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OPD : 06-Oct-2026 01:23PM Demographic Details Child's Name: Arav sharma Age: 1 Year 6 Month 6 Days Gender: Male DOB: 2025-03-30 Mother’s age (years): 26 years Mother’s occupation: homemaker Father’s age (years): 26 years Father’s occupation: Farmer Type of family: Joint Number of family members: 5 Number of siblings: 0 Address: Ashoknagar Contact: 9630760040 Referred By: Doctor Informant: Parents Current medications: Syp Gardenal 5 ml HS, Syp Levera 1 ml BD Investigations done: EEG- Generalized sharp wave discharges of 100-200microvolt . MRI Brain- hypoxic injury (Right frontoparietal periventricular white matter injury with associated volume loss, PVL. Presenting Concerns Chief concerns: delayed development Interaction history: Eye contact: Poor 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: Yes Details of Resuscitation: Not available NICU stay: Yes If yes- Duration & Indication: 5 days. Perinatal asphyxia, NNHB. Past history: Hospitalization: Yes Seizures: Yes Others: after 10 days- sepsis, admitted in bhopal 25 days. Was on oxygenation. At 3 months seizures noted in form of infantile spasms. On AEDs since 6 months. since 2 -3 months seizures in the form of spasms f/b GTCS, no LOC f/b crying or irrelevant laughing Past/Current therapies: Nil Past/Current medications: syp Gardenal, syp Levera since 6 months Investigations done- Hearing assessment: Done Details: OAE- B/l pass Vision assessment: Done Details: NAD Family history: Neuropsychiatric condition: No 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: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Expressive:- Cooing: Achieved Age of attainment: 1 year Babbling: Not achieved Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 1 year 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: 1 year 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: Mixed. Bottlefeeding+ Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 7-8 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 10 Kg Height: 78 cm Head circumference: 42.5 cm c. General Examination Dysmorphology: ab Neurocutaneous markers: ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypertonia Deep tendon reflexes: KJ-3 +/3+, AJ-3+/3+ Superficial reflexes: Plantars- B/l extensors Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper Others: H/o choking episodes while eating Examination summary: Spasticity++, Prone- Doesnt lift head, doesnt bear weight on foream. Pull to sit- complete head lag. AF_ closed CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. Spastic Quadriplegic CP. HIE sequelae Advice Intervention plan: IDP + PT. Home startegies adviced Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 06-Oct-2026 01:23PM Demographic Details

Child's Name: Arav sharma
Age: 1 Year 6 Month 6 Days
Gender: Male
DOB: 2025-03-30
Mother’s age (years): 26 years
Mother’s occupation: homemaker
Father’s age (years): 26 years
Father’s occupation: Farmer
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Address: Ashoknagar
Contact: 9630760040
Referred By: Doctor
Informant: Parents
Current medications: Syp Gardenal 5 ml HS, Syp Levera 1 ml BD
Investigations done: EEG- Generalized sharp wave discharges of 100-200microvolt . MRI Brain- hypoxic injury (Right frontoparietal periventricular white matter injury with associated volume loss, PVL.

Presenting Concerns

Chief concerns: delayed development

Interaction history:

Eye contact: Poor

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: Yes
Details of Resuscitation: Not available
NICU stay: Yes
If yes- Duration & Indication: 5 days. Perinatal asphyxia, NNHB.

Past history:

Hospitalization: Yes Seizures: Yes Others: after 10 days- sepsis, admitted in bhopal 25 days. Was on oxygenation. At 3 months seizures noted in form of infantile spasms. On AEDs since 6 months. since 2 -3 months seizures in the form of spasms f/b GTCS, no LOC f/b crying or irrelevant laughing

Past/Current therapies: Nil Past/Current medications: syp Gardenal, syp Levera since 6 months Investigations done-

Hearing assessment: Done Details: OAE- B/l pass Vision assessment: Done Details: NAD

Family history:

Neuropsychiatric condition: No

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: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 1 year

Babbling: Not achieved

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 1 year

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: 1 year
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: Mixed. Bottlefeeding+
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 7-8 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 10 Kg Height: 78 cm Head circumference: 42.5 cm

c. General Examination

Dysmorphology: ab Neurocutaneous markers: ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypertonia
Deep tendon reflexes: KJ-3 +/3+, AJ-3+/3+
Superficial reflexes: Plantars- B/l extensors

Oromotor Examination

Drooling: Yes
Chewing: Improper
Swallowing: Improper
Blowing: Improper
Sucking: Improper
Others: H/o choking episodes while eating

Examination summary: Spasticity++, Prone- Doesnt lift head, doesnt bear weight on foream. Pull to sit- complete head lag. AF_ closed CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD. Spastic Quadriplegic CP. HIE sequelae

Advice

Intervention plan: IDP + PT. Home startegies adviced
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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