5 ml BD Investigations done-

Hearing assessment: Done Details: Normal. Details not there 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
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

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent
Drag for needs: Absent
Joint attention: Absent
Pointing: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
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 : 3. Onlooker Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed
Food allergies: No
Junk food intake: Nil

Sleep History

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

Daily Screen Time

Duration: <30 minutes
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 8.6 Kg Height: 77 cm Head circumference: 47.5 cm

c. General Examination

Dysmorphology: Low set ears, mild depression of nasal bridge Neurocutaneous markers: Ab. Mongolian spot over back.

d. CNS: Higher Mental Functions

Consciousness: irritable

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

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

Oromotor Examination

Drooling: Yes
Chewing: Proper
Swallowing: Proper
Blowing: Improper
Sucking: Improper
Others: Frequent choking. Needs force feeding.

CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD ? Genetic

Advice

Intervention plan: Intervention strategies adviced for home
Evaluation: Neuromotor assessment 1
Investigations: CBC, Iron profile, CPK, EEG, Whole Exome Sequencing, Complete ophthalmological Examination.
Follow up plan: After investigations
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

Setting Panel

Select Layout

Light Dark

Sidebar Color

Color Theme

Mini Sidebar

Sticky Header

Patient Details print

Select Layout

Sidebar Color

Color Theme

Patient Details