Create - Child Development Centre

Patient Details


OPD : 19-Jun-2026 05:38PM Demographic Details Child's Name: Aryan Age: 2 Year 8 Month 27 Days Gender: Male DOB: 2023-09-23 Mother’s age (years): 21 Years Mother’s occupation: Homemaker Father’s age (years): 30 years Father’s occupation: Shop Type of family: Nuclear Number of family members: 4 Number of siblings: 1 Details of siblings (Age and sex): 18 months age Address: Dhaulpur Contact: 7610202755 Referred By: Doctor Informant: Paternal uncles Presenting Concerns Chief concerns: Doesnt walk Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: H/o sibling death at 2 months age Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: Not known Cry at birth: Delayed cry Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: NICU stay- 15 days. Past history: Hospitalization: No Others: Repeated episodes of febrile illness. H/o abnormal body movements Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 months Roll over: Achieved Age of attainment: 6 months Sitting without support: Achieved Age of attainment: 12 months Standing without support: Achieved Age of attainment: 24 months Walking without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Achieved Age of attainment: 6 months Pincer grasp: Achieved Age of attainment: 12 months Scribbling: Achieved Age of attainment: Drinking from cup: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: Pointing: Achieved Age of attainment: Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Details:: Kinship words 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 Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Absent Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: 18 months Comes when called: Achieved Age of attainment: 24 months Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 2. Started attempting Details:: Doesnt indicate for urine and stool. Type of Play : 4. Parallel Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: Yes Junk food intake: Frequent Sleep History Total sleep duration (night): 10-11 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours Daily Screen Time Duration: < 1 hour Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 11 Kg Height: 86 cm Head circumference: 48.5 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: 1 cafe au lait macule at right side of abdomen d. CNS: Higher Mental Functions Consciousness: Active, alert, interactive 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: Plantars- extensors Gait issues: Stands with support on toe, doesnt cruise Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Spastic diplegic cerebral palsy Advice Intervention plan: IDP + PT 3/week + PMT Evaluation: Neuromotor assessment 1 Investigations: Pediatric orthopedician assessment Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 19-Jun-2026 05:38PM Demographic Details

Child's Name: Aryan
Age: 2 Year 8 Month 27 Days
Gender: Male
DOB: 2023-09-23
Mother’s age (years): 21 Years
Mother’s occupation: Homemaker
Father’s age (years): 30 years
Father’s occupation: Shop
Type of family: Nuclear
Number of family members: 4
Number of siblings: 1
Details of siblings (Age and sex): 18 months age
Address: Dhaulpur
Contact: 7610202755
Referred By: Doctor
Informant: Paternal uncles

Presenting Concerns

Chief concerns: Doesnt walk

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: H/o sibling death at 2 months age

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: Not known
Cry at birth: Delayed cry
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: NICU stay- 15 days.

Past history:

Hospitalization: No Others: Repeated episodes of febrile illness. H/o abnormal body movements

Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 months
Roll over: Achieved

Age of attainment: 6 months
Sitting without support: Achieved

Age of attainment: 12 months
Standing without support: Achieved

Age of attainment: 24 months
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp: Achieved

Age of attainment: 6 months

Pincer grasp: Achieved

Age of attainment: 12 months

Scribbling: Achieved

Age of attainment:

Drinking from cup: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment:
Pointing: Achieved

Age of attainment:
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Details:: Kinship words

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
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Absent

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment: 18 months
Comes when called: Achieved

Age of attainment: 24 months

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

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

Details:: Doesnt indicate for urine and stool.

Type of Play : 4. Parallel Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed
Food allergies: Yes
Junk food intake: Frequent

Sleep History

Total sleep duration (night): 10-11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours

Daily Screen Time

Duration: < 1 hour
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 11 Kg Height: 86 cm Head circumference: 48.5 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: 1 cafe au lait macule at right side of abdomen

d. CNS: Higher Mental Functions

Consciousness: Active, alert, interactive

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: Plantars- extensors
Gait issues: Stands with support on toe, doesnt cruise

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Proper
Sucking: Proper

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

Impression: Spastic diplegic cerebral palsy

Advice

Intervention plan: IDP + PT 3/week + PMT
Evaluation: Neuromotor assessment 1
Investigations: Pediatric orthopedician assessment
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

Setting Panel

Select Layout

Light Dark

Sidebar Color

Color Theme

Mini Sidebar

Sticky Header

Patient Details print

Select Layout

Sidebar Color

Color Theme

Patient Details