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OPD : 17-Sep-2026 01:42PM Demographic Details Child's Name: Ayan Sahu Age: 7 Year 9 Month 27 Days Gender: Male DOB: 2018-11-21 Type of family: Joint Number of family members: 5 Number of siblings: 1 Details of siblings (Age and sex): 3 year old male Address: Dabra Contact: 8269580393 Referred By: Doctor Informant: Parent Investigations done: MRI Brain- schizencephalic cleft, polymicrogyria right side. EEG- normal Presenting Concerns Chief concerns: O/C/O Planovalgus Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate 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: Late PT Birth Weight: 2.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No If yes- Duration & Indication: On day 3 admitted for NNHB Past history: Hospitalization: Yes Seizures: Yes Others: At 1.5 year age - Febrile seizures 3 episodes. AEDs were given for 3 years. At 3.5 years ATT was given Past/Current therapies: On PT since 1.5 years age. Past/Current medications: AEDs given for 3-4 years. Discontinued after 5 years age. ATT for 6 months Investigations done- Hearing assessment: Done Details: Normal Vision assessment: Done Details: Normal Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 6 months Roll over: Achieved Age of attainment: 7 months Sitting without support: Achieved Age of attainment: 9 months Standing without support: Achieved Age of attainment: 14 months Walking without support: Achieved Age of attainment: 1.5 years 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: 2-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: Complete sentences: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: Complete sentences: Achieved Age of attainment: Details:: Limited use of Left hand 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): 3-step Answering Questions:- What Where Who Why When How Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: 9 months Comes when called: Achieved Age of attainment: 12 months Copying parents in tasks: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 5. Independent Toilet training: 5. Independent Dressing: 5. Independent Undressing: 5. Independent Type of Play : 5. Associative Academic History: Is child enrolled in school: Yes Type of school: Special Name of School: IPS school Grade: 2 Hours spent in school: 4 Board: CBSE Location: Dabra Additional information: On medical leave Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Daily Sleep History Total sleep duration (night): 10 hours Afternoon nap: No Daily Screen Time Duration: > 5 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Head circumference: 53.5 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination Examination summary: Tone increased in left upper limb. CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Spastic hempiplegic cerebral palsy with P/O/C of planovalgus Advice Intervention plan: IDP+ PT 5 days/week for 15 days then 3/week Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 17-Sep-2026 01:42PM Demographic Details

Child's Name: Ayan Sahu
Age: 7 Year 9 Month 27 Days
Gender: Male
DOB: 2018-11-21
Type of family: Joint
Number of family members: 5
Number of siblings: 1
Details of siblings (Age and sex): 3 year old male
Address: Dabra
Contact: 8269580393
Referred By: Doctor
Informant: Parent
Investigations done: MRI Brain- schizencephalic cleft, polymicrogyria right side. EEG- normal

Presenting Concerns

Chief concerns: O/C/O Planovalgus

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

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: Late PT
Birth Weight: 2.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No
If yes- Duration & Indication: On day 3 admitted for NNHB

Past history:

Hospitalization: Yes Seizures: Yes Others: At 1.5 year age - Febrile seizures 3 episodes. AEDs were given for 3 years. At 3.5 years ATT was given

Past/Current therapies: On PT since 1.5 years age. Past/Current medications: AEDs given for 3-4 years. Discontinued after 5 years age. ATT for 6 months Investigations done-

Hearing assessment: Done Details: Normal Vision assessment: Done Details: Normal

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 6 months
Roll over: Achieved

Age of attainment: 7 months
Sitting without support: Achieved

Age of attainment: 9 months
Standing without support: Achieved

Age of attainment: 14 months
Walking without support: Achieved

Age of attainment: 1.5 years

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: 2-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment:

Complete sentences: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment:

Complete sentences: Achieved

Age of attainment:

Details:: Limited use of Left hand

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): 3-step

Answering Questions:-

What Where Who Why When How

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment: 9 months
Comes when called: Achieved

Age of attainment: 12 months
Copying parents in tasks: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 5. Independent
Bathing: 5. Independent
Toilet training: 5. Independent
Dressing: 5. Independent
Undressing: 5. Independent

Type of Play : 5. Associative Academic History:

Is child enrolled in school: Yes
Type of school: Special
Name of School: IPS school
Grade: 2
Hours spent in school: 4
Board: CBSE
Location: Dabra
Additional information: On medical leave

Diet History:

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

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: No

Daily Screen Time

Duration: > 5 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Head circumference: 53.5 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

Examination summary: Tone increased in left upper limb. CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: Spastic hempiplegic cerebral palsy with P/O/C of planovalgus

Advice

Intervention plan: IDP+ PT 5 days/week for 15 days then 3/week
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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