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OPD : 22-Oct-2026 05:37PM Demographic Details Child's Name: Lekhans Gurjar Age: 7 Month 29 Days Gender: Male DOB: 2026-02-23 Mother’s age (years): 24 years Mother’s occupation: Homemaker Father’s age (years): 24 years Type of family: Joint Number of siblings: 0 Address: Shivpuri Link road Contact: 7047828970 Referred By: Doctor Informant: Mother, paternal aunt Investigations done: MRI Brain- WNL Interaction history: Eye contact: Sustained 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: 2.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Not achieved Roll over: Not achieved Sitting without support: Not achieved Fine Motor Bidextrous grasp: Not achieved Unidextrous grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Social smile: Achieved Age of attainment: Stranger anxiety: Not achieved Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Type of Play : 1. Unoccupied Academic History: Diet History: Food preferences: Top feeding + Breastfeeding Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 12 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 naps= 8-9 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 8 Kg Height: 69 cm Head circumference: 41.5 cm c. General Examination 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+ Superficial reflexes: Plantars- B/l extensors Oromotor Examination Drooling: No Examination summary: Tone increased in all 4 limbs, left> right. Predominant fisting. AF- at level. Pull to sit- complete head lag, rounded back. Prone- uplifts head around 30 degree. CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. Spastic CP. (No history of perinatal insult, regression, frequent illness, seizures, episodic decompensation) Advice Intervention plan: IDP 5/week Investigations: EEG, BERA. WES. CBC, Thyroid profile, Ca, Mg, Vit D Medications: As adviced by pediatrician Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 22-Oct-2026 05:37PM Demographic Details

Child's Name: Lekhans Gurjar
Age: 7 Month 29 Days
Gender: Male
DOB: 2026-02-23
Mother’s age (years): 24 years
Mother’s occupation: Homemaker
Father’s age (years): 24 years
Type of family: Joint
Number of siblings: 0
Address: Shivpuri Link road
Contact: 7047828970
Referred By: Doctor
Informant: Mother, paternal aunt
Investigations done: MRI Brain- WNL

Interaction history:

Eye contact: Sustained

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: 2.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

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

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Not achieved
Roll over: Not achieved
Sitting without support: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Unidextrous grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Social smile: Achieved

Age of attainment:
Stranger anxiety: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Type of Play : 1. Unoccupied Academic History:

Diet History:

Food preferences: Top feeding + Breastfeeding
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 12 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 naps= 8-9 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 8 Kg Height: 69 cm Head circumference: 41.5 cm

c. General Examination

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+
Superficial reflexes: Plantars- B/l extensors

Oromotor Examination

Drooling: No

Examination summary: Tone increased in all 4 limbs, left> right. Predominant fisting. AF- at level. Pull to sit- complete head lag, rounded back. Prone- uplifts head around 30 degree. CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD. Spastic CP. (No history of perinatal insult, regression, frequent illness, seizures, episodic decompensation)

Advice

Intervention plan: IDP 5/week
Investigations: EEG, BERA. WES. CBC, Thyroid profile, Ca, Mg, Vit D
Medications: As adviced by pediatrician
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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