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OPD : 01-Jun-2026 10:53AM Demographic Details Child's Name: Aashutosh Asati Age: 1 Year 1 Month 5 Days Gender: Male DOB: 2025-04-27 Mother’s age (years): 37 years Mother’s occupation: Homemaker Father’s age (years): 38 years Father’s occupation: Shop Type of family: Joint Number of siblings: 3 Details of siblings (Age and sex): 10y.9y.5y females Address: Chhatarpur Contact: 7566489028 Referred By: Healthcare worker Informant: Parents Presenting Concerns Chief concerns: Development delay Duration of symptoms: Since birth 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: During transportation Mode of Delivery: NVD Gestational Age: FT Birth Weight: 2.9 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: Breech presentation, difficult labor. HIE 2, MV- 4 days, NICU stay- 1 month. Discharged on AED- 2 mon. MRI brain- mild cerebral atrophic changes, Periventricular white matter cahnges. Past history: Hospitalization: No Others: Syp Levilex started 1 month back 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. 1 year 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 Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: 11 months Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 11 months Babbling: 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: 3 months Stranger anxiety: Achieved Age of attainment: 8 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: Is child enrolled in school: No Diet History: Food preferences: Predominantly bottlefeeding Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 11-12 hours Afternoon nap: Yes Sleep disturbances: No Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 7 Kg Height: 77 cm Head circumference: 43 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypotonia Deep tendon reflexes: KH- 3+/3+, AJ -2+/2+ Superficial reflexes: Plantars- flexors/flexors Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper Examination summary: Generalised hypotonia. V shaped upper lip, maxillary prominence CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. Hypotonia. Birth asphyxia sequelae ? Genetic Advice Evaluation: Neuromotor assessment 1 Medications: Continue as adviced as pediatrician Follow up plan: Follow up after 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 01-Jun-2026 10:53AM Demographic Details

Child's Name: Aashutosh Asati
Age: 1 Year 1 Month 5 Days
Gender: Male
DOB: 2025-04-27
Mother’s age (years): 37 years
Mother’s occupation: Homemaker
Father’s age (years): 38 years
Father’s occupation: Shop
Type of family: Joint
Number of siblings: 3
Details of siblings (Age and sex): 10y.9y.5y females
Address: Chhatarpur
Contact: 7566489028
Referred By: Healthcare worker
Informant: Parents

Presenting Concerns

Chief concerns: Development delay
Duration of symptoms: Since birth

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: During transportation
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 2.9 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: Breech presentation, difficult labor. HIE 2, MV- 4 days, NICU stay- 1 month. Discharged on AED- 2 mon. MRI brain- mild cerebral atrophic changes, Periventricular white matter cahnges.

Past history:

Hospitalization: No Others: Syp Levilex started 1 month back

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. 1 year
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

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 11 months

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 11 months

Babbling: 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: 3 months
Stranger anxiety: Achieved

Age of attainment: 8 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:

Is child enrolled in school: No

Diet History:

Food preferences: Predominantly bottlefeeding
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 11-12 hours
Afternoon nap: Yes
Sleep disturbances: No

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 7 Kg Height: 77 cm Head circumference: 43 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypotonia
Deep tendon reflexes: KH- 3+/3+, AJ -2+/2+
Superficial reflexes: Plantars- flexors/flexors

Oromotor Examination

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

Examination summary: Generalised hypotonia. V shaped upper lip, maxillary prominence CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD. Hypotonia. Birth asphyxia sequelae ? Genetic

Advice

Evaluation: Neuromotor assessment 1
Medications: Continue as adviced as pediatrician
Follow up plan: Follow up after 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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