OPD :
18-May-2026 02:04PM
Demographic Details
- :
Kunal Yadav
- :
1 Year 10 Month 11 Days
- :
Male
- :
2024-07-07
- :
35 years
- :
Homemaker
- :
38 years
- :
Farmer
- :
Joint
- :
4
- :
1
- :
9 year old female
- :
Jhansi (Babina)
- :
7390055016
- :
Mother, Paternal grandmother and brothers
Interaction history:
- :
Sustained
- :
age-appropriate
Behavioral history:
Temper tantrums
Stubbornness
Sensory Concerns:
- :
Fear of loud sounds
Birth & Perinatal History:
Antenatal History
- :
No
- :
Natural
Natal and Postnatal History:
- :
Institutional
- :
NVD
- :
FT
- :
2.5 Kg
- :
Delayed cry
- :
Yes
- :
12-13 days. Neonatal seizures. NNHB.
Past history:
:
No
:
At 1 mon- BT for anemia.
:
Nil
Investigations done-
:
Not done
:
Not done
Family history:
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
4 months
-
:
Achieved
:
12 months
-
:
Achieved
:
18 months
-
:
Not achieved
-
:
Not achieved
Fine Motor
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Not achieved
Language
Receptive:-
-
:
Achieved
:
9 months
-
:
Achieved
:
12 months
- :
Not following
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
12 months
:
Not achieved
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
12 months
:
Not achieved
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Consistent
- :
Consistent
- :
Consistent
- :
Consistent meaningful pointing
- :
Emerging
- :
Nil
Answering Questions:-
Social
-
:
Achieved
:
2 months
-
:
Achieved
:
8 months
-
:
Achieved
:
18 months
Response to Name Call
Sitting tolerance- (in minutes)
ADL Skills (Age-appropriate)-
- :
2. Started attempting
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
:
Gives cues
Type of Play : 3. Onlooker
Academic History:
- :
No
Diet History:
- :
Mixed diet
- :
No
- :
Occasional
Sleep History
- :
9-10 hours
- :
Yes
- :
2 hours
Daily Screen Time
Examination
a. Vitals:
b. Anthropometry:
:
11 Kg
:
81 cm
:
44 cm
c. General Examination
:
NAD
:
NAD
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
- :
Gross motor and Fine motor
- :
Hypertonia
- :
KJ-2+/2+, AJ- 2+/2+
- :
Present
- :
Toe walking
Oromotor Examination
- :
Yes
- :
Proper
- :
Proper
- :
Proper
- :
Proper
:
Squint+, Decreased movement of right limbs :
NAD
:
NAD
:
NAD
:
GDD. Rt sided hemiparesis.
Advice
- :
To be discussed after evaluation
- :
Neuromotor assessment 1
- :
MRI Brain, BERA, Ophthalmological examination. CBC, S calcium, S. Vitamin D, S vitamin B12, LFT, RFT
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food
|