Neenad, a 2 year 8 month old male, was born prematurely at 34 weeks gestation due to his mother's uncontrolled hypertension during pregnancy. He had developmental delays, with gross motor skills significantly delayed. He was able to say some words at 1.5 years old but feeding difficulties persisted. Two months prior he experienced seizure-like episodes. He is currently admitted for physiotherapy to address his developmental delays.

1. General Clinics

2. Demographic Details
Name : Neenad
Age : 2 years 8 months
Gender : male
Date of birth :5th
February 2013
Religion: Hindu
Place : Mangalore
Date of admission: 10th
October 2015
Informant : mother
Reliability : good

3. Chief Complaint
- Developmental delay
Currently admitted for second round of
physiotherapy.

4. Birth History

5. Antenatal History
- Birth order : first child
- Mother was 27 years old when she was
pregnant with the child.
First trimester
- Mother conceived spontaneously.
- She was a booked case.
- Folic acid tablets were taken.
- No history of fever with rash.
- No history of drug intake or radiation
exposure.

6. Second trimester
- Quickening felt at 5th
month of gestation.
- Regular antenatal check-ups were attended.
- Iron and calcium supplementation taken.
- Two doses of tetanus toxoid injections taken.
- No h/s/o Pre-eclampsia,GDM,Anemia
- No h/o Bleeding PV
Third trimester
- Regular antenatal check-ups attended.
- Fetal movements were well appreciated.
- Mother was diagnosed to have hypertension during one
of her antenatal check-ups and she received medication
for the same.
- No h/o GDM,Burning micturition, Suprapubic
pain,Bleeding PV.

7. Natal History
- Labour was induced at 34 weeks of gestation due
to uncontrolled hypertension in the mother at
Government Lady Goschen Hospital on 5th
February 2013.
- Normal vaginal delivery.
- No history of instrumentation or prolonged
labour.
- Baby did not cry immediately after birth.
- Baby was shifted to NICU soon after birth, airway
was stabilised and mother’s breast milk was
withheld.
- Birth weight is 2.125kg.

8. Postnatal History
- Baby was transferred from Government Lady
Goschen Hospital NICU to KMC Hospital Attavar
NICU on the 4th
postnatal day.
- Baby remained in NICU for 1 month.
- Expressed breast milk from the mother was
introduced at the end of first week, given as
pallada feeds.
- Breastfeeding started at the end of 4th
week.
- No history of poor feeding and occasional
regurgitation of milk.
- Baby was discharged after a total duration of 1.5
months of stay at KMC Hospital Attavar.

9. Developmental History
Domains of
development
Milestones Age of
attainment
Expected age of
attainment
Developmental
quotient (DQ)
Gross Motor Head control
Rolling over
-
-
3 months
5 months
(0 months/32 months)
x 100%
= 0%
Fine Motor Immature
pincer grasp
2 years 9 months (9 months/32 months)
x 100%
=28%
Personal and
Social
Asks for food
when hungry
2 years 8
months
2 years (24 months/32
months) x 100%
= 75%
Speech Monosyllables 1.5 years 6 months (6 months/32 months)
x 100%
= 19%

10. - Mother complains that child never attained
head control, is unable to get up or even turn
about in bed.
- Child’s first active movements were noticed
by mother around 1.5 years of age. Child
would move both upper limbs, more so in the
left upper limb, with both palms closed in a
fist.
- By the end of 2 years, child was actively
moving the left arm, reaching out to objects
with his fingers, right hand still held firm with
the palm closed in a fist.

11. - Child recognises the mother, maintains eye
contact with her, laughs out loud when happy.
- Child could say ‘ma,ba’ at the end of 1.5 years.
- He could convey that he is hungry.
- Child is dry by day.
- Feeding the child has been difficult because
child’s appetite is less, after 3-4 mouthfuls, he
refuses further feeding.
- No history of occasional nasal regurgitation,
coughing during feeding or spillage from
either angles of the mouth.

12. Two months back, when the mother was
feeding him in the morning, she noticed
deviation of the left angle of the mouth,
lasting for about 5 seconds. No history of loss
of consciousness. Mother took the child to
RAPCC on the same day. Child was admitted
and started on medications.
Mother was informed about the
developmental delay and was told to start
physiotherapy for her child. Child was
discharged and was given syrup for the
seizures to be taken once daily at night.

13. One month later, child developed another
similar episode and was brought to RAPCC.
The child’s seizure medication was changed
and physiotherapy was given. The child was
discharged and was adviced to come back
after 1 month for physiotherapy and review of
medication.
No history of any regression of milestones,
projectile vomiting, altered sensorium, cranial
nerve involvement, bowel and bladder
incontinence, constipation, lethargy, fever or
generalised seizures.

14. Immunization History
- Child is immunised up to date.
- BCG scar is seen on the left upper arm.
- Last immunization was at the age of 1.5 years.

15. Diet History
Child was exclusively breastfed until 4 months of age and
complementary feeding was started thereafter with ragi
Time Food Energy (Kcal) Protein ( grams)
8.30 am ½ glass milk
½ dosa
33.5
61
1.65
1.55
10.00 am ½ glass milk
1 banana
33.5
46
1.65
0.48
12.00 pm ½ cup sambhar
½ cup boiled rice
68
88
3.25
1.7
4.00 pm ½ glass milk
3 rusk
33.5
50
1.65
0.5
8.00 pm ½ cup sambhar
½ cup boiled rice
68
88
3.25
1.7
Total 569.5 17.38
RDA 1150 18.2
Deficit 580.5 0.82

16. 2 years
8 months
29 years33 years
Family history
 Child is born out of a non-consanguinous marriage
 No history of similar complaints in the family