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Demographic Details Child's Name: Utkarsh Age: 1 Year 11 Month 22 Days Gender: Male DOB: 2024-04-03 Mother’s age (years): 23 years Mother’s occupation: Homemaker Father’s age (years): 30 years Father’s occupation: Farming Type of family: Joint Number of family members: 6 Number of siblings: 0 Address: Porsa Contact: 8889586833 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Developmental delay Duration of symptoms: Since birth Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: GDM Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: Not known (?2Kg) Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No If yes- Duration & Indication: Not admitted at birth Past history: Hospitalization: Yes Others: At 2 month- excessive crying (admitted for 3 months) Past/Current medications: Syp Cognigrow, becetam 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: 12 months Roll over: Achieved Age of attainment: 14 months Sitting without support: Achieved Age of attainment: 18 months Standing without support: Achieved Age of attainment: 20 months Walking without support: Achieved Age of attainment: 21 months Fine Motor Bidextrous grasp: Achieved Age of attainment: 18 months Unidextrous grasp: Achieved Age of attainment: 20 months Pincer grasp: Achieved Age of attainment: 24 months Language Receptive:- Joint attention: Achieved Age of attainment: Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following 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: 12 months Stranger anxiety: Achieved Age of attainment: 18 months Waving bye bye: Not achieved Asking for food and toilet: Not achieved Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 1. Unoccupied Academic History: Is child enrolled in school: No Diet History: Food preferences: Picky eating Junk food intake: Daily Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: Yes Duration of Afternoon nap: Infrequent naps Daily Screen Time Duration: <30 minutes Type of screen: Mobile Examination a. Vitals: b. Anthropometry: Weight: 8.9 Kg Height: 80 cm Head circumference: 42 cm c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypertonia Deep tandon reflexes: DTR- KJ 3+/3+, AJ 3+/3+ Other: Babinski sign- absent Oromotor Examination Drooling: Yes Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD Advice Intervention plan: To be planned after BERA Investigations: BERA General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Utkarsh
Age: 1 Year 11 Month 22 Days
Gender: Male
DOB: 2024-04-03
Mother’s age (years): 23 years
Mother’s occupation: Homemaker
Father’s age (years): 30 years
Father’s occupation: Farming
Type of family: Joint
Number of family members: 6
Number of siblings: 0
Address: Porsa
Contact: 8889586833
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Developmental delay
Duration of symptoms: Since birth

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. GDM

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: Not known (?2Kg)
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No
If yes- Duration & Indication: Not admitted at birth

Past history:

Hospitalization: Yes Others: At 2 month- excessive crying (admitted for 3 months)

Past/Current medications: Syp Cognigrow, becetam 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: 12 months
Roll over: Achieved

Age of attainment: 14 months
Sitting without support: Achieved

Age of attainment: 18 months
Standing without support: Achieved

Age of attainment: 20 months
Walking without support: Achieved

Age of attainment: 21 months

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 18 months

Unidextrous grasp: Achieved

Age of attainment: 20 months

Pincer grasp: Achieved

Age of attainment: 24 months

Language

Receptive:-

Joint attention: Achieved

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

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: 12 months
Stranger anxiety: Achieved

Age of attainment: 18 months
Waving bye bye: Not achieved
Asking for food and toilet: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Type of Play : 1. Unoccupied Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Picky eating
Junk food intake: Daily

Sleep History

Total sleep duration (night): 9-10 hours
Afternoon nap: Yes
Duration of Afternoon nap: Infrequent naps

Daily Screen Time

Duration: <30 minutes
Type of screen: Mobile

Examination

a. Vitals:

b. Anthropometry:

Weight: 8.9 Kg Height: 80 cm Head circumference: 42 cm

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypertonia
Deep tandon reflexes: DTR- KJ 3+/3+, AJ 3+/3+
Other: Babinski sign- absent

Oromotor Examination

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

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

Impression: GDD

Advice

Intervention plan: To be planned after BERA
Investigations: BERA
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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