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Demographic Details Child's Name: Pranam Yadav Age: 1 Year 2 Month 25 Days Gender: Male DOB: 2024-11-25 Mother’s age (years): 22 years Mother’s occupation: Homemaker Father’s age (years): 24 years Father’s occupation: Farmer Type of family: Joint Number of family members: 22 Number of siblings: 1 Address: Near Tighra Road Contact: 6261698861 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Developmental delay Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Non progression of labor Gestational Age: FT Birth Weight: 2.6 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: On day 3 admitted for refusal to feed. (Hypoglyce,ic seizures, Hypocalcemia)10 days Past history: Hospitalization: Yes Others: At 8 months- abnormal body movements in the form of jerks 6-7 times /day. Past/Current medications: On Syp Encorate 2ml BD, Syp Nucarno Ds 2ml BD, Syp Noocet BD 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: 6 months Roll over: Not achieved Sitting without support: Not achieved Fine Motor Bidextrous grasp: Not achieved Language Receptive:- Joint attention: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Not achieved Stranger anxiety: 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: Predominantly milk, doesnt want rto chew Sleep History Total sleep duration (night): At night- on a stretch 7 hours then 3-4 hours Afternoon nap: Yes Sleep disturbances: Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 8 Kg Height: 79 cm Head circumference: 45 cm c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypotonia Deep tandon reflexes: KJ-2+/2+, AJ-+/+ Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: Motor assessment 1, IDP (+PT) 2/week, PMT 1/mon. Stop Bottlefeeding Investigations: BERA, Complete ophthalmological examination, Thyroid profile Medications: Continue Syp encorate (200mg/5ml) BD General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Pranam Yadav
Age: 1 Year 2 Month 25 Days
Gender: Male
DOB: 2024-11-25
Mother’s age (years): 22 years
Mother’s occupation: Homemaker
Father’s age (years): 24 years
Father’s occupation: Farmer
Type of family: Joint
Number of family members: 22
Number of siblings: 1
Address: Near Tighra Road
Contact: 6261698861
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Developmental delay

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Non progression of labor
Gestational Age: FT
Birth Weight: 2.6 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: On day 3 admitted for refusal to feed. (Hypoglyce,ic seizures, Hypocalcemia)10 days

Past history:

Hospitalization: Yes Others: At 8 months- abnormal body movements in the form of jerks 6-7 times /day.

Past/Current medications: On Syp Encorate 2ml BD, Syp Nucarno Ds 2ml BD, Syp Noocet BD 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: 6 months
Roll over: Not achieved
Sitting without support: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Not achieved
Stranger anxiety: 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: Predominantly milk, doesnt want rto chew

Sleep History

Total sleep duration (night): At night- on a stretch 7 hours then 3-4 hours
Afternoon nap: Yes
Sleep disturbances:

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 8 Kg Height: 79 cm Head circumference: 45 cm

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypotonia
Deep tandon reflexes: KJ-2+/2+, AJ-+/+

Oromotor Examination

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

Advice

Intervention plan: Motor assessment 1, IDP (+PT) 2/week, PMT 1/mon. Stop Bottlefeeding
Investigations: BERA, Complete ophthalmological examination, Thyroid profile
Medications: Continue Syp encorate (200mg/5ml) BD
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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