OPD :
01-Jul-2026 06:05PM
Demographic Details
- :
Sahisha
- :
4 Year
- :
Female
- :
2022-06-17
- :
0
- :
7909847646
- :
Doctor
- :
Parents
Presenting Concerns
- :
Right side weakness of body
Interaction history:
- :
Sustained
- :
age-appropriate
Behavioral history:
Temper tantrums
Stubbornness
Birth & Perinatal History:
Antenatal History
- :
Yes
- :
3
-
High-risk factors in pregnancy:
- Pre-eclampsia
Natal and Postnatal History:
- :
Institutional
- :
NVD
- :
28 weeks
- :
1.2 Kg
- :
Delayed cry
- :
Yes
- :
Yes
- :
NICU stay- 1 month (PT RDS) ON MN - 5 days
Past history:
:
No
:
No
Investigations done-
:
Not done
:
Done
:
Normal
Family history:
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
4 months
-
:
Achieved
:
5 months
-
:
Achieved
:
8 months
-
:
Achieved
:
3.5 years
-
:
Achieved
:
after 3.5 years
-
:
Not achieved
-
:
Not achieved
Fine Motor
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
12 months
:
Not achieved
Language
Receptive:-
-
:
Achieved
:
8 months
-
:
Achieved
:
12 months
-
:
Achieved
:
- :
2-step
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
2 years
:
Achieved
:
3 years
:
Not achieved
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
2 years
:
Achieved
:
3 years
:
Not achieved
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Consistent
- :
Consistent
- :
Consistent
- :
Consistent meaningful pointing
- :
Consistent
- :
2-step
Answering Questions:-
:
Absent
:
Absent
Social
-
:
Achieved
:
2 months
-
:
Achieved
:
6 months
-
:
Achieved
:
9 months
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
Response to Name Call
Sitting tolerance- (in minutes)
ADL Skills (Age-appropriate)-
- :
2. Started attempting
- :
2. Started attempting
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
Type of Play : 5. Associative
Academic History:
- :
No
Diet History:
- :
Mixed
- :
No
- :
Daily
Sleep History
- :
10-11 hours
- :
No
Daily Screen Time
-
:
> 5 hours
- :
Mobile and TV
Examination
a. Vitals:
b. Anthropometry:
:
10.6 Kg
:
93 cm
:
44.5 cm
c. General Examination
:
Ab
:
Ab
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
- :
Gross motor and Fine motor
- :
Generalised Wasting+
- :
Hypertonia
- :
KJ - 3+/2+, AJ-2+/2+
- :
Hemiparetic, toe walking on Rt side
Oromotor Examination
- :
No
- :
Proper
- :
Proper
- :
Proper
- :
Proper
:
Rt side hemiparesis, speech delay. :
NAD
:
NAD
:
NAD
Advice
- :
Neuromotor assessment 1
- :
After assessment
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food