OPD :
20-Apr-2026 10:25AM
Demographic Details
- :
Rehnuma Khan
- :
7 Month 8 Days
- :
Female
- :
2025-09-12
- :
27 years
- :
Homemaker
- :
32 years
- :
Teacher
- :
Joint
- :
13
- :
1
- :
4 year old female
- :
Datia
- :
9131160273
- :
Doctor
- :
Parents
Presenting Concerns
- :
Delayed development
Interaction history:
Behavioral history:
Birth & Perinatal History:
Antenatal History
- :
Yes
- :
3
- :
Natural
Natal and Postnatal History:
- :
Institutional
- :
LSCS
- :
Prev LSCS
- :
FT
- :
2.4Kg
- :
Cried immediately after birth
- :
No
- :
Yes
- :
On day 2 for NNHB for 1 day
Past history:
:
No
:
No
Investigations done-
:
Not done
:
Not done
Family history:
:
No
Developmental History:
Gross Motor
-
:
Not achieved
-
:
Not achieved
Fine Motor
:
Not achieved
:
Not achieved
Language
Receptive:-
-
:
Not achieved
-
:
Not achieved
Expressive:-
:
Not achieved
:
Not achieved
Expressive:-
:
Not achieved
:
Not achieved
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Absent
Answering Questions:-
Social
-
:
Not achieved
-
:
Not achieved
Response to Name Call
Sitting tolerance- (in minutes)
ADL Skills (Age-appropriate)-
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
Type of Play : 1. Unoccupied
Academic History:
Diet History:
- :
On bottlefeeding (Buffalo's milk)
Sleep History
- :
At night 4-5 hours
-
:
Yes
Daily Screen Time
Examination
a. Vitals:
b. Anthropometry:
:
4.8 Kg
:
60 cm
:
39 cm
c. General Examination
:
Downs phenotype
:
Mongolian spot
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
- :
Gross motor and Fine motor
- :
Severe generalised wasting
- :
Hypotonia
- :
KJ-1+,1+, AJ- ab/ab
Oromotor Examination
- :
No
- :
Improper
- :
Improper
:
NAD
:
NAD
:
NAD
:
Trisomy 21.
Advice
- :
IDP (+PT) 3/week
- :
Thyroid profile
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food