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OPD : 03-Jun-2026 10:34AM Demographic Details Child's Name: Dhairya Sen Age: 4 Year 5 Month 26 Days Gender: Male DOB: 2021-12-08 Mother’s age (years): 31 years Mother’s occupation: Homemaker Father’s age (years): 40 years Father’s occupation: Teacher Type of family: Nuclear Number of family members: 4 Number of siblings: 1 Details of siblings (Age and sex): 13 year female Address: Bina Contact: 9685629982 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Poor response to name call Interaction history: Eye contact: Suboptimal Interaction: Likes to play with kids who are known Quality of Interaction: limited Behavioral history: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Others Emotional History Details: Irrelevant laughing Sensory Concerns: Auditory: Hypersensitive Visual: Seeks visuals Proprioception: Seeks pressure Details:: Doesnt cooperate for haircut Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: H/o renal stones during pregnancy Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 3.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No Past history: Hospitalization: Yes Seizures: Yes Others: At 1year age- 1st episode of GTCS (? febrile seizure) for 5 minutes f/b LOC, not associated with fever. No seizures after that. Recurrent infective illness since birth. Past/Current therapies: nil Past/Current medications: Syp Valprol 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: 4 months Roll over: Achieved Age of attainment: 5 months Sitting without support: Achieved Age of attainment: 6 months Standing without support: Achieved Age of attainment: 10 months Walking without support: Achieved Age of attainment: 18 months Running: Achieved Age of attainment: Climbing upstairs: Achieved Age of attainment: Climbing downstairs: Achieved Age of attainment: Hopping: Achieved Age of attainment: Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Achieved Age of attainment: 6 months Pincer grasp: Achieved Age of attainment: 12 months Scribbling: Achieved Age of attainment: Drinking from cup: Achieved Age of attainment: Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following 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 Details:: Regression of milestones noticed by parents after seizures Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Drag for needs: Consistent Joint attention: Absent Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 9 months Waving bye bye: Not achieved Comes when called: Not achieved Response to Name Call Details: Response to name call better with mother Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: better for tasks ADL Skills (Age-appropriate)- Eating: 3. Needs significant assistance Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Passes stool on floor in lying down position Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Daily Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 1.5 hour Daily Screen Time Duration: > 2 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 15 Kg Height: 96 cm Head circumference: 49 cm c. General Examination Dysmorphology: Preauricular tag Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Normal Deep tendon reflexes: 2+/2+ Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Evaluation: DQ, ISAA Investigations: CBC, Thyroid profile, Calcium, s vitamin d, S. vitamin B12, s. homocysteine. MRI Brain. General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 03-Jun-2026 10:34AM Demographic Details

Child's Name: Dhairya Sen
Age: 4 Year 5 Month 26 Days
Gender: Male
DOB: 2021-12-08
Mother’s age (years): 31 years
Mother’s occupation: Homemaker
Father’s age (years): 40 years
Father’s occupation: Teacher
Type of family: Nuclear
Number of family members: 4
Number of siblings: 1
Details of siblings (Age and sex): 13 year female
Address: Bina
Contact: 9685629982
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Poor response to name call

Interaction history:

Eye contact: Suboptimal
Interaction: Likes to play with kids who are known
Quality of Interaction: limited

Behavioral history:

Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Others Emotional History Details: Irrelevant laughing
Sensory Concerns:

Auditory: Hypersensitive
Visual: Seeks visuals
Proprioception: Seeks pressure

Details:: Doesnt cooperate for haircut

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: H/o renal stones during pregnancy

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 3.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No

Past history:

Hospitalization: Yes Seizures: Yes Others: At 1year age- 1st episode of GTCS (? febrile seizure) for 5 minutes f/b LOC, not associated with fever. No seizures after that. Recurrent infective illness since birth.

Past/Current therapies: nil Past/Current medications: Syp Valprol 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: 4 months
Roll over: Achieved

Age of attainment: 5 months
Sitting without support: Achieved

Age of attainment: 6 months
Standing without support: Achieved

Age of attainment: 10 months
Walking without support: Achieved

Age of attainment: 18 months
Running: Achieved

Age of attainment:
Climbing upstairs: Achieved

Age of attainment:
Climbing downstairs: Achieved

Age of attainment:
Hopping: Achieved

Age of attainment:

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp: Achieved

Age of attainment: 6 months

Pincer grasp: Achieved

Age of attainment: 12 months

Scribbling: Achieved

Age of attainment:

Drinking from cup: Achieved

Age of attainment:

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

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

Details:: Regression of milestones noticed by parents after seizures

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 9 months
Waving bye bye: Not achieved
Comes when called: Not achieved

Response to Name Call

Details: Response to name call better with mother

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: better for tasks

ADL Skills (Age-appropriate)-

Eating: 3. Needs significant assistance
Bathing: 2. Started attempting
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Details:: Passes stool on floor in lying down position

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed
Food allergies: No
Junk food intake: Daily

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1.5 hour

Daily Screen Time

Duration: > 2 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 15 Kg Height: 96 cm Head circumference: 49 cm

c. General Examination

Dysmorphology: Preauricular tag Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Normal
Deep tendon reflexes: 2+/2+

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Improper
Sucking: Proper

CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Advice

Evaluation: DQ, ISAA
Investigations: CBC, Thyroid profile, Calcium, s vitamin d, S. vitamin B12, s. homocysteine. MRI Brain.
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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