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OPD : 19-May-2026 04:49PM Demographic Details Child's Name: Lavya Kushwah Age: 2 Year 1 Month 26 Days Gender: Female DOB: 2024-03-23 Mother’s age (years): 25 years Mother’s occupation: Homemaker Father’s age (years): 26 years Father’s occupation: Private job Type of family: Joint Number of family members: 9 Number of siblings: 1 Details of siblings (Age and sex): 6 year old female Address: Bhind Contact: 8964878336 Referred By: Doctor Informant: Mother, maternal uncle Presenting Concerns Chief concerns: Development delay Interaction history: Eye contact: Sustained Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: H/o 1 spontaneous abortion in mother Natal and Postnatal History: Place of Birth: Home Mode of Delivery: NVD Gestational Age: FT Birth Weight: Not known If yes- Duration & Indication: Event during labor not known- ? Distress Past history: Hospitalization: Yes Seizures: No Past/Current therapies: Nil Past/Current medications: 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: 4 months Roll over: Achieved Age of attainment: 5 months Sitting without support: Achieved Age of attainment: 7 months 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: 6 months Pincer grasp: Achieved Age of attainment: 12 months Scribbling: Not achieved Drinking from cup: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Drag for needs: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Not achieved 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 Type of Play : 3. Onlooker Academic History: Is child enrolled in school: No Diet History: Food preferences: Predominantly milk by bottle Food allergies: No Junk food intake: nil Sleep History Total sleep duration (night): 10-11 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 9.4 Kg Height: 76 cm Head circumference: 44 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypotonia Deep tendon reflexes: KJ-ab, AJ- ab Superficial reflexes: Plantar- extensor/extensor Other: Kyperpigmented knuckles, Pallor+, Tremors+ , Ptosis Left eye Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. ITS Advice Intervention plan: Parents counselled. Diet adviced Investigations: CBC, Iron profile, S calcium, Thyroid profile, Vitamin D, Vitamin B12, CPK Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 19-May-2026 04:49PM Demographic Details

Child's Name: Lavya Kushwah
Age: 2 Year 1 Month 26 Days
Gender: Female
DOB: 2024-03-23
Mother’s age (years): 25 years
Mother’s occupation: Homemaker
Father’s age (years): 26 years
Father’s occupation: Private job
Type of family: Joint
Number of family members: 9
Number of siblings: 1
Details of siblings (Age and sex): 6 year old female
Address: Bhind
Contact: 8964878336
Referred By: Doctor
Informant: Mother, maternal uncle

Presenting Concerns

Chief concerns: Development delay

Interaction history:

Eye contact: Sustained

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: H/o 1 spontaneous abortion in mother

Natal and Postnatal History:

Place of Birth: Home
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: Not known
If yes- Duration & Indication: Event during labor not known- ? Distress

Past history:

Hospitalization: Yes Seizures: No

Past/Current therapies: Nil Past/Current medications: 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: 4 months
Roll over: Achieved

Age of attainment: 5 months
Sitting without support: Achieved

Age of attainment: 7 months
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: 6 months

Pincer grasp: Achieved

Age of attainment: 12 months

Scribbling: Not achieved

Drinking from cup: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent
Drag for needs: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Not achieved
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

Type of Play : 3. Onlooker Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Predominantly milk by bottle
Food allergies: No
Junk food intake: nil

Sleep History

Total sleep duration (night): 10-11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 9.4 Kg Height: 76 cm Head circumference: 44 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypotonia
Deep tendon reflexes: KJ-ab, AJ- ab
Superficial reflexes: Plantar- extensor/extensor
Other: Kyperpigmented knuckles, Pallor+, Tremors+ , Ptosis Left eye

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Improper
Sucking: Improper

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

Impression: GDD. ITS

Advice

Intervention plan: Parents counselled. Diet adviced
Investigations: CBC, Iron profile, S calcium, Thyroid profile, Vitamin D, Vitamin B12, CPK
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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