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OPD : 13-Jul-2026 05:30PM Demographic Details Child's Name: Himanshu Kushwah Age: 2 Year 1 Month 2 Days Gender: Male DOB: 2024-06-11 Mother’s age (years): 26 years Mother’s occupation: Homemaker Father’s age (years): 26 years Father’s occupation: Farming Type of family: Joint Number of family members: 6 Number of siblings: 0 Details of siblings (Age and sex): Currently ANC 9 mon Address: Baira, shivpuri Contact: 7610646522 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Delayed milestones Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Sensory Concerns: Auditory: Hypersensitive Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 2.5 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: NICU stay- 1.5 months, On MV- 2 days, HIE 2 Past history: Hospitalization: No Seizures: Yes Past/Current therapies: Nil Past/Current medications: Phenobarb till 3 months 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 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: Achieved Age of attainment: 1.5 years Babbling: Not achieved Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 1.5 years Babbling: Not achieved Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Drag for needs: Absent Joint attention: Absent Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Social Social smile: Not achieved Stranger anxiety: Not achieved Waving bye bye: Not achieved Comes when called: Not achieved Response to Name Call Details: 1/10 Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Predominantly milk Type of Play : 1. Unoccupied Academic History: Is child enrolled in school: No Diet History: Food preferences: Predominantly milk Food allergies: No Junk food intake: nil Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 7kg Height: 68 cm Head circumference: 43 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: KJ-3+/3+, AJ-2+/2+ Superficial reflexes: Plantars- B/l extensors Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. Spastic Quadriplegic cerebral palsy Advice Intervention plan: After assessment. Physical sessions + Home strategies for early intervention Evaluation: Neuromotor assessment 1 Follow up plan: Every month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 13-Jul-2026 05:30PM Demographic Details

Child's Name: Himanshu Kushwah
Age: 2 Year 1 Month 2 Days
Gender: Male
DOB: 2024-06-11
Mother’s age (years): 26 years
Mother’s occupation: Homemaker
Father’s age (years): 26 years
Father’s occupation: Farming
Type of family: Joint
Number of family members: 6
Number of siblings: 0
Details of siblings (Age and sex): Currently ANC 9 mon
Address: Baira, shivpuri
Contact: 7610646522
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Delayed milestones

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Sensory Concerns:

Auditory: Hypersensitive

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 2.5 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: NICU stay- 1.5 months, On MV- 2 days, HIE 2

Past history:

Hospitalization: No Seizures: Yes

Past/Current therapies: Nil Past/Current medications: Phenobarb till 3 months 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

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: Achieved

Age of attainment: 1.5 years

Babbling: Not achieved

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 1.5 years

Babbling: Not achieved

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent
Drag for needs: Absent
Joint attention: Absent
Pointing: Absent
Understanding gestures: Absent
Following commands (gesture + verbal): Nil

Answering Questions:-

Social

Social smile: Not achieved
Stranger anxiety: Not achieved
Waving bye bye: Not achieved
Comes when called: Not achieved

Response to Name Call

Details: 1/10

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Details:: Predominantly milk

Type of Play : 1. Unoccupied Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Predominantly milk
Food allergies: No
Junk food intake: nil

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 7kg Height: 68 cm Head circumference: 43 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: KJ-3+/3+, AJ-2+/2+
Superficial reflexes: Plantars- B/l extensors

Oromotor Examination

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

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

Impression: GDD. Spastic Quadriplegic cerebral palsy

Advice

Intervention plan: After assessment. Physical sessions + Home strategies for early intervention
Evaluation: Neuromotor assessment 1
Follow up plan: Every month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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