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Patient Details


OPD : 18-May-2026 02:53PM Demographic Details Child's Name: Shivansh Gupta Age: 10 Month 28 Days Gender: Male DOB: 2025-06-20 Type of family: Nuclear Number of family members: 4 Number of siblings: 1 Details of siblings (Age and sex): 5 year male Address: Datia Contact: 9111331885 Referred By: Doctor Informant: Parents Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Repetitive behaviors (RRBs): Mouthing of objects Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: GDM Others:: Medications were not required Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Malpresentation Gestational Age: 35 weeks Birth Weight: 1.7 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: 18 days. Oxygenation- 7 days. Sepsis, thromobocytopenia- 4 Platelet transfusion Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Done Details: BERA- profound hearing loss Vision assessment: Done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 8 months Roll over: Achieved Age of attainment: 9 months Sitting without support: Not achieved Standing without support: Not achieved Walking without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Achieved Age of attainment: 8 months Pincer grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: 9 months Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 9 months 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: 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: Prefers eating in puree form Sleep History Total sleep duration (night): as per age Afternoon nap: Yes Duration of Afternoon nap: 2 naps- 1-2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Drooling: No Others: No teeth eruptions CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD with Profound hearing impairment Advice Intervention plan: IDP +PT 3 days/week. (Home strategies advised) Investigations: MRI Brain+ MR spectroscopy. Repeat BERA. CBC, thyroid profile, Calcium, Vitamin D, Vitamin B12 Medications: As adviced by pediatricians Follow up plan: Review after consultation with ENT specialist General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 18-May-2026 02:53PM Demographic Details

Child's Name: Shivansh Gupta
Age: 10 Month 28 Days
Gender: Male
DOB: 2025-06-20
Type of family: Nuclear
Number of family members: 4
Number of siblings: 1
Details of siblings (Age and sex): 5 year male
Address: Datia
Contact: 9111331885
Referred By: Doctor
Informant: Parents

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Repetitive behaviors (RRBs): Mouthing of objects

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. GDM
Others:: Medications were not required

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Malpresentation
Gestational Age: 35 weeks
Birth Weight: 1.7 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: 18 days. Oxygenation- 7 days. Sepsis, thromobocytopenia- 4 Platelet transfusion

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Nil Investigations done-

Hearing assessment: Done Details: BERA- profound hearing loss Vision assessment: Done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 8 months
Roll over: Achieved

Age of attainment: 9 months
Sitting without support: Not achieved
Standing without support: Not achieved
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp: Achieved

Age of attainment: 8 months

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 9 months

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 9 months

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: 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: Prefers eating in puree form

Sleep History

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

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Drooling: No
Others: No teeth eruptions

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

Impression: GDD with Profound hearing impairment

Advice

Intervention plan: IDP +PT 3 days/week. (Home strategies advised)
Investigations: MRI Brain+ MR spectroscopy. Repeat BERA. CBC, thyroid profile, Calcium, Vitamin D, Vitamin B12
Medications: As adviced by pediatricians
Follow up plan: Review after consultation with ENT specialist
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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