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OPD : 22-May-2026 09:56AM Demographic Details Child's Name: Avyan Dubey Age: 2 Year 7 Month 7 Days Gender: Male DOB: 2023-10-15 Mother’s age (years): 25 years Mother’s occupation: Homemaker Father’s age (years): 29 years Father’s occupation: Governmentt job Type of family: Joint Number of family members: 7 Number of siblings: 0 Address: Gudi Guda ka naka Contact: 8982014573 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Unable to stand, weakness of Right side of body Duration of symptoms: Noticed since 7 months Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Temper tantrums Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Non progression of labor Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: Yes Others: At 2 mon- Aspiration pneumonia. H/o 1 episode of seizures (sepsis+ aspiration pneumonia)- at 3 mon, admitted for 2days. Rt sided hemiparesis noted since 7 months Past/Current medications: Nil 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: 4 months Roll over: Achieved Age of attainment: 12 months Sitting without support: Achieved Age of attainment: 13 months Standing without support: Not achieved Walking without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: Unidextrous grasp: Achieved Age of attainment: Pincer grasp: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 12 months Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: Initiated Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: Initiated Details:: Right sided hemiparesis. (Reduced reach out for objects by right hand) Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Drag for needs: Consistent Joint attention: Consistent Pointing: Consistent meaningful pointing Understanding gestures: Consistent Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: 9 months Response to Name Call Details: 10/10 Sitting tolerance- (in minutes) For interaction: Age appropriate For tasks: Age appropriate ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Indicates for urine and stool by cues Type of Play : 4. Parallel Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Daily Screen Time Duration: > 2 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 11.95Kg Head circumference: 45.5 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Consciousness: awake, active, playful Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypertonia Deep tendon reflexes: KJ- 3+/3+, AJ 3+/3+ Superficial reflexes: Plantar extensors/extensors Oromotor Examination Drooling: Yes Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. CP. Rt sided Hemiparesis Advice Intervention plan: IDP 3/week Evaluation: Neuromotor assessment 1 Investigations: CBC, Calcium, Vitamin D, Vitamin B12, thyroid profile. Repeat MRI Brain (later) Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 22-May-2026 09:56AM Demographic Details

Child's Name: Avyan Dubey
Age: 2 Year 7 Month 7 Days
Gender: Male
DOB: 2023-10-15
Mother’s age (years): 25 years
Mother’s occupation: Homemaker
Father’s age (years): 29 years
Father’s occupation: Governmentt job
Type of family: Joint
Number of family members: 7
Number of siblings: 0
Address: Gudi Guda ka naka
Contact: 8982014573
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Unable to stand, weakness of Right side of body
Duration of symptoms: Noticed since 7 months

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Temper tantrums

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Non progression of labor
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: Yes Others: At 2 mon- Aspiration pneumonia. H/o 1 episode of seizures (sepsis+ aspiration pneumonia)- at 3 mon, admitted for 2days. Rt sided hemiparesis noted since 7 months

Past/Current medications: Nil 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: 4 months
Roll over: Achieved

Age of attainment: 12 months
Sitting without support: Achieved

Age of attainment: 13 months
Standing without support: Not achieved
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment:

Unidextrous grasp: Achieved

Age of attainment:

Pincer grasp: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 12 months

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: Initiated

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: Initiated

Details:: Right sided hemiparesis. (Reduced reach out for objects by right hand)

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Drag for needs: Consistent
Joint attention: Consistent
Pointing: Consistent meaningful pointing
Understanding gestures: Consistent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment: 9 months

Response to Name Call

Details: 10/10

Sitting tolerance- (in minutes)

For interaction: Age appropriate
For tasks: Age appropriate

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Details:: Indicates for urine and stool by cues

Type of Play : 4. Parallel Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed
Food allergies: No
Junk food intake: Occasional

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours

Daily Screen Time

Duration: > 2 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 11.95Kg Head circumference: 45.5 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Consciousness: awake, active, playful

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypertonia
Deep tendon reflexes: KJ- 3+/3+, AJ 3+/3+
Superficial reflexes: Plantar extensors/extensors

Oromotor Examination

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

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

Impression: GDD. CP. Rt sided Hemiparesis

Advice

Intervention plan: IDP 3/week
Evaluation: Neuromotor assessment 1
Investigations: CBC, Calcium, Vitamin D, Vitamin B12, thyroid profile. Repeat MRI Brain (later)
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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