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OPD : 22-Sep-2026 12:22PM Demographic Details Child's Name: Aashutosh Asati Age: 1 Year 1 Month 5 Days Gender: Male DOB: 2025-04-27 Contact: 7566489028 Current Improvements: Neck control Current medications: Syp Levilex Investigations done: MRI Brain- Cerebral atrophy, preiventricular white matter changes ? HIE sequelae. EEG- abnormal Interaction history: Eye contact: Suboptimal Behavioral history: Birth & Perinatal History: Antenatal History Natal and Postnatal History: Past history: Investigations done- Family history: Developmental History: Gross Motor Neck holding: Achieved Age of attainment: Partial Roll over: Not achieved Fine Motor Bidextrous grasp: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Social smile: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Academic History: Diet History: Food preferences: On predominantly milk Food allergies: No Junk food intake: Biscuits Sleep History Total sleep duration (night): 11- 12 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Height: 78.5 cm Head circumference: 43.5 cm c. General Examination Dysmorphology: Generalised hypotonia. V shaped upper lip, maxillary prominence Neurocutaneous markers: ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypotonia Deep tendon reflexes: KJ-3+/3+, AJ-2+/2+ Superficial reflexes: Plantars- B/l extensors Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper Examination summary: Generalised hypotonia. DTR- KJ3+/3+, AJ-2+/2+. Plantars- B/l flexors. Pull to sit- starting uplifting head, prone- neck holding 30 degree CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. Hypotonia. Birth asphyxia sequelae? Genetic Advice Intervention plan: Home startegies adviced Investigations: WES Medications: Tab lanzol junior 10 mg 1 tab OD empty stomach after dissolution Follow up plan: Next months General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 22-Sep-2026 12:22PM Demographic Details

Child's Name: Aashutosh Asati
Age: 1 Year 1 Month 5 Days
Gender: Male
DOB: 2025-04-27
Contact: 7566489028
Current Improvements: Neck control
Current medications: Syp Levilex
Investigations done: MRI Brain- Cerebral atrophy, preiventricular white matter changes ? HIE sequelae. EEG- abnormal

Interaction history:

Eye contact: Suboptimal

Behavioral history:

Birth & Perinatal History: Antenatal History

Natal and Postnatal History:

Past history:

Investigations done-

Family history:

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: Partial
Roll over: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment:

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Social smile: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Academic History:

Diet History:

Food preferences: On predominantly milk
Food allergies: No
Junk food intake: Biscuits

Sleep History

Total sleep duration (night): 11- 12 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Height: 78.5 cm Head circumference: 43.5 cm

c. General Examination

Dysmorphology: Generalised hypotonia. V shaped upper lip, maxillary prominence Neurocutaneous markers: ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypotonia
Deep tendon reflexes: KJ-3+/3+, AJ-2+/2+
Superficial reflexes: Plantars- B/l extensors

Oromotor Examination

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

Examination summary: Generalised hypotonia. DTR- KJ3+/3+, AJ-2+/2+. Plantars- B/l flexors. Pull to sit- starting uplifting head, prone- neck holding 30 degree CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD. Hypotonia. Birth asphyxia sequelae? Genetic

Advice

Intervention plan: Home startegies adviced
Investigations: WES
Medications: Tab lanzol junior 10 mg 1 tab OD empty stomach after dissolution
Follow up plan: Next months
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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