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OPD : 11-Apr-2026 05:04PM Demographic Details Child's Name: Arhan Khan Age: 1 Year 10 Month 22 Days Gender: Male DOB: 2024-05-20 Mother’s age (years): 28 years Mother’s occupation: Housewife Father’s age (years): 30 years Father’s occupation: Own shop Type of family: Joint Number of family members: 8 Number of siblings: 1 Details of siblings (Age and sex): 4 year old female Address: Datia ( Vil- Indergarh) Contact: 9111569017 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Dev delay Interaction history: Eye contact: Sustained Behavioral history: Sensory Concerns: Auditory: Hypersensitive Birth & Perinatal History: Antenatal History Consanguinity: Yes If yes Degree: 2 Type of conception: Natural Natal and Postnatal History: Place of Birth: Home Mode of Delivery: LSCS Indication for LSCS (if applicable): Prev LSCS Gestational Age: FT Birth Weight: Around 3 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Admitted for 15 days on day 15 for excessive crying, tonic posturing, discharged on AEDs Past history: Others: Multiple episodes of abnormal body movements (tonic posturing) since 15 days of age. Dystonia triggered by crying. Multiple hospitalization. Past/Current therapies: Nil Investigations done- Hearing assessment: Done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Not achieved Roll over: Not achieved Fine Motor Bidextrous grasp: Not achieved Unidextrous grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: 1.5 year Babbling: Not achieved Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 1.5 year Babbling: Not achieved Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 3.5 years 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: Diet History: Food preferences: Milk by Katori spoon. Vomits when fed other foods. Sleep History Total sleep duration (night): 6-8 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 naps of 1.5 hours Sleep disturbances: Yes Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 6.4 Kg Height: 71 cm Head circumference: 39 cm c. General Examination Dysmorphology: Mildly depressed nasal bridge 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: Severe wasting Tone: Hypertonia Deep tendon reflexes: KJ_ 3+/3+, Plantar 3+/3+ Oromotor Examination Drooling: No Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper Examination summary: Spasticity, Left foot equinovarus, Fisting, complete head lag, Increased extensor tone CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Spastic quadriplegic cerebral palsy with GDD Advice Intervention plan: IDP (+PT) 3/week General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 11-Apr-2026 05:04PM Demographic Details

Child's Name: Arhan Khan
Age: 1 Year 10 Month 22 Days
Gender: Male
DOB: 2024-05-20
Mother’s age (years): 28 years
Mother’s occupation: Housewife
Father’s age (years): 30 years
Father’s occupation: Own shop
Type of family: Joint
Number of family members: 8
Number of siblings: 1
Details of siblings (Age and sex): 4 year old female
Address: Datia ( Vil- Indergarh)
Contact: 9111569017
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Dev delay

Interaction history:

Eye contact: Sustained

Behavioral history:

Sensory Concerns:

Auditory: Hypersensitive

Birth & Perinatal History: Antenatal History

Consanguinity: Yes
If yes Degree: 2
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Home
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Prev LSCS
Gestational Age: FT
Birth Weight: Around 3 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Admitted for 15 days on day 15 for excessive crying, tonic posturing, discharged on AEDs

Past history:

Others: Multiple episodes of abnormal body movements (tonic posturing) since 15 days of age. Dystonia triggered by crying. Multiple hospitalization.

Past/Current therapies: Nil Investigations done-

Hearing assessment: Done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Not achieved
Roll over: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Unidextrous grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 1.5 year

Babbling: Not achieved

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 1.5 year

Babbling: Not achieved

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 3.5 years
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:

Diet History:

Food preferences: Milk by Katori spoon. Vomits when fed other foods.

Sleep History

Total sleep duration (night): 6-8 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 naps of 1.5 hours
Sleep disturbances: Yes

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 6.4 Kg Height: 71 cm Head circumference: 39 cm

c. General Examination

Dysmorphology: Mildly depressed nasal bridge 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: Severe wasting
Tone: Hypertonia
Deep tendon reflexes: KJ_ 3+/3+, Plantar 3+/3+

Oromotor Examination

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

Examination summary: Spasticity, Left foot equinovarus, Fisting, complete head lag, Increased extensor tone CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: Spastic quadriplegic cerebral palsy with GDD

Advice

Intervention plan: IDP (+PT) 3/week
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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