Create - Child Development Centre

Patient Details


OPD : 11-May-2026 12:06PM Demographic Details Child's Name: Harshit Kumar Age: 10 Month 16 Days Gender: Male DOB: 2025-06-25 Mother’s age (years): 21 years Mother’s occupation: Homemaker Father’s age (years): 30 years Father’s occupation: Farmer Type of family: Joint Number of family members: 7 Number of siblings: 0 Address: Dhaulpur Contact: 8058774542 Referred By: Doctor Informant: Mother father Presenting Concerns Chief concerns: Delayed development Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Maternal age at conception (years):: 20 Type of conception: Natural High-risk factors in pregnancy: Oligohydramnios Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Leaking pv, oligohydramnios Gestational Age: PT (7 mon gestation) Birth Weight: 900gm Cry at birth: Cried immediately after birth NICU stay: Yes If yes- Duration & Indication: 40 days. Under O2. PT RDS NNHB Past history: Hospitalization: Yes Seizures: No Others: Admitted at 2 months of age for pneumonia for 2 days Past/Current therapies: Nil Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Not achieved Roll over: Not achieved Sitting without support: Not achieved Fine Motor Bidextrous grasp: Not achieved Unidextrous grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: 9 monthjs Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 9 monthjs Babbling: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Drag for needs: Absent Joint attention: Absent Pointing: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 9 months Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- 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: On topfeeding bottlefeeding. Sleep History Total sleep duration (night): as per age Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 6 Kg Height: 68cm Head circumference: 39.5 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: 1 cafe au lait maule over abdomen 1.5*1 cm d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Deep tendon reflexes: KJ-3+/3+, Plantar- 2+/2+ Superficial reflexes: Plantar- extensors Oromotor Examination Drooling: No Chewing: Improper Swallowing: Improper Examination summary: Pull to sit- partial head lag, prone- lifts head till 30 degree. Tone decreased, on supine- abduction at hip CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD Advice Intervention plan: IDP (+PT) 2/week Evaluation: BERA, Pediatric ophthalmology reference Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 11-May-2026 12:06PM Demographic Details

Child's Name: Harshit Kumar
Age: 10 Month 16 Days
Gender: Male
DOB: 2025-06-25
Mother’s age (years): 21 years
Mother’s occupation: Homemaker
Father’s age (years): 30 years
Father’s occupation: Farmer
Type of family: Joint
Number of family members: 7
Number of siblings: 0
Address: Dhaulpur
Contact: 8058774542
Referred By: Doctor
Informant: Mother father

Presenting Concerns

Chief concerns: Delayed development

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Maternal age at conception (years):: 20
Type of conception: Natural
High-risk factors in pregnancy:
1. Oligohydramnios

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Leaking pv, oligohydramnios
Gestational Age: PT (7 mon gestation)
Birth Weight: 900gm
Cry at birth: Cried immediately after birth
NICU stay: Yes
If yes- Duration & Indication: 40 days. Under O2. PT RDS NNHB

Past history:

Hospitalization: Yes Seizures: No Others: Admitted at 2 months of age for pneumonia for 2 days

Past/Current therapies: Nil Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

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

Fine Motor

Bidextrous grasp: Not achieved

Unidextrous grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 9 monthjs

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 9 monthjs

Babbling: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent
Drag for needs: Absent
Joint attention: Absent
Pointing: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 9 months

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

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: On topfeeding bottlefeeding.

Sleep History

Total sleep duration (night): as per age

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 6 Kg Height: 68cm Head circumference: 39.5 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: 1 cafe au lait maule over abdomen 1.5*1 cm

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Deep tendon reflexes: KJ-3+/3+, Plantar- 2+/2+
Superficial reflexes: Plantar- extensors

Oromotor Examination

Drooling: No
Chewing: Improper
Swallowing: Improper

Examination summary: Pull to sit- partial head lag, prone- lifts head till 30 degree. Tone decreased, on supine- abduction at hip CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD

Advice

Intervention plan: IDP (+PT) 2/week
Evaluation: BERA, Pediatric ophthalmology reference
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

Setting Panel

Select Layout

Light Dark

Sidebar Color

Color Theme

Mini Sidebar

Sticky Header

Patient Details print

Select Layout

Sidebar Color

Color Theme

Patient Details