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OPD : 04-Jun-2026 05:20PM Demographic Details Child's Name: Darshita Jain Age: 6 Month 19 Days Gender: Female DOB: 2025-11-16 Mother’s age (years): 25 years Mother’s occupation: Homemaker Father’s age (years): 29 years Father’s occupation: Shop Type of family: Nuclear Number of family members: 13 Number of siblings: 1 Details of siblings (Age and sex): 5 year old female Address: Chandranagar, Chhatarpur Contact: 7999903125 Referred By: Healthcare worker Informant: Parents Presenting Concerns Chief concerns: Developmental delay, Strengths of child: seizures Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Hypothyroidism Others:: Fever epiosdes. Neonatal screening- normal Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 3.2 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: NICU stay- 17 days for HIE 2. discharged on syp phenobarbitone. Past history: Hospitalization: Yes Seizures: Yes Others: On gardenal since birth. From 6 month of age seizure started again, multifocal seizure multiple episodes in a day Investigations done- Hearing assessment: Done Details: OAE- pass Vision assessment: Done Details: Normal Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Not achieved Roll over: Not achieved Fine Motor Bidextrous grasp: Not achieved Unidextrous grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Expressive:- Cooing: Not achieved Babbling: Not achieved Expressive:- Cooing: Not achieved Babbling: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: Stranger anxiety: Achieved Age of attainment: 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: On breastfeeding Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): sleeps 18 hours in a day Afternoon nap: Yes Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 4.04 Kg Height: 57 cm Head circumference: 35 cm c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Bulk of muscles: Generalised wasting Tone: Hypertonia Deep tendon reflexes: exagerrated/ exagerrated Superficial reflexes: Plantar- b/l extensor Oromotor Examination Drooling: No Examination summary: hypertonia, dystonia +. Fixation to objects absent, doesnt alerts to sound. Pull to sit- uplifts head. prone- lifts head, bears weight on forearm. Increased extensor tone. CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. high risk of Cerebral Palsy Advice Intervention plan: Stimulation therapy for home. Complimentary feeding. Medications: Continue carbamazepine 0.7 ml TDS, syp baclofen ml 1 BD. Syp Gardenal 2.5 ml HS. Review after 7 days Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play

OPD : 04-Jun-2026 05:20PM Demographic Details

Child's Name: Darshita Jain
Age: 6 Month 19 Days
Gender: Female
DOB: 2025-11-16
Mother’s age (years): 25 years
Mother’s occupation: Homemaker
Father’s age (years): 29 years
Father’s occupation: Shop
Type of family: Nuclear
Number of family members: 13
Number of siblings: 1
Details of siblings (Age and sex): 5 year old female
Address: Chandranagar, Chhatarpur
Contact: 7999903125
Referred By: Healthcare worker
Informant: Parents

Presenting Concerns

Chief concerns: Developmental delay,

Strengths of child: seizures

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Hypothyroidism
Others:: Fever epiosdes. Neonatal screening- normal

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 3.2 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: NICU stay- 17 days for HIE 2. discharged on syp phenobarbitone.

Past history:

Hospitalization: Yes Seizures: Yes Others: On gardenal since birth. From 6 month of age seizure started again, multifocal seizure multiple episodes in a day

Investigations done-

Hearing assessment: Done Details: OAE- pass Vision assessment: Done Details: Normal

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Not achieved
Roll over: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Unidextrous grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved

Expressive:-

Cooing: Not achieved

Babbling: Not achieved

Expressive:-

Cooing: Not achieved

Babbling: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment:
Stranger anxiety: Achieved

Age of attainment:

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: On breastfeeding
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): sleeps 18 hours in a day
Afternoon nap: Yes

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 4.04 Kg Height: 57 cm Head circumference: 35 cm

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Bulk of muscles: Generalised wasting
Tone: Hypertonia
Deep tendon reflexes: exagerrated/ exagerrated
Superficial reflexes: Plantar- b/l extensor

Oromotor Examination

Drooling: No

Examination summary: hypertonia, dystonia +. Fixation to objects absent, doesnt alerts to sound. Pull to sit- uplifts head. prone- lifts head, bears weight on forearm. Increased extensor tone. CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD. high risk of Cerebral Palsy

Advice

Intervention plan: Stimulation therapy for home. Complimentary feeding.
Medications: Continue carbamazepine 0.7 ml TDS, syp baclofen ml 1 BD. Syp Gardenal 2.5 ml HS. Review after 7 days
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play

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