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OPD : 27-Jul-2026 01:04PM Demographic Details Child's Name: Aman Age: 1 Year 6 Month 21 Days Gender: Male DOB: 2025-01-06 Mother’s age (years): 21 years Mother’s occupation: Homemaker Father’s age (years): 30 years Father’s occupation: Shop Type of family: Joint Number of family members: 5 Number of siblings: 0 Address: Jhansi Contact: 9935499908 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Delayed milestones Interaction history: Eye contact: Poor Behavioral history: Repetitive behaviors (RRBs): 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): CPD Gestational Age: FT Birth Weight: 2.8 Kg Cry at birth: Delayed cry NICU stay: Yes If yes- Duration & Indication: NICU- 21 days, ventilator- 15 days, HIE 3 Past history: Hospitalization: No Seizures: Yes Others: Multiple episodes of abnormal body movement (head turning to side) Past/Current therapies: Doing execises at home Past/Current medications: Syp Leveriracetam 5 ml BD Investigations done- Hearing assessment: Done Details: OAE- pass Vision assessment: Done Details: at birth- normal Family history: Neuropsychiatric condition: Yes Others: Maternal aunt has H/o Epilepsy. ID in distant relatives 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: 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: Achieved Age of attainment: 15 mon 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 Type of Play : 1. Unoccupied Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed. Bottlefeeding. Food allergies: No Junk food intake: Daily Sleep History Total sleep duration (night): 11-12 hours Afternoon nap: No Duration of Afternoon nap: 2-3 naps Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: c. General Examination Dysmorphology: Microcephaly Neurocutaneous markers: ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypertonia Deep tendon reflexes: KJ-3+/3+, AJ-2+/2+ Oromotor Examination Drooling: No Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper Examination summary: Scissoring+, spasticity + in all 4 limbs, sutural overriding, AF- closed CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Spastic quadriplegic cerebral palsy with microcephaly Advice Intervention plan: Home plan adviced Evaluation: Neuromotor assessment 1 (Next month) Medications: Syp Baclof 0.5 ml TDS General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 27-Jul-2026 01:04PM Demographic Details

Child's Name: Aman
Age: 1 Year 6 Month 21 Days
Gender: Male
DOB: 2025-01-06
Mother’s age (years): 21 years
Mother’s occupation: Homemaker
Father’s age (years): 30 years
Father’s occupation: Shop
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Address: Jhansi
Contact: 9935499908
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Delayed milestones

Interaction history:

Eye contact: Poor

Behavioral history:

Repetitive behaviors (RRBs):

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): CPD
Gestational Age: FT
Birth Weight: 2.8 Kg
Cry at birth: Delayed cry
NICU stay: Yes
If yes- Duration & Indication: NICU- 21 days, ventilator- 15 days, HIE 3

Past history:

Hospitalization: No Seizures: Yes Others: Multiple episodes of abnormal body movement (head turning to side)

Past/Current therapies: Doing execises at home Past/Current medications: Syp Leveriracetam 5 ml BD Investigations done-

Hearing assessment: Done Details: OAE- pass Vision assessment: Done Details: at birth- normal

Family history:

Neuropsychiatric condition: Yes Others: Maternal aunt has H/o Epilepsy. ID in distant relatives

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: 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: Achieved

Age of attainment: 15 mon
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

Type of Play : 1. Unoccupied Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed. Bottlefeeding.
Food allergies: No
Junk food intake: Daily

Sleep History

Total sleep duration (night): 11-12 hours
Afternoon nap: No
Duration of Afternoon nap: 2-3 naps

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

Dysmorphology: Microcephaly Neurocutaneous markers: ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypertonia
Deep tendon reflexes: KJ-3+/3+, AJ-2+/2+

Oromotor Examination

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

Examination summary: Scissoring+, spasticity + in all 4 limbs, sutural overriding, AF- closed CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: Spastic quadriplegic cerebral palsy with microcephaly

Advice

Intervention plan: Home plan adviced
Evaluation: Neuromotor assessment 1 (Next month)
Medications: Syp Baclof 0.5 ml TDS
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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