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OPD : 30-Sep-2026 12:23PM Demographic Details Child's Name: Parth Rajwani Age: 1 Year Gender: Male DOB: 2025-09-03 Mother’s age (years): 32 years Mother’s occupation: Homemaker Father’s age (years): 38 years Father’s occupation: Business Type of family: Joint Number of family members: 5 Number of siblings: 0 Address: Datia Contact: 9752252102 Referred By: Doctor Informant: Mother, Grandmother Current medications: Syp Levepsy, Pacitane, clonazepam Investigations done: MRI Brain- Periventricular leukomalacic changes or late sequel of perinatal hypoxic injury. EEG (6mon)- Generalised epileptiform discharges Presenting Concerns Chief concerns: Delayed milestones Duration of symptoms: Since 6 months age Strengths of child: Interaction is good Interaction history: Eye contact: Suboptimal Behavioral history: Mouthing of objects Sensory Concerns: Auditory: Hypersensitive Visual: Seeks visuals Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Maternal age at conception (years):: 31 Type of conception: Natural High-risk factors in pregnancy: Pre-eclampsia GDM Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): PIH Gestational Age: Late PT Birth Weight: 2.4 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Admitted for 9 days in NICU. Hypoglycemia, sepsis, NNHB. Past history: Hospitalization: No Seizures: Yes Others: At 6 months epileptic spasms noted. Seizure free since july. H/o Thallesemia minor Past/Current therapies: Nil Past/Current medications: Inj ACTH, Vigabatrin discontinued Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 months Roll over: Achieved Age of attainment: 6 months Sitting without support: Not achieved Standing without support: Not achieved Walking without support: Achieved Age of attainment: Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Achieved Age of attainment: 6 months Pincer grasp: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: Initiated Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: Initiated Meaningful words: Not achieved Details:: Restricted movement of Left hand 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: 2 months Stranger anxiety: Achieved Age of attainment: 8 months 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 : 3. Onlooker Academic History: Diet History: Food preferences: Mixed. Bottlefeeding Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 3-4 hours Daily Screen Time Duration: <30 minutes Type of screen: Mobile Examination a. Vitals: b. Anthropometry: Weight: 9 Kg Height: 73 cm Head circumference: 43.5 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Proper Swallowing: Improper Blowing: Improper Examination summary: Tone increased in right upper limb. Restricted movement of right upper limb. Predominant fisting. Neck holding+, pull to sit- anticipates lifting, back curved, prone- head at 90 degree, bear weight on arms. CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. CP. Infantile spasms Hopes from the consultation: Unable to come for phsyical sessions Advice Intervention plan: Home strategies adviced Investigations: BERA, Ophthalmologic examination Medications: Continue as adviced by Neurologist Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 30-Sep-2026 12:23PM Demographic Details

Child's Name: Parth Rajwani
Age: 1 Year
Gender: Male
DOB: 2025-09-03
Mother’s age (years): 32 years
Mother’s occupation: Homemaker
Father’s age (years): 38 years
Father’s occupation: Business
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Address: Datia
Contact: 9752252102
Referred By: Doctor
Informant: Mother, Grandmother
Current medications: Syp Levepsy, Pacitane, clonazepam
Investigations done: MRI Brain- Periventricular leukomalacic changes or late sequel of perinatal hypoxic injury. EEG (6mon)- Generalised epileptiform discharges

Presenting Concerns

Chief concerns: Delayed milestones
Duration of symptoms: Since 6 months age

Strengths of child: Interaction is good

Interaction history:

Eye contact: Suboptimal

Behavioral history:

Mouthing of objects
Sensory Concerns:

Auditory: Hypersensitive
Visual: Seeks visuals
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No
Maternal age at conception (years):: 31
Type of conception: Natural
High-risk factors in pregnancy:
1. Pre-eclampsia
2. GDM

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): PIH
Gestational Age: Late PT
Birth Weight: 2.4 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Admitted for 9 days in NICU. Hypoglycemia, sepsis, NNHB.

Past history:

Hospitalization: No Seizures: Yes Others: At 6 months epileptic spasms noted. Seizure free since july. H/o Thallesemia minor

Past/Current therapies: Nil Past/Current medications: Inj ACTH, Vigabatrin discontinued Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 months
Roll over: Achieved

Age of attainment: 6 months
Sitting without support: Not achieved
Standing without support: Not achieved
Walking without support: Achieved

Age of attainment:

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp: Achieved

Age of attainment: 6 months

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: Initiated

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: Initiated

Meaningful words: Not achieved

Details:: Restricted movement of Left hand

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: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months

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 : 3. Onlooker Academic History:

Diet History:

Food preferences: Mixed. Bottlefeeding
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 3-4 hours

Daily Screen Time

Duration: <30 minutes
Type of screen: Mobile

Examination

a. Vitals:

b. Anthropometry:

Weight: 9 Kg Height: 73 cm Head circumference: 43.5 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Improper
Blowing: Improper

Examination summary: Tone increased in right upper limb. Restricted movement of right upper limb. Predominant fisting. Neck holding+, pull to sit- anticipates lifting, back curved, prone- head at 90 degree, bear weight on arms. CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD. CP. Infantile spasms

Hopes from the consultation: Unable to come for phsyical sessions
Advice

Intervention plan: Home strategies adviced
Investigations: BERA, Ophthalmologic examination
Medications: Continue as adviced by Neurologist
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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