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OPD : 05-Oct-2026 05:59PM Demographic Details Child's Name: Chirag Age: 1 Year 11 Month 6 Days Gender: Male DOB: 2024-10-29 Mother’s age (years): 26 years Mother’s occupation: Homemaker Father’s age (years): 26 years Father’s occupation: Farmer Type of family: Joint Number of siblings: 1 Details of siblings (Age and sex): 3 months Address: 12 Contact: 9617142429 Referred By: Doctor Informant: Grandparents Investigations done: MRI Brain- reduced white matter volume , severe posterior part of body of corpus callosum Presenting Concerns Chief concerns: Development delay 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: 38 wk Birth Weight: 2.7 Kg Cry at birth: Delayed cry Resuscitation required: Yes Details of Resuscitation: Bag and mask NICU stay: Yes If yes- Duration & Indication: 23 days. HIE sequelae. Discharged on syp phenobarbitone for 2 to 3 days. Past history: Hospitalization: No 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: 12 months Roll over: Not achieved Sitting without support: Not achieved Standing without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 12 months Unidextrous grasp: Not achieved Pincer grasp: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Achieved Age of attainment: 12 months Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Achieved Age of attainment: 12 months Details:: started speaking few kinship words- baba, mumma, papa Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Drag for needs: Inconsistent Joint attention: Inconsistent Pointing: Inconsistent meaningful pointing Understanding gestures: Emerging Following commands (gesture + verbal): Nil Answering Questions:- Social Social smile: Achieved Age of attainment: 12 month Stranger anxiety: Achieved Age of attainment: 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: Occasional Sleep History Total sleep duration (night): 10-11 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Height: 86 cm Head circumference: 44.5 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-3+/3+ Superficial reflexes: Plantars- B/l extensors Oromotor Examination Drooling: Yes Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper Examination summary: Pull to sit- head lag, back curved. On prone- doesnt lift head. Increased adductor- tone CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. Quadriplegic CP Advice Intervention plan: Home based startegies Investigations: BERA, ophthal examination Medications: Syp cogniwella 3 5 ml OD Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 05-Oct-2026 05:59PM Demographic Details

Child's Name: Chirag
Age: 1 Year 11 Month 6 Days
Gender: Male
DOB: 2024-10-29
Mother’s age (years): 26 years
Mother’s occupation: Homemaker
Father’s age (years): 26 years
Father’s occupation: Farmer
Type of family: Joint
Number of siblings: 1
Details of siblings (Age and sex): 3 months
Address: 12
Contact: 9617142429
Referred By: Doctor
Informant: Grandparents
Investigations done: MRI Brain- reduced white matter volume , severe posterior part of body of corpus callosum

Presenting Concerns

Chief concerns: Development delay

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: 38 wk
Birth Weight: 2.7 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
Details of Resuscitation: Bag and mask
NICU stay: Yes
If yes- Duration & Indication: 23 days. HIE sequelae. Discharged on syp phenobarbitone for 2 to 3 days.

Past history:

Hospitalization: No

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: 12 months
Roll over: Not achieved
Sitting without support: Not achieved
Standing without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 12 months

Unidextrous grasp: Not achieved

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Achieved

Age of attainment: 12 months

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Achieved

Age of attainment: 12 months

Details:: started speaking few kinship words- baba, mumma, papa

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 12 month
Stranger anxiety: Achieved

Age of attainment:

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: Occasional

Sleep History

Total sleep duration (night): 10-11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Height: 86 cm Head circumference: 44.5 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-3+/3+
Superficial reflexes: Plantars- B/l extensors

Oromotor Examination

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

Examination summary: Pull to sit- head lag, back curved. On prone- doesnt lift head. Increased adductor- tone CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD. Quadriplegic CP

Advice

Intervention plan: Home based startegies
Investigations: BERA, ophthal examination
Medications: Syp cogniwella 3 5 ml OD
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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