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Demographic Details Child's Name: Hazlal Khan Age: 11 Month 10 Days Gender: Male DOB: 2025-04-07 Mother’s age (years): 23 years Mother’s occupation: Homemaker Father’s age (years): 25 years Father’s occupation: Private job Type of family: Joint Number of family members: 13 Number of siblings: 1 Address: Tigra Road Contact: 7804033376 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Delayed milestones Interaction history: Eye contact: Sustained Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: Yes If yes Degree: 3 Type of conception: Natural High-risk factors in pregnancy: Oligohydramnios Others:: 4 spontaneous abortion (in 1st trimester). Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Oligohydramnios Gestational Age: ?32-34 wk Birth Weight: 2.5 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: Nicu- stay 14 days (under oxygen) Past history: Hospitalization: No Seizures: No Past/Current therapies: 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: 8 months Roll over: Not achieved Sitting without support: Not achieved Fine Motor Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Details:: started using kinship words (papa for father) Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Social smile: Achieved Age of attainment: 2 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 Academic History: Diet History: Food preferences: Complimentary feed started at 6 months Food allergies: No Junk food intake: Biscuits Sleep History Total sleep duration (night): Appropriate as per age Afternoon nap: Yes Duration of Afternoon nap: 1-2 naps Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 6.8 Kg Height: 72 cm Head circumference: 46 cm c. General Examination Dysmorphology: Triangular facies, low set ear, depressed nasal bridge Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Bulk of muscles: wasting+ Tone: Hypertonia Deep tandon reflexes: DTR- KJ3+/3+, AJ-2+/2+ Other: AF -wide open Oromotor Examination Drooling: No Swallowing: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD with SAM ? HIE ? Genetic Advice Intervention plan: IDP (+PT) 3 /week + PMT 1/month Investigations: MRI Brain (Later), CBC, S. Calcium, S. Vitamin D2, Thyroid profile General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Hazlal Khan
Age: 11 Month 10 Days
Gender: Male
DOB: 2025-04-07
Mother’s age (years): 23 years
Mother’s occupation: Homemaker
Father’s age (years): 25 years
Father’s occupation: Private job
Type of family: Joint
Number of family members: 13
Number of siblings: 1
Address: Tigra Road
Contact: 7804033376
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Delayed milestones

Interaction history:

Eye contact: Sustained

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: Yes
If yes Degree: 3
Type of conception: Natural
High-risk factors in pregnancy:
1. Oligohydramnios
Others:: 4 spontaneous abortion (in 1st trimester).

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Oligohydramnios
Gestational Age: ?32-34 wk
Birth Weight: 2.5 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: Nicu- stay 14 days (under oxygen)

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: 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: 8 months
Roll over: Not achieved
Sitting without support: Not achieved

Fine Motor

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Details:: started using kinship words (papa for father)

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 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

Academic History:

Diet History:

Food preferences: Complimentary feed started at 6 months
Food allergies: No
Junk food intake: Biscuits

Sleep History

Total sleep duration (night): Appropriate as per age
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 naps

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 6.8 Kg Height: 72 cm Head circumference: 46 cm

c. General Examination

Dysmorphology: Triangular facies, low set ear, depressed nasal bridge Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Bulk of muscles: wasting+
Tone: Hypertonia
Deep tandon reflexes: DTR- KJ3+/3+, AJ-2+/2+
Other: AF -wide open

Oromotor Examination

Drooling: No
Swallowing: Proper

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

Impression: GDD with SAM ? HIE ? Genetic

Advice

Intervention plan: IDP (+PT) 3 /week + PMT 1/month
Investigations: MRI Brain (Later), CBC, S. Calcium, S. Vitamin D2, Thyroid profile
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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