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Demographic Details Child's Name: Harshiv Gupta Age: 2 Year 2 Month 22 Days Gender: Male DOB: 2023-12-01 Mother’s age (years): 31 years Mother’s occupation: Housewife Father’s age (years): 35 years Father’s occupation: Private job (sewda) Type of family: Joint Number of family members: 5 Number of siblings: 1 Contact: 7489936093 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Developmental delay Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Obstructed labor Gestational Age: 32-34 wk Birth Weight: 2.2Kg Cry at birth: Delayed cry Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: PT, RDS, HIE3- admitted for 8 days, For Neonatal seziures, septic shock readmitted- ventilator for 1 day, on oxygen- 16 days, discharged on antiepileptics Past history: Hospitalization: No Others: H/o Seizures till 1.5 month age. No episodes after that Past/Current therapies: Physiotherapy Past/Current medications: Syp phenytoin, phenobarb. Currently levera 1.5ml BD Investigations done- Hearing assessment: Not done Vision assessment: Done Details: ROP- absent , Family history: Neuropsychiatric condition: Yes Details (If yes): H/o ID, epilepsy in 1st paternal cousin Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 8 months Roll over: Achieved Age of attainment: 12 months Sitting without support: Achieved Age of attainment: Standing without support: Achieved Age of attainment: 15 days Walking without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 12 months Unidextrous grasp: Achieved Age of attainment: 14 months Pincer grasp: Achieved Age of attainment: 18 months Language Receptive:- Joint attention: Achieved Age of attainment: 12 months Pointing: Achieved Age of attainment: 18 months Expressive:- Cooing: Achieved Age of attainment: 12 months Babbling: Achieved Age of attainment: 18 months Meaningful words: Achieved Age of attainment: Started using kinship words (20 mon) Expressive:- Cooing: Achieved Age of attainment: 12 months Babbling: Achieved Age of attainment: 18 months Meaningful words: Achieved Age of attainment: Started using kinship words (20 mon) Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Social smile: Achieved Age of attainment: 12 months Stranger anxiety: Achieved Age of attainment: 18 months 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 Academic History: Diet History: Food allergies: No Sleep History Afternoon nap: Yes Sleep disturbances: Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 10 Kg Height: 83 cm Head circumference: 42 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross Tone: Hypertonia Deep tandon reflexes: DTR- KJ-4+,4+, Ankle Clonus+, hyperextended knees, b/l equinovarus Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP (+PT) 3/week Investigations: Orthopedic opinion Medications: Continue levera (100mg/ml) General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Harshiv Gupta
Age: 2 Year 2 Month 22 Days
Gender: Male
DOB: 2023-12-01
Mother’s age (years): 31 years
Mother’s occupation: Housewife
Father’s age (years): 35 years
Father’s occupation: Private job (sewda)
Type of family: Joint
Number of family members: 5
Number of siblings: 1
Contact: 7489936093
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Developmental delay

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Obstructed labor
Gestational Age: 32-34 wk
Birth Weight: 2.2Kg
Cry at birth: Delayed cry
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: PT, RDS, HIE3- admitted for 8 days, For Neonatal seziures, septic shock readmitted- ventilator for 1 day, on oxygen- 16 days, discharged on antiepileptics

Past history:

Hospitalization: No Others: H/o Seizures till 1.5 month age. No episodes after that

Past/Current therapies: Physiotherapy Past/Current medications: Syp phenytoin, phenobarb. Currently levera 1.5ml BD Investigations done-

Hearing assessment: Not done Vision assessment: Done Details: ROP- absent ,

Family history:

Neuropsychiatric condition: Yes Details (If yes): H/o ID, epilepsy in 1st paternal cousin

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 8 months
Roll over: Achieved

Age of attainment: 12 months
Sitting without support: Achieved

Age of attainment:
Standing without support: Achieved

Age of attainment: 15 days
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 12 months

Unidextrous grasp: Achieved

Age of attainment: 14 months

Pincer grasp: Achieved

Age of attainment: 18 months

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 12 months
Pointing: Achieved

Age of attainment: 18 months

Expressive:-

Cooing: Achieved

Age of attainment: 12 months

Babbling: Achieved

Age of attainment: 18 months

Meaningful words: Achieved

Age of attainment: Started using kinship words (20 mon)

Expressive:-

Cooing: Achieved

Age of attainment: 12 months

Babbling: Achieved

Age of attainment: 18 months

Meaningful words: Achieved

Age of attainment: Started using kinship words (20 mon)

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 12 months
Stranger anxiety: Achieved

Age of attainment: 18 months

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

Academic History:

Diet History:

Food allergies: No

Sleep History

Afternoon nap: Yes
Sleep disturbances:

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 10 Kg Height: 83 cm Head circumference: 42 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross
Tone: Hypertonia
Deep tandon reflexes: DTR- KJ-4+,4+, Ankle Clonus+, hyperextended knees, b/l equinovarus

Oromotor Examination

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

Advice

Intervention plan: IDP (+PT) 3/week
Investigations: Orthopedic opinion
Medications: Continue levera (100mg/ml)
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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