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OPD : 22-May-2026 06:04PM Demographic Details Child's Name: Fatima Age: 7 Month 16 Days Gender: Female DOB: 2025-10-06 Mother’s age (years): 27 years Mother’s occupation: Housewife Father’s age (years): 27 years Father’s occupation: private job Type of family: Joint Number of family members: 8 Number of siblings: 0 Address: shivpuri Contact: 9131756877 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Delayed development Duration of symptoms: Since birth Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Hypothyroidism Others:: Thyroid screening- not done Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 3.1 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: Admitted for 10 days for HIE2. RD. Past history: Hospitalization: No Others: No seizures after newborn period Past/Current therapies: Nil Investigations done- Hearing assessment: Not done Vision assessment: Done Details: Normal Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Not achieved Roll over: Not achieved Sitting 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: 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: 6 months Stranger anxiety: 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: Diet History: Food preferences: On bottlefeeding Food allergies: No Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 naps of 1-2 hours Daily Screen Time Duration: <30 minutes Type of screen: Mobile Examination a. Vitals: b. Anthropometry: Weight: 5 Kg Height: 64 cm Head circumference: 38 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypertonia Deep tendon reflexes: Exaggerated Superficial reflexes: Absent Oromotor Examination Drooling: No Swallowing: Improper Others: No teeth eruption till date. Frequent choking. Examination summary: Complete head lag, scissoring on vertical suspension. Social interaction is good. CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. CP. Microcephaly Advice Intervention plan: Neurodevelopmental therapy +Physiotherapy . Home startegies adviced Investigations: MRI Brain. OAE/ BERA. Medications: As adviced by pediatrician Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 22-May-2026 06:04PM Demographic Details

Child's Name: Fatima
Age: 7 Month 16 Days
Gender: Female
DOB: 2025-10-06
Mother’s age (years): 27 years
Mother’s occupation: Housewife
Father’s age (years): 27 years
Father’s occupation: private job
Type of family: Joint
Number of family members: 8
Number of siblings: 0
Address: shivpuri
Contact: 9131756877
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Delayed development
Duration of symptoms: Since birth

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Hypothyroidism
Others:: Thyroid screening- not done

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 3.1 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: Admitted for 10 days for HIE2. RD.

Past history:

Hospitalization: No Others: No seizures after newborn period

Past/Current therapies: Nil Investigations done-

Hearing assessment: Not done Vision assessment: Done Details: Normal

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Not achieved
Roll over: Not achieved
Sitting 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: 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: 6 months
Stranger anxiety: 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:

Diet History:

Food preferences: On bottlefeeding
Food allergies: No

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 naps of 1-2 hours

Daily Screen Time

Duration: <30 minutes
Type of screen: Mobile

Examination

a. Vitals:

b. Anthropometry:

Weight: 5 Kg Height: 64 cm Head circumference: 38 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypertonia
Deep tendon reflexes: Exaggerated
Superficial reflexes: Absent

Oromotor Examination

Drooling: No
Swallowing: Improper
Others: No teeth eruption till date. Frequent choking.

Examination summary: Complete head lag, scissoring on vertical suspension. Social interaction is good. CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD. CP. Microcephaly

Advice

Intervention plan: Neurodevelopmental therapy +Physiotherapy . Home startegies adviced
Investigations: MRI Brain. OAE/ BERA.
Medications: As adviced by pediatrician
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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