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Demographic Details Child's Name: Tanishk Yadav Age: 8 Month 16 Days Gender: Male DOB: 2025-06-09 Mother’s age (years): 28 years Mother’s occupation: Homemaker Father’s age (years): 36 years Father’s occupation: Business Number of family members: 13 Number of siblings: 4 Details of siblings (Age and sex): 1- 4 years male Address: Sabalgarh Contact: 7247206861 Referred By: Doctor Presenting Concerns Chief concerns: Dev delay Duration of symptoms: Since birth Interaction history: Eye contact: Sustained Behavioral history: Birth & Perinatal History: Antenatal History Type of conception: Natural High-risk factors in pregnancy: Hypothyroidism Others:: Gestational hypothyroidism. L thyoxine was taken Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 3.4 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Admitted on day 1 for NNHB and Rh incompatibility (For 15 days). H/o Neonatal seizures. Exchange transfusion done. Syp phenobarb for 1 mon post discharge Past history: Hospitalization: No Seizures: No Investigations done- Hearing assessment: Done Details: OAE- normal Vision assessment: Not done Family history: Neuropsychiatric condition: Yes Others: H/o ID in distant relatives Developmental History: Gross Motor Neck holding: Roll over: Not achieved Fine Motor Bidextrous grasp: Not achieved Language Receptive:- Joint attention: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Social smile: Achieved Age of attainment: 2 mon Stranger anxiety: Achieved Age of attainment: 7 mon 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 after 6 month Sleep History Total sleep duration (night): Total duration - 6hrs (divided into 2-3 hours) Afternoon nap: Yes Daily Screen Time Duration: < 2 hours Examination a. Vitals: b. Anthropometry: Weight: 7.6 Kg Height: 63 cm Head circumference: 43.5 cm c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Deep tandon reflexes: DTR KJ- 2+/2+,AJ-2+,2+ Oromotor Examination Others: Pull to sit- head lag, curved back. Social interaction- good CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP (2/week) Investigations: Thyroid profile General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Tanishk Yadav
Age: 8 Month 16 Days
Gender: Male
DOB: 2025-06-09
Mother’s age (years): 28 years
Mother’s occupation: Homemaker
Father’s age (years): 36 years
Father’s occupation: Business
Number of family members: 13
Number of siblings: 4
Details of siblings (Age and sex): 1- 4 years male
Address: Sabalgarh
Contact: 7247206861
Referred By: Doctor

Presenting Concerns

Chief concerns: Dev delay
Duration of symptoms: Since birth

Interaction history:

Eye contact: Sustained

Behavioral history:

Birth & Perinatal History: Antenatal History

Type of conception: Natural
High-risk factors in pregnancy:
1. Hypothyroidism
Others:: Gestational hypothyroidism. L thyoxine was taken

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 3.4 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Admitted on day 1 for NNHB and Rh incompatibility (For 15 days). H/o Neonatal seizures. Exchange transfusion done. Syp phenobarb for 1 mon post discharge

Past history:

Hospitalization: No Seizures: No

Investigations done-

Hearing assessment: Done Details: OAE- normal Vision assessment: Not done

Family history:

Neuropsychiatric condition: Yes Others: H/o ID in distant relatives

Developmental History:

Gross Motor

Neck holding:
Roll over: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 mon
Stranger anxiety: Achieved

Age of attainment: 7 mon
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 after 6 month

Sleep History

Total sleep duration (night): Total duration - 6hrs (divided into 2-3 hours)
Afternoon nap: Yes

Daily Screen Time

Duration: < 2 hours

Examination

a. Vitals:

b. Anthropometry:

Weight: 7.6 Kg Height: 63 cm Head circumference: 43.5 cm

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Deep tandon reflexes: DTR KJ- 2+/2+,AJ-2+,2+

Oromotor Examination

Others: Pull to sit- head lag, curved back. Social interaction- good

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

Advice

Intervention plan: IDP (2/week)
Investigations: Thyroid profile
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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