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OPD : 02-Jun-2026 05:02PM Demographic Details Child's Name: Astitva Dangaur Age: 1 Year 2 Month 30 Days Gender: Male DOB: 2025-03-03 Mother’s age (years): 25 years Mother’s occupation: Homemaker Father’s age (years): 29 years Father’s occupation: Bouncer Type of family: Joint Number of family members: 5 Number of siblings: 0 Address: Jhansi Contact: 9621210764 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Developmental delay Strengths of child: Social interaction Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Mouthing of objects Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Indication for LSCS (if applicable): Malpresentation Gestational Age: 32 weeks Birth Weight: 1.8 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: On day 3 admitted for RDS. NICU stay 5 days Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Nil 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: Achieved Age of attainment: Partial (12 mon) Sitting without support: Not achieved Standing 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: 6 months Babbling: Not achieved Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Not achieved Meaningful words: Not achieved Details:: Says amma inconsistently. Brings hands to midline and started doing mouthing 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:- Echolalia: Absent Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 9 months 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: Complimentary feeding Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 2 naps- 2- 3 hours Sleep disturbances: No Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 7.5 Kg Height: 74 cm Head circumference: 41 cm c. General Examination Dysmorphology: depressed nasal bridge, flat occiput, pinna small, curved Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Consciousness: alert, playful Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Bulk of muscles: Wasting present Tone: Hypotonia Deep tendon reflexes: 1+/1+ Superficial reflexes: Plnatar- flexor/flexor Oromotor Examination Drooling: No Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper Others: Frequent choking Examination summary: Generalised hypotonia. On pull to sit- lifts his, back curved. Prone- lifts head till >60 degree, bears weight on forearms CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD with generalised hyptonia and microcephaly s/o central etiology ? Genetic Advice Investigations: CBC, Thyroid profile, CPK, Calcium, RBS, LFT, RFT, Vitamin D. MRI Brain + MR spectroscopy, BERA, Ophthal examination. Whole exome sequencing (Later) General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 02-Jun-2026 05:02PM Demographic Details

Child's Name: Astitva Dangaur
Age: 1 Year 2 Month 30 Days
Gender: Male
DOB: 2025-03-03
Mother’s age (years): 25 years
Mother’s occupation: Homemaker
Father’s age (years): 29 years
Father’s occupation: Bouncer
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Address: Jhansi
Contact: 9621210764
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Developmental delay

Strengths of child: Social interaction

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Mouthing of objects

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Indication for LSCS (if applicable): Malpresentation
Gestational Age: 32 weeks
Birth Weight: 1.8 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: On day 3 admitted for RDS. NICU stay 5 days

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Nil 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: Achieved

Age of attainment: Partial (12 mon)
Sitting without support: Not achieved
Standing 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: 6 months

Babbling: Not achieved

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Not achieved

Meaningful words: Not achieved

Details:: Says amma inconsistently. Brings hands to midline and started doing mouthing

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:-

Echolalia: Absent

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 9 months
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: Complimentary feeding
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 naps- 2- 3 hours
Sleep disturbances: No

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 7.5 Kg Height: 74 cm Head circumference: 41 cm

c. General Examination

Dysmorphology: depressed nasal bridge, flat occiput, pinna small, curved Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Consciousness: alert, playful

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Bulk of muscles: Wasting present
Tone: Hypotonia
Deep tendon reflexes: 1+/1+
Superficial reflexes: Plnatar- flexor/flexor

Oromotor Examination

Drooling: No
Chewing: Improper
Swallowing: Improper
Blowing: Improper
Sucking: Improper
Others: Frequent choking

Examination summary: Generalised hypotonia. On pull to sit- lifts his, back curved. Prone- lifts head till >60 degree, bears weight on forearms CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD with generalised hyptonia and microcephaly s/o central etiology ? Genetic

Advice

Investigations: CBC, Thyroid profile, CPK, Calcium, RBS, LFT, RFT, Vitamin D. MRI Brain + MR spectroscopy, BERA, Ophthal examination. Whole exome sequencing (Later)
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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