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OPD : 21-Jul-2026 12:25PM Demographic Details Child's Name: Rudransh Parmar Age: 1 Year 3 Month 7 Days Gender: Male DOB: 2025-04-14 Mother’s age (years): Deceased Father’s age (years): 28 years Father’s occupation: Private job Type of family: Joint Number of family members: 6 Number of siblings: 0 Address: Mohna Contact: 7247517896 Referred By: Doctor Informant: Grandmother Presenting Concerns Chief concerns: Delayed milestones 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: Late preterm Birth Weight: 2.2 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: Hypotension in mother during delivery. Mother deceased 2 hours after delivery. Nicu stay- 1.5 month.HIE3, fungal sepsis, AKI. discharged on AEDs Past history: Hospitalization: Yes Seizures: Yes Past/Current therapies: Nil 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 Walking 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 Expressive:- Cooing: Not achieved Babbling: Not achieved Meaningful words: Not achieved Expressive:- Cooing: Not achieved 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 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 Academic History: Diet History: Food preferences: On bottlefeeding Sleep History Total sleep duration (night): 16 hours sleep in 24 hours Afternoon nap: Yes Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 5.6 Kg Height: 66 cm Head circumference: 33.5 cm c. General Examination 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- 3+/3+ Superficial reflexes: Plantar extensors Meningeal signs: Absent Oromotor Examination Drooling: No Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper Examination summary: Spasticity++, Scissoring+, severe microcephaly, AF closed, Limb length discrepancy, fisting, synophrys, thick eyebrows. No visual fixation. Alerts to sound, doesnt turn to sound CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Spastic quadriplegic cerebral palsy, GDD, microcephaly Advice Intervention plan: Early intervention adviced, Unable to visit. Advised for home. Evaluation: Neuromotor assessment 1 Investigations: EEG, MRI Brain, Complete ophthalmological examination, OAE Medications: Syp Baclof (5mg/5ml) 0.8 ml TDS Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 21-Jul-2026 12:25PM Demographic Details

Child's Name: Rudransh Parmar
Age: 1 Year 3 Month 7 Days
Gender: Male
DOB: 2025-04-14
Mother’s age (years): Deceased
Father’s age (years): 28 years
Father’s occupation: Private job
Type of family: Joint
Number of family members: 6
Number of siblings: 0
Address: Mohna
Contact: 7247517896
Referred By: Doctor
Informant: Grandmother

Presenting Concerns

Chief concerns: Delayed milestones

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: Late preterm
Birth Weight: 2.2 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: Hypotension in mother during delivery. Mother deceased 2 hours after delivery. Nicu stay- 1.5 month.HIE3, fungal sepsis, AKI. discharged on AEDs

Past history:

Hospitalization: Yes Seizures: Yes

Past/Current therapies: Nil 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
Walking 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

Expressive:-

Cooing: Not achieved

Babbling: Not achieved

Meaningful words: Not achieved

Expressive:-

Cooing: Not achieved

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

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

Academic History:

Diet History:

Food preferences: On bottlefeeding

Sleep History

Total sleep duration (night): 16 hours sleep in 24 hours
Afternoon nap: Yes

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 5.6 Kg Height: 66 cm Head circumference: 33.5 cm

c. General Examination

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- 3+/3+
Superficial reflexes: Plantar extensors

Meningeal signs: Absent

Oromotor Examination

Drooling: No
Chewing: Improper
Swallowing: Improper
Blowing: Improper
Sucking: Improper

Examination summary: Spasticity++, Scissoring+, severe microcephaly, AF closed, Limb length discrepancy, fisting, synophrys, thick eyebrows. No visual fixation. Alerts to sound, doesnt turn to sound CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: Spastic quadriplegic cerebral palsy, GDD, microcephaly

Advice

Intervention plan: Early intervention adviced, Unable to visit. Advised for home.
Evaluation: Neuromotor assessment 1
Investigations: EEG, MRI Brain, Complete ophthalmological examination, OAE
Medications: Syp Baclof (5mg/5ml) 0.8 ml TDS
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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