This document contains medical information about a 6-month-old female infant named Anika Khatoon. She was born at 36 weeks gestation via C-section due to the indication of cephalopelvic disproportion. Her birth weight was 2.3kg and she experienced neonatal jaundice and convulsions. Currently, Anika has poor head and trunk control and is unable to sit without support. Her assessment shows signs consistent with hypoxic ischemic insult. The recommended treatment is an activity-based motor and cognitive skill training program focused on facilitation of cognitive motor multi-sensory learning for 20 minutes per day, 5 days a week.

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2. Name: Anika Khatoon
Age: 6months Sex: F
Address: Basirhat, North 24 parganas
Hand of dominance: Right
Date of assessment: 09-05-23

3. Mother’s age at conception: 22
Mode of conception: spontaneous
Gravida: G2
Para: P1
Gestation weeks: 36 weeks
Mother’s blood group: A-
Presentation: vertex

4. No history of alcohol consumption,
cigarette smoking
No history of mother’s gestational
diabetes, hypertension, and thyroid
No history of per vaginal bleeding
No history of trauma and “TORCH”
infection
No history of steroid intake

5. E
EDD: 4.12.22 Date of delivery:
Gestational age: 36 weeks
Labor: Uneventful
Type of delivery: LUCS(Indication of C/S:

6. POST NATAL HISTORY
APGAR SCORE IN 5 MINUTE
ACTIVITY ACTIVE 02
PULSE 184 02
GRIMACE PROMPT RESPONSE TO STIMULATION 02
APPEARANCE PINK 02
RESPIRATION SLOW IRREGULAR 01
TOTAL SCORE 10 09
First cry:
immediately after
birth (Feeble)
Birth weight: 2.3 kg

7. Sucking: Poor
Blood sugar: 76 mg/dl
Oxygen saturation: 93%
History of neonatal jaundice on D4
Rh incompatibility
History of Neonatal convulsion on D4

8. • Head and Neck control is not achieved yet
• Hand approach to hold any object with both
hands yet not achieved
• Response to voice achieved in 5 months
• Turn to sound : yet not achieved

9. • Interaction with parents and Stranger awareness is
achieved in 4-5 months
• Baby is dependent on breastfeeding

10. Consanguineous
There was no relevant family history

12. CHIEF COMPLAINT
Unable to control her neck for a long time

13. Weight: 6.4 kg
Height: 59 cm
Head
circumference:
46 cm
BMI: 18.4Kg/Cm2

14. BODY PARTS POSITION
SHOULDER ADDUCTED AND FLEXED
ELBOW FLEXED
HIP AND KNEE FLEXED
HEAD ALIGNED MIDLINE OF THE
BODY

15. Symmetry of the
body: Maintained
Involuntary
movements: Not
observed
Visual fixation
and tracking:
Present
No squint and
no nystagmus
Rolling: Yet not
Achieved
Response to
auditory stimulus
(DISTRACTION
TEST): Reduced
Social smile and
eye contact:
Achieved
Able to makes
noise
accordingly
Bidextrous reach:
Yet not achieved

16. Body part Position of the Body part
Shoulder Adducted and flexed
elbow flexed
Hip and knee flat pelvis with extended hip and knee
flexed
Head Flexed in the right side

17. Head holding at the midline:
less than 30s
can not lift the head
spontaneously
Weight-bearing on hand with
extended arm : yet not achieved

18. Pull-to-sit
observation:
Sitting :
Ventral
suspension
Head lagging
• Poor Head and trunk
control
• Cannot sit without support
Unable to hold her head
in the horizontal plane with
the upper and lower limbs
flexed

19. Reflex maturation
Rooting reflex: Present
Palmar grasp: Absent
Plantar grasp: Present
Doll eye: Absent

20. Stepping reflex :
Present
ATNR: Present
STNR: Present
Galants reflex: Lateral
flexion towards e stimulated
side

21. Extensor thrust:
absent
Withdrawal
reflex: present
Neck righting
reflex: present

23. • Muscle tone:
Within the normal limit for both the flexor
and extensor group of muscle of the upper
and lower limb
• Spasticity:
There was no evidence of spasticity in both limbs.
• Tightness contracture and deformity: absent

27. Hypoxic ischemic insult
Focal demyelination
Subdural hygroma

28. •

30. • ACTIVITY BASED MOTOR AND COGNITIVE SKILL
TRAINING
• FACILITATION OF COGNITIVE MOTOR MULTI
SENSORY LEARNING
DOSE: 20MINS EVERY DAY
FOR 5 DAYS A WEEK

31. 1. Benfer KA, Novak I, Morgan C, Whittingham K, Khan
NZ, Ware RS, Bell KL, Bandaranayake S, Salt A, Ghosh
AK, Bhattacharya A, Samanta S, Moula G, Bose D,
Tripathi S, Boyd RN. Community-based parent-
delivered early detection and intervention program for
infants at high risk of cerebral palsy in a low-resource
country (Learning through Everyday Activities with
Parents (LEAP-CP): protocol for a randomized
controlled trial. BMJ Open. 2018 Jun 22;8