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OPD : 15-Jun-2026 12:14PM Demographic Details Child's Name: Yuvraj Gupta Age: 1 Year 2 Month 5 Days Gender: Male DOB: 2025-04-10 Mother’s age (years): 31 years Mother’s occupation: Homemaker Father’s age (years): 31 years Father’s occupation: Shop Type of family: Joint Number of family members: 5 Number of siblings: 0 Address: Tikamgarh Contact: 7694870383 Referred By: Doctor Informant: Parents Interaction history: Eye contact: Poor Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: PIH Others:: Severe pruritus during last trimester Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Fetal distress. MSL. PIH Gestational Age: FT IUGR Birth Weight: 1.1 Kg Cry at birth: Delayed cry NICU stay: Yes If yes- Duration & Indication: Nicu stay- for 2 months (Sepsis, Respiratory distress, VLBW) Past history: Hospitalization: No Seizures: Yes Others: Abnormal body movements ? Infantile spasms 4-5 episodes in an hour, mostly immediately after waking up Past/Current medications: On Gardenal 3.5 ml BD. Tab clobazam 2.5 mg BD 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 Standing without support: Not achieved Walking without support: Not achieved Fine Motor Bidextrous grasp: Not achieved Unidextrous grasp: Not achieved Pincer grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Not achieved Babbling: Not achieved Meaningful words: Not achieved Expressive:- Cooing: Not achieved Babbling: Not achieved Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Not achieved Stranger anxiety: Not achieved 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 Type of Play : 1. Unoccupied Academic History: Is child enrolled in school: No Diet History: Food preferences: Eats in puree form. Choking episodes+ Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 1 hour 1-2 naps Sleep disturbances: Yes Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 6 Kg Height: 69 cm Head circumference: 40.5 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Bulk of muscles: Wasting+ Tone: Hypertonia Deep tendon reflexes: Exaggerated Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper Examination summary: GDD. CP. CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. CP. Advice Evaluation: Neuromotor assessment. Investigations: Neurologist opinion. Ophthalmologist opinion. BERA Follow up plan: After evaluations General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 15-Jun-2026 12:14PM Demographic Details

Child's Name: Yuvraj Gupta
Age: 1 Year 2 Month 5 Days
Gender: Male
DOB: 2025-04-10
Mother’s age (years): 31 years
Mother’s occupation: Homemaker
Father’s age (years): 31 years
Father’s occupation: Shop
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Address: Tikamgarh
Contact: 7694870383
Referred By: Doctor
Informant: Parents

Interaction history:

Eye contact: Poor

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. PIH
Others:: Severe pruritus during last trimester

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Fetal distress. MSL. PIH
Gestational Age: FT IUGR
Birth Weight: 1.1 Kg
Cry at birth: Delayed cry
NICU stay: Yes
If yes- Duration & Indication: Nicu stay- for 2 months (Sepsis, Respiratory distress, VLBW)

Past history:

Hospitalization: No Seizures: Yes Others: Abnormal body movements ? Infantile spasms 4-5 episodes in an hour, mostly immediately after waking up

Past/Current medications: On Gardenal 3.5 ml BD. Tab clobazam 2.5 mg BD 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
Standing without support: Not achieved
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Unidextrous grasp: Not achieved

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Not achieved

Babbling: Not achieved

Meaningful words: Not achieved

Expressive:-

Cooing: Not achieved

Babbling: Not achieved

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Not achieved
Stranger anxiety: Not achieved
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

Type of Play : 1. Unoccupied Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Eats in puree form. Choking episodes+
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1 hour 1-2 naps
Sleep disturbances: Yes

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 6 Kg Height: 69 cm Head circumference: 40.5 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Bulk of muscles: Wasting+
Tone: Hypertonia
Deep tendon reflexes: Exaggerated

Oromotor Examination

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

Examination summary: GDD. CP. CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD. CP.

Advice

Evaluation: Neuromotor assessment.
Investigations: Neurologist opinion. Ophthalmologist opinion. BERA
Follow up plan: After evaluations
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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