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OPD : 20-Jul-2026 09:52AM Demographic Details Child's Name: Daksh Namdev Age: 1 Year 2 Month 25 Days Gender: Male DOB: 2025-04-25 Mother’s age (years): 28 years Mother’s occupation: Homemaker Father’s age (years): 34 years Type of family: Joint Number of siblings: 1 Details of siblings (Age and sex): Deceased Address: 6 Contact: 7011314475 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Development delay Interaction history: Eye contact: Sustained Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 2.5 kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: Yes Seizures: Yes Others: Excessive crying since birth. Tightness of limbs. 6 mon back admitted for pneumonia Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: Yes Others: 2 year old female expired due to pain in abdomen. Epilepsy in paternal uncle (since 15 years age) Developmental History: Gross Motor Neck holding: Not achieved Roll over: Not achieved Sitting without support: Not achieved Standing without support: Not achieved Walking without support: Not achieved Fine Motor Bidextrous grasp: Not achieved Unidextrous grasp: Not achieved Pincer grasp: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 12 months Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 12 months Babbling: Not achieved Meaningful words: Not achieved 2 word Phrases: Not achieved Expressive:- Cooing: Achieved Age of attainment: 12 months Babbling: Not achieved Meaningful words: Not achieved 2 word Phrases: 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: 3 months Stranger anxiety: Not achieved Waving bye bye: Not achieved Comes when called: 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: Predominantly breastfeed Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 3-4 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 6.6 Kg Height: 66 cm Head circumference: 40 cm c. General Examination Dysmorphology: Ab 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+ Superficial reflexes: Plantar extensors Meningeal signs: Absent Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper Examination summary: Spasticity+, scissoring+, AF- closed, microcephaly. CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: spastic quadriplegic cerebral palsy with GDD with microcephaly Advice Intervention plan: To be decided after evaluation Evaluation: Neuromotor assessment 1 Investigations: MRI Brain, EEG, BERA, Complete Ophthalmological Examination. CBC, RBS, S. electrolytes, Ca, Thyroid profile, LFT, RFT Medications: Continue medications as adviced by pediatrician Follow up plan: After investigations General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 20-Jul-2026 09:52AM Demographic Details

Child's Name: Daksh Namdev
Age: 1 Year 2 Month 25 Days
Gender: Male
DOB: 2025-04-25
Mother’s age (years): 28 years
Mother’s occupation: Homemaker
Father’s age (years): 34 years
Type of family: Joint
Number of siblings: 1
Details of siblings (Age and sex): Deceased
Address: 6
Contact: 7011314475
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Development delay

Interaction history:

Eye contact: Sustained

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 2.5 kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: Yes Seizures: Yes Others: Excessive crying since birth. Tightness of limbs. 6 mon back admitted for pneumonia

Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: Yes Others: 2 year old female expired due to pain in abdomen. Epilepsy in paternal uncle (since 15 years age)

Developmental History:

Gross Motor

Neck holding: Not achieved
Roll over: Not achieved
Sitting without support: Not achieved
Standing without support: Not achieved
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Unidextrous grasp: Not achieved

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 12 months
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 12 months

Babbling: Not achieved

Meaningful words: Not achieved

2 word Phrases: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 12 months

Babbling: Not achieved

Meaningful words: Not achieved

2 word Phrases: 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: 3 months
Stranger anxiety: Not achieved
Waving bye bye: Not achieved
Comes when called: 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: Predominantly breastfeed
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 3-4 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 6.6 Kg Height: 66 cm Head circumference: 40 cm

c. General Examination

Dysmorphology: Ab 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+
Superficial reflexes: Plantar extensors

Meningeal signs: Absent

Oromotor Examination

Drooling: Yes
Chewing: Improper
Swallowing: Improper
Blowing: Improper
Sucking: Improper

Examination summary: Spasticity+, scissoring+, AF- closed, microcephaly. CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: spastic quadriplegic cerebral palsy with GDD with microcephaly

Advice

Intervention plan: To be decided after evaluation
Evaluation: Neuromotor assessment 1
Investigations: MRI Brain, EEG, BERA, Complete Ophthalmological Examination. CBC, RBS, S. electrolytes, Ca, Thyroid profile, LFT, RFT
Medications: Continue medications as adviced by pediatrician
Follow up plan: After investigations
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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