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OPD : 08-Sep-2026 03:53PM Demographic Details Child's Name: Arav Jatav Age: 1 Year 1 Month 22 Days Gender: Male DOB: 2025-07-17 Mother’s age (years): 28 years Mother’s occupation: Homemaker Father’s age (years): 28 years Type of family: Joint Number of siblings: 0 Contact: 8821053927 Referred By: Doctor Informant: Parents Investigations done: MRI- Encephalomalacia, Fakeza Grade 2 PVL, Benign enlargement of CSF space. Presenting Concerns Chief concerns: Development delay Strengths of child: Interaction is good Interaction history: Eye contact: Sustained Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Maternal age at conception (years):: 26 Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: Admitted for 20 days for HIE. Discharged then readmitted after 2 days for diarrhea for 5 days. Discharged on AEDs. Given for 15 days. Past history: Hospitalization: Yes Others: Admitted for febrile illness Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Done Details: OAE- pass B/l Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 9 months 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: Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months 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: 3 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Not achieved Comes when called: Not achieved Copying parents in tasks: Not achieved Asking for food and toilet: 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: On complimentary feed Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 11 hours Afternoon nap: Yes Duration of Afternoon nap: 2 naps Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 8 Kg Height: 72 cm Head circumference: 45 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-2+/2+ Oromotor Examination Drooling: No Examination summary: Spasticity++ in all 4 limbs, scissoring +, fisting B/l, Partial neck holding CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Quadriplegic cerebral palsy. HIE sequelae. Advice Evaluation: Neuromotor assessment Medications: Continue as adviced by pediatrician General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 08-Sep-2026 03:53PM Demographic Details

Child's Name: Arav Jatav
Age: 1 Year 1 Month 22 Days
Gender: Male
DOB: 2025-07-17
Mother’s age (years): 28 years
Mother’s occupation: Homemaker
Father’s age (years): 28 years
Type of family: Joint
Number of siblings: 0
Contact: 8821053927
Referred By: Doctor
Informant: Parents
Investigations done: MRI- Encephalomalacia, Fakeza Grade 2 PVL, Benign enlargement of CSF space.

Presenting Concerns

Chief concerns: Development delay

Strengths of child: Interaction is good

Interaction history:

Eye contact: Sustained

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Maternal age at conception (years):: 26
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: Admitted for 20 days for HIE. Discharged then readmitted after 2 days for diarrhea for 5 days. Discharged on AEDs. Given for 15 days.

Past history:

Hospitalization: Yes Others: Admitted for febrile illness

Past/Current therapies: Nil Past/Current medications: Nil Investigations done-

Hearing assessment: Done Details: OAE- pass B/l Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 9 months
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:
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

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: 3 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Not achieved
Comes when called: Not achieved
Copying parents in tasks: Not achieved
Asking for food and toilet: 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: On complimentary feed
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 naps

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 8 Kg Height: 72 cm Head circumference: 45 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-2+/2+

Oromotor Examination

Drooling: No

Examination summary: Spasticity++ in all 4 limbs, scissoring +, fisting B/l, Partial neck holding CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: Quadriplegic cerebral palsy. HIE sequelae.

Advice

Evaluation: Neuromotor assessment
Medications: Continue as adviced by pediatrician
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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