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OPD : 04-Apr-2026 10:12AM Demographic Details Child's Name: Sushant Sen Age: 8 Year 6 Month 21 Days Gender: Male DOB: 2017-09-14 Contact: 7524803767 Behavioral history: 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: 4.5 Kg Cry at birth: Delayed cry Resuscitation required: Yes If yes- Duration & Indication: On day 4 admitted in Jhansi for 8 days. HIE 2. Discharged on Gardenal Past history: Hospitalization: Yes Seizures: Yes Others: At 1.5 years seizure episodes (GTCS) noted f/b LOC, last episodes 2 days back Past/Current medications: Syp Levesam 2.5 ml BD, T Lacoxa 1/4th OD Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Any recent stressful events in family: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 6 years Roll over: Achieved Age of attainment: 7 years Sitting without support: Achieved Age of attainment: 7 years Standing without support: Not achieved Walking without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 3 years Unidextrous grasp: Achieved Age of attainment: 4 years Pincer grasp: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 3 years Pointing: Achieved Age of attainment: Understanding gestures: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: 6 years Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 6 years Babbling: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Social smile: Achieved Age of attainment: 3 year Stranger anxiety: Achieved Age of attainment: 3 years Waving bye bye: Not achieved Comes when called: Achieved Age of attainment: 3 years 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 : 3. Onlooker Academic History: Is child enrolled in school: No Diet History: Food allergies: No Sleep History Total sleep duration (night): 8 hours Afternoon nap: No Sleep disturbances: Daily Screen Time Duration: < 2 hours Examination a. Vitals: b. Anthropometry: Weight: 20 Kg Height: 117 cm Head circumference: 48 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: 1 cafe au lait macule 0.5*0.5 cm over lower back Others: Keeps Mouth predominantly open d. CNS: Higher Mental Functions Consciousness: Conscious Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypertonia Deep tendon reflexes: KJ- Rt: Ab Lt:3+, AJ -ab/ab Superficial reflexes: Abd reflex- absent Oromotor Examination Drooling: Yes Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper Examination summary: Spasticity ++, ?contracture over Rt knee, b/l foot inverted plantar flexed (Rt> Lt) CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Spastic Quadriplegic Cerebral Palsy with ID with Epilepsy Advice Intervention plan: Physiotherapy. Parents councelled for home program. AFO Investigations: X ray neck lat view (for adenoids) Follow up plan: Review after 15 days General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 04-Apr-2026 10:12AM Demographic Details

Child's Name: Sushant Sen
Age: 8 Year 6 Month 21 Days
Gender: Male
DOB: 2017-09-14
Contact: 7524803767

Behavioral history:

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: 4.5 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
If yes- Duration & Indication: On day 4 admitted in Jhansi for 8 days. HIE 2. Discharged on Gardenal

Past history:

Hospitalization: Yes Seizures: Yes Others: At 1.5 years seizure episodes (GTCS) noted f/b LOC, last episodes 2 days back

Past/Current medications: Syp Levesam 2.5 ml BD, T Lacoxa 1/4th OD Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No Any recent stressful events in family: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 6 years
Roll over: Achieved

Age of attainment: 7 years
Sitting without support: Achieved

Age of attainment: 7 years
Standing without support: Not achieved
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 3 years

Unidextrous grasp: Achieved

Age of attainment: 4 years

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 3 years
Pointing: Achieved

Age of attainment:
Understanding gestures: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment: 6 years

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 6 years

Babbling: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 3 year
Stranger anxiety: Achieved

Age of attainment: 3 years
Waving bye bye: Not achieved
Comes when called: Achieved

Age of attainment: 3 years

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 : 3. Onlooker Academic History:

Is child enrolled in school: No

Diet History:

Food allergies: No

Sleep History

Total sleep duration (night): 8 hours
Afternoon nap: No
Sleep disturbances:

Daily Screen Time

Duration: < 2 hours

Examination

a. Vitals:

b. Anthropometry:

Weight: 20 Kg Height: 117 cm Head circumference: 48 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: 1 cafe au lait macule 0.5*0.5 cm over lower back Others: Keeps Mouth predominantly open

d. CNS: Higher Mental Functions

Consciousness: Conscious

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypertonia
Deep tendon reflexes: KJ- Rt: Ab Lt:3+, AJ -ab/ab
Superficial reflexes: Abd reflex- absent

Oromotor Examination

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

Examination summary: Spasticity ++, ?contracture over Rt knee, b/l foot inverted plantar flexed (Rt> Lt) CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: Spastic Quadriplegic Cerebral Palsy with ID with Epilepsy

Advice

Intervention plan: Physiotherapy. Parents councelled for home program. AFO
Investigations: X ray neck lat view (for adenoids)
Follow up plan: Review after 15 days
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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