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OPD : 27-Jul-2026 12:18PM Demographic Details Child's Name: Jigyansh Tyagi Age: 2 Year 4 Month 3 Days Gender: Male DOB: 2024-03-24 Mother’s age (years): 35 years Mother’s occupation: Homemaker Father’s age (years): 37 years Father’s occupation: Farmer Type of family: Joint Number of siblings: 0 Address: Joura Contact: 9009117962 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Delayed milestones Strengths of child: Interaction is good Interaction history: Eye contact: Suboptimal Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Hypothyroidism Others:: H/o still births in previous 4 pregnancies Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Gestational Age: 26 wks Birth Weight: 920 gm Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: Nicu stay- 85 days. CPAP- 15 days. PT ELBW, apnea of prematurity, NEC, ivh, RDS. Self amptation of left hand Past history: Hospitalization: No Others: Focal seizures noted since few months Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Not done Vision assessment: Done Details: ROP- spontaneous regression Family history: Neuropsychiatric condition: No Others: 4 still births Developmental History: Gross Motor Neck holding: Not achieved Roll over: Not achieved Sitting without support: Not achieved Standing without support: Not achieved Walking without support: Not achieved Fine Motor Bidextrous grasp: Not achieved Unidextrous grasp: Achieved Age of attainment: 12 months Pincer grasp: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 1 years Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 1 year Babbling: Achieved Age of attainment: after 1 year Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 1 year Babbling: Achieved Age of attainment: after 1 year Meaningful words: Not achieved Details:: Receptive language better Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Drag for needs: Absent Joint attention: Absent Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Social Social smile: Achieved Age of attainment: 1 year Stranger anxiety: Achieved Age of attainment: 1 year Waving bye bye: Achieved Age of attainment: 2 year Asking for food and toilet: Not achieved Response to Name Call Sitting tolerance- (in minutes) Details:: Alerts to sound 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: Mixed Food allergies: No Junk food intake: 1-2/week Sleep History Total sleep duration (night): 8-9 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Daily Screen Time Duration: <30 minutes Examination a. Vitals: b. Anthropometry: Weight: 8 Kg Head circumference: 49 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypotonia Deep tendon reflexes: KJ- 3+/2+, AJ- 2+/2+ Superficial reflexes: Plantars- flexors/flexors Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Proper Blowing: Improper Sucking: Improper Examination summary: Hypotonia, CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD with hypotonia Advice Evaluation: Neuromotor assessment 1 Investigations: MRI Brain, EEG. CBC, Ca, Vitamin D, Vitamin B12, thyroid profile, ophthalmologist opinion, OAE/BERA Follow up plan: After evaluations General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 27-Jul-2026 12:18PM Demographic Details

Child's Name: Jigyansh Tyagi
Age: 2 Year 4 Month 3 Days
Gender: Male
DOB: 2024-03-24
Mother’s age (years): 35 years
Mother’s occupation: Homemaker
Father’s age (years): 37 years
Father’s occupation: Farmer
Type of family: Joint
Number of siblings: 0
Address: Joura
Contact: 9009117962
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Delayed milestones

Strengths of child: Interaction is good

Interaction history:

Eye contact: Suboptimal

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Hypothyroidism
Others:: H/o still births in previous 4 pregnancies

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Gestational Age: 26 wks
Birth Weight: 920 gm
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: Nicu stay- 85 days. CPAP- 15 days. PT ELBW, apnea of prematurity, NEC, ivh, RDS. Self amptation of left hand

Past history:

Hospitalization: No Others: Focal seizures noted since few months

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

Hearing assessment: Not done Vision assessment: Done Details: ROP- spontaneous regression

Family history:

Neuropsychiatric condition: No Others: 4 still births

Developmental History:

Gross Motor

Neck holding: Not achieved
Roll over: Not achieved
Sitting without support: Not achieved
Standing without support: Not achieved
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Unidextrous grasp: Achieved

Age of attainment: 12 months

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 1 years
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 1 year

Babbling: Achieved

Age of attainment: after 1 year

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 1 year

Babbling: Achieved

Age of attainment: after 1 year

Meaningful words: Not achieved

Details:: Receptive language better

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Emerging
Drag for needs: Absent
Joint attention: Absent
Pointing: Absent
Understanding gestures: Absent
Following commands (gesture + verbal): Nil

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 1 year
Stranger anxiety: Achieved

Age of attainment: 1 year
Waving bye bye: Achieved

Age of attainment: 2 year
Asking for food and toilet: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

Details:: Alerts to sound

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: Mixed
Food allergies: No
Junk food intake: 1-2/week

Sleep History

Total sleep duration (night): 8-9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours

Daily Screen Time

Duration: <30 minutes

Examination

a. Vitals:

b. Anthropometry:

Weight: 8 Kg Head circumference: 49 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypotonia
Deep tendon reflexes: KJ- 3+/2+, AJ- 2+/2+
Superficial reflexes: Plantars- flexors/flexors

Oromotor Examination

Drooling: Yes
Chewing: Improper
Swallowing: Proper
Blowing: Improper
Sucking: Improper

Examination summary: Hypotonia, CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD with hypotonia

Advice

Evaluation: Neuromotor assessment 1
Investigations: MRI Brain, EEG. CBC, Ca, Vitamin D, Vitamin B12, thyroid profile, ophthalmologist opinion, OAE/BERA
Follow up plan: After evaluations
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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