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OPD : 13-Jul-2026 11:23AM Demographic Details Child's Name: Himanshu Jatav Age: 10 Month 23 Days Gender: Male DOB: 2025-08-20 Contact: 7581869217 Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Sensory Concerns: Auditory: Fear of loud sounds Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Obstructed labor Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: NICU stay- 10 days. HIE 2 Past history: Hospitalization: No Seizures: Yes Past/Current therapies: Nil Past/Current medications: Syp Phenobarbitone given till 3 months age. Discontinued medicines. 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: Achieved Age of attainment: 8 months Unidextrous grasp: Achieved Age of attainment: 9 months Pincer grasp: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 9 months Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 9 months Babbling: Not achieved 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:- Social Social smile: Achieved Age of attainment: 6 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 : 3. Onlooker Academic History: Is child enrolled in school: No Diet History: Food preferences: predominantly milk. Vomits food. Food allergies: No Sleep History Total sleep duration (night): as per age Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Daily Screen Time Duration: Zero Type of screen: Mobile Examination a. Vitals: b. Anthropometry: Weight: 6.4 Kg Height: 67 cm Head circumference: 42 cm c. General Examination Dysmorphology: ab Neurocutaneous markers: ab d. CNS: Higher Mental Functions Consciousness: playful, social smile+ Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypotonia Deep tendon reflexes: KJ-2+/3+, AJ- 2+/3+ Superficial reflexes: Plantars- B/l extensors Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper Examination summary: AF closed, pull to sit- partial neck holding, prone- lifts head till 60degree, knuckle hyperpigmentation CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD Advice Intervention plan: Home startegies advised for early intervention. Diet advised. Investigations: VItamin B12 Follow up plan: Every month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 13-Jul-2026 11:23AM Demographic Details

Child's Name: Himanshu Jatav
Age: 10 Month 23 Days
Gender: Male
DOB: 2025-08-20
Contact: 7581869217

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Sensory Concerns:

Auditory: Fear of loud sounds

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Obstructed labor
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: NICU stay- 10 days. HIE 2

Past history:

Hospitalization: No Seizures: Yes

Past/Current therapies: Nil Past/Current medications: Syp Phenobarbitone given till 3 months age. Discontinued medicines. 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: Achieved

Age of attainment: 8 months

Unidextrous grasp: Achieved

Age of attainment: 9 months

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 9 months

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 9 months

Babbling: Not achieved

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:-

Social

Social smile: Achieved

Age of attainment: 6 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 : 3. Onlooker Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: predominantly milk. Vomits food.
Food allergies: No

Sleep History

Total sleep duration (night): as per age
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours

Daily Screen Time

Duration: Zero
Type of screen: Mobile

Examination

a. Vitals:

b. Anthropometry:

Weight: 6.4 Kg Height: 67 cm Head circumference: 42 cm

c. General Examination

Dysmorphology: ab Neurocutaneous markers: ab

d. CNS: Higher Mental Functions

Consciousness: playful, social smile+

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypotonia
Deep tendon reflexes: KJ-2+/3+, AJ- 2+/3+
Superficial reflexes: Plantars- B/l extensors

Oromotor Examination

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

Examination summary: AF closed, pull to sit- partial neck holding, prone- lifts head till 60degree, knuckle hyperpigmentation CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD

Advice

Intervention plan: Home startegies advised for early intervention. Diet advised.
Investigations: VItamin B12
Follow up plan: Every month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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