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OPD : 14-Sep-2026 04:11PM Demographic Details Child's Name: Aryan Yadav Age: 9 Year 4 Month 5 Days Gender: Male DOB: 2017-05-09 Mother’s age (years): 30 years Mother’s occupation: Homemaker Father’s age (years): 43 years Father’s occupation: Private job Type of family: Joint Number of family members: -1 Number of siblings: 2 Details of siblings (Age and sex): 1-12 year old female, 2- 7 year old male Address: Etawah Contact: 7290098860 Referred By: Doctor Informant: Parents Current medications: Syp Levetiracetam Investigations done: MRI , EEG done- reports not brought 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: FT Birth Weight: 3.5 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: admitted for 10-12 days. ? HIE2. Was not discharged on antiepileptic. Past history: Hospitalization: Yes Seizures: Yes Others: Multiple episodes of abnormal body movements, focal with secondary generalization, f/b LOC. Not asssociated with fever. Multiple hospitalisations. Last episode 2 months back Past/Current therapies: Nil Past/Current medications: Prescriptions not brought 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: Partial 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 Scribbling: Not achieved Drinking from cup: Not achieved Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 3 years Pointing: Achieved Age of attainment: 4 years Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 3 years Babbling: Not achieved Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 years Babbling: Not achieved Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Drag for needs: Absent Joint attention: Emerging Pointing: Attempts Understanding gestures: Emerging Following commands (gesture + verbal): Nil Answering Questions:- Social Social smile: Achieved Age of attainment: 6 months Stranger anxiety: Achieved Age of attainment: 9 months Waving bye bye: 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 Food allergies: No Junk food intake: 3 times/week Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 30 minutes Daily Screen Time Duration: <30 minutes Type of screen: Mobile Examination a. Vitals: b. Anthropometry: Weight: 10 Kg Height: 107 cm Head circumference: 49.5 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Bulk of muscles: Severe wasting Tone: Hypertonia Deep tendon reflexes: KJ- 3+/3+, AJ-3+/3+ Superficial reflexes: Plantars- B/l Flexors Oromotor Examination Drooling: Yes Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper Examination summary: Spasticity+ in all 4 limbs, Scissoring. Partial neck control, Tries to reach for objects but no grasp. Interaction is good. CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Spastic Quadriplegic Cerebral Palsy, GDD, Epilepsy Advice Intervention plan: Home startegies adviced Investigations: Review with previous reports Medications: Continue same Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 14-Sep-2026 04:11PM Demographic Details

Child's Name: Aryan Yadav
Age: 9 Year 4 Month 5 Days
Gender: Male
DOB: 2017-05-09
Mother’s age (years): 30 years
Mother’s occupation: Homemaker
Father’s age (years): 43 years
Father’s occupation: Private job
Type of family: Joint
Number of family members: -1
Number of siblings: 2
Details of siblings (Age and sex): 1-12 year old female, 2- 7 year old male
Address: Etawah
Contact: 7290098860
Referred By: Doctor
Informant: Parents
Current medications: Syp Levetiracetam
Investigations done: MRI , EEG done- reports not brought

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: FT
Birth Weight: 3.5 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: admitted for 10-12 days. ? HIE2. Was not discharged on antiepileptic.

Past history:

Hospitalization: Yes Seizures: Yes Others: Multiple episodes of abnormal body movements, focal with secondary generalization, f/b LOC. Not asssociated with fever. Multiple hospitalisations. Last episode 2 months back

Past/Current therapies: Nil Past/Current medications: Prescriptions not brought 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: Partial
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

Scribbling: Not achieved

Drinking from cup: Not achieved

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 3 years
Pointing: Achieved

Age of attainment: 4 years
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 3 years

Babbling: Not achieved

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 years

Babbling: Not achieved

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Emerging
Drag for needs: Absent
Joint attention: Emerging
Pointing: Attempts
Understanding gestures: Emerging
Following commands (gesture + verbal): Nil

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 6 months
Stranger anxiety: Achieved

Age of attainment: 9 months
Waving bye bye: 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
Food allergies: No
Junk food intake: 3 times/week

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 30 minutes

Daily Screen Time

Duration: <30 minutes
Type of screen: Mobile

Examination

a. Vitals:

b. Anthropometry:

Weight: 10 Kg Height: 107 cm Head circumference: 49.5 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Bulk of muscles: Severe wasting
Tone: Hypertonia
Deep tendon reflexes: KJ- 3+/3+, AJ-3+/3+
Superficial reflexes: Plantars- B/l Flexors

Oromotor Examination

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

Examination summary: Spasticity+ in all 4 limbs, Scissoring. Partial neck control, Tries to reach for objects but no grasp. Interaction is good. CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: Spastic Quadriplegic Cerebral Palsy, GDD, Epilepsy

Advice

Intervention plan: Home startegies adviced
Investigations: Review with previous reports
Medications: Continue same
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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