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Demographic Details Child's Name: Harsh Kushwah Age: 1 Year 8 Month 9 Days Gender: Male DOB: 2024-06-08 Mother’s age (years): 28 years Mother’s occupation: Homemaker Father’s age (years): 33 years Father’s occupation: Pvt job Type of family: Nuclear Number of family members: 3 Number of siblings: 0 Address: Shivpuri Contact: 8358933476 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Delayed development Interaction history: Eye contact: Sustained Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: Obstructed labor, H/o clavicular fracture Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 3Kg Cry at birth: Delayed cry NICU stay: Yes If yes- Duration & Indication: NICU stay 12 days, HIE, gradenal and levera given till 1 year age Past history: Hospitalization: Yes Seizures: No Others: Febrile seizure Past/Current therapies: Took PT 3 months Investigations done- Hearing assessment: Done Vision assessment: Done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 1 year Roll over: Achieved Age of attainment: 13 months Sitting without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 12 months Unidextrous grasp: Achieved Age of attainment: 14 months Pincer grasp: Not achieved Language Receptive:- Joint attention: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 12 months Waving bye bye: 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: EBF till 6 months. Then complimentary feed started Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Sleep disturbances: Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 10.9 Kg Height: 82 cm Head circumference: 47 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypotonia Deep tandon reflexes: DTR : KJ 2+/2+ Oromotor Examination Drooling: Yes CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD with Right sided hemiparesis with UMN facial palsy Advice Intervention plan: Parents counselled (Continue Physiotherapy at Shivpuri) + Home program advised Investigations: DQ, Motor assessment, Language and speech evaluation Follow up plan: Review after 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Harsh Kushwah
Age: 1 Year 8 Month 9 Days
Gender: Male
DOB: 2024-06-08
Mother’s age (years): 28 years
Mother’s occupation: Homemaker
Father’s age (years): 33 years
Father’s occupation: Pvt job
Type of family: Nuclear
Number of family members: 3
Number of siblings: 0
Address: Shivpuri
Contact: 8358933476
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Delayed development

Interaction history:

Eye contact: Sustained

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: Obstructed labor, H/o clavicular fracture

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 3Kg
Cry at birth: Delayed cry
NICU stay: Yes
If yes- Duration & Indication: NICU stay 12 days, HIE, gradenal and levera given till 1 year age

Past history:

Hospitalization: Yes Seizures: No Others: Febrile seizure

Past/Current therapies: Took PT 3 months Investigations done-

Hearing assessment: Done Vision assessment: Done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 1 year
Roll over: Achieved

Age of attainment: 13 months
Sitting without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 12 months

Unidextrous grasp: Achieved

Age of attainment: 14 months

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 12 months
Waving bye bye: 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: EBF till 6 months. Then complimentary feed started

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Sleep disturbances:

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 10.9 Kg Height: 82 cm Head circumference: 47 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypotonia
Deep tandon reflexes: DTR : KJ 2+/2+

Oromotor Examination

Drooling: Yes

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

Impression: GDD with Right sided hemiparesis with UMN facial palsy

Advice

Intervention plan: Parents counselled (Continue Physiotherapy at Shivpuri) + Home program advised
Investigations: DQ, Motor assessment, Language and speech evaluation
Follow up plan: Review after 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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