OPD :
23-May-2026 05:27PM
Demographic Details
- :
Abhay Singh
- :
3 Year 1 Month 0 Days
- :
Male
- :
2023-04-23
- :
32 years
- :
Homemaker
- :
37 years
- :
Nuclear
- :
4
- :
1
- :
3 year 1 month
- :
Sachin Tendulkar marg, Gwalior
- :
7723911046
- :
Doctor
- :
Parents
Presenting Concerns
- :
difficulty in walking,
Behavioral history:
Birth & Perinatal History:
Antenatal History
- :
No
- :
Natural
-
High-risk factors in pregnancy:
- PIH
- :
On labetalol
Natal and Postnatal History:
- :
Institutional
- :
NVD
- :
FT. Twin 1
- :
2.6 Kg
- :
Cried immediately after birth
- :
? Delayed cry in discharge ticket. Admitted in NICU for 16 days. On ventilator- 4 days
Past history:
:
No
:
PT*6 days*45 min. OT and speech- since March
Investigations done-
:
Done
:
Normal
:
Done
:
Squint- Patching adviced
Family history:
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
4 months
-
:
Achieved
:
7 months
-
:
Achieved
:
1 year
-
:
Achieved
:
1.5 years
-
:
Achieved
:
2.5 years
-
:
Not achieved
-
:
Not achieved
-
:
Not achieved
Fine Motor
:
Achieved
:
1 year
:
Achieved
:
1 year
:
Achieved
:
Age not known
:
Achieved
:
Language
Receptive:-
-
:
Achieved
:
2.5 years
-
:
Achieved
:
2.5 years
-
:
Not achieved
- :
1-step
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
1 year
:
Achieved
:
2.5 years
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
1 year
:
Achieved
:
2.5 years
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Emerging
- :
Inconsistent
- :
Inconsistent
- :
Inconsistent meaningful pointing
Answering Questions:-
Social
-
:
Achieved
:
2 months
-
:
Achieved
:
9 months
-
:
Achieved
:
-
:
Achieved
:
Response to Name Call
Sitting tolerance- (in minutes)
- :
Doesnt sit
- :
sits better for tasks
ADL Skills (Age-appropriate)-
- :
2. Started attempting
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
Type of Play : 3. Onlooker
Academic History:
- :
No
Diet History:
- :
Mixed
- :
No
- :
daily
Sleep History
- :
7 hours
- :
Yes
- :
2 hours
Daily Screen Time
Examination
a. Vitals:
b. Anthropometry:
:
12.65 Kg
:
93 cm
:
44 cm
c. General Examination
:
Present
:
1 hypopigmented macule
d. CNS:
Higher Mental Functions
- :
active, alert/ playful
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
- :
Hypertonia
- :
Brisk, brisk
:
Normal
Oromotor Examination
- :
No
- :
Proper
- :
Proper
- :
Proper
:
Hypertonia (Rt> Lt), Left eye Squint, B/l feet deformity, :
NAD
:
NAD
:
NAD
Advice
- :
Parents counselled
- :
After 1 month
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food
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