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OPD : 30-Mar-2026 09:21AM Demographic Details Child's Name: Khemchand Sahu Age: 6 Year 4 Month 16 Days Gender: Male DOB: 2019-11-14 Mother’s age (years): 48 years Mother’s occupation: Homemaker Father’s age (years): 52 years Father’s occupation: Labor Type of family: Nuclear Number of family members: 3 Number of siblings: 0 Address: Chhatarpur Contact: 8224052240 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Poor understanding, behavioral issues Duration of symptoms: Since early infancy Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Inattention Impulsivity Stubbornness Aggression Mouthing of objects Sensory Concerns: Proprioception: Seeks pressure Details:: Skin picking Birth & Perinatal History: Antenatal History Consanguinity: Yes Type of conception: Natural Others:: Conceived after 35 years of marriage. (H/o uterine anomaly- surgery was done) Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Was kept in NICU fpr 4 days for respiratory distress Past history: Hospitalization: No Seizures: 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: 4 months Roll over: Achieved Age of attainment: 6 months Sitting without support: Achieved Age of attainment: 8 months Standing without support: Achieved Age of attainment: 16 months Walking without support: Achieved Age of attainment: 18 months Fine Motor Bidextrous grasp: Achieved Age of attainment: 6 months Unidextrous grasp: Achieved Age of attainment: 8 months Pincer grasp: Achieved Age of attainment: 12 months Buttoning / Unbuttoning: Achieved Age of attainment: Unbuttoning achieved Language Receptive:- Following commands: 2-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 3 years 2 word Phrases: Achieved Age of attainment: 4 years Complete sentences: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 3 years 2 word Phrases: Achieved Age of attainment: 4 years Complete sentences: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Following commands (gesture + verbal): 2-step Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 7 months Waving bye bye: Achieved Age of attainment: 30 months Comes when called: Achieved Age of attainment: Copying parents in tasks: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) For interaction: 2-3 minutes ADL Skills (Age-appropriate)- Eating: 4. Needs minimal assistance Bathing: 5. Independent Toilet training: 4. Needs minimal assistance Dressing: 3. Needs significant assistance Undressing: 4. Needs minimal assistance Details:: Prefers fed by mother. Needs assistance to be fed by mother Type of Play : 5. Associative Details:: Gets involved in frequent fights. Academic History: Is child enrolled in school: No Additional information: Went to school for few days. Discontinued due to aggressive behavior Diet History: Food allergies: No Junk food intake: Everyday Sleep History Total sleep duration (night): 12 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours Daily Screen Time Duration: <30 minutes Type of screen: TV Examination a. Vitals: b. Anthropometry: Head circumference: 43.5 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Normal Deep tendon reflexes: DTR- KJ3+/3+, AJ 3+/3+ Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ID. Microcephaly Advice Investigations: CBC, Calcium, S vitamin D2, S. Vitamin B12, Thyroid profile, MRI Brain Medications: Syp Histafer (30mg/5ml) 5 ml BD, Syp Calcimax P 5 ml BD Follow up plan: Follow up with reports General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 30-Mar-2026 09:21AM Demographic Details

Child's Name: Khemchand Sahu
Age: 6 Year 4 Month 16 Days
Gender: Male
DOB: 2019-11-14
Mother’s age (years): 48 years
Mother’s occupation: Homemaker
Father’s age (years): 52 years
Father’s occupation: Labor
Type of family: Nuclear
Number of family members: 3
Number of siblings: 0
Address: Chhatarpur
Contact: 8224052240
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Poor understanding, behavioral issues
Duration of symptoms: Since early infancy

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Inattention Impulsivity Stubbornness Aggression Mouthing of objects
Sensory Concerns:

Proprioception: Seeks pressure

Details:: Skin picking

Birth & Perinatal History: Antenatal History

Consanguinity: Yes
Type of conception: Natural
Others:: Conceived after 35 years of marriage. (H/o uterine anomaly- surgery was done)

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Was kept in NICU fpr 4 days for respiratory distress

Past history:

Hospitalization: No Seizures: 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: 4 months
Roll over: Achieved

Age of attainment: 6 months
Sitting without support: Achieved

Age of attainment: 8 months
Standing without support: Achieved

Age of attainment: 16 months
Walking without support: Achieved

Age of attainment: 18 months

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 6 months

Unidextrous grasp: Achieved

Age of attainment: 8 months

Pincer grasp: Achieved

Age of attainment: 12 months

Buttoning / Unbuttoning: Achieved

Age of attainment: Unbuttoning achieved

Language

Receptive:-

Following commands: 2-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 3 years

2 word Phrases: Achieved

Age of attainment: 4 years

Complete sentences: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 3 years

2 word Phrases: Achieved

Age of attainment: 4 years

Complete sentences: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Following commands (gesture + verbal): 2-step

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 7 months
Waving bye bye: Achieved

Age of attainment: 30 months
Comes when called: Achieved

Age of attainment:
Copying parents in tasks: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: 2-3 minutes

ADL Skills (Age-appropriate)-

Eating: 4. Needs minimal assistance
Bathing: 5. Independent
Toilet training: 4. Needs minimal assistance
Dressing: 3. Needs significant assistance
Undressing: 4. Needs minimal assistance

Details:: Prefers fed by mother. Needs assistance to be fed by mother

Type of Play : 5. Associative Details:: Gets involved in frequent fights. Academic History:

Is child enrolled in school: No
Additional information: Went to school for few days. Discontinued due to aggressive behavior

Diet History:

Food allergies: No
Junk food intake: Everyday

Sleep History

Total sleep duration (night): 12 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours

Daily Screen Time

Duration: <30 minutes
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

Head circumference: 43.5 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Normal
Deep tendon reflexes: DTR- KJ3+/3+, AJ 3+/3+

Oromotor Examination

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

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

Impression: ID. Microcephaly

Advice

Investigations: CBC, Calcium, S vitamin D2, S. Vitamin B12, Thyroid profile, MRI Brain
Medications: Syp Histafer (30mg/5ml) 5 ml BD, Syp Calcimax P 5 ml BD
Follow up plan: Follow up with reports
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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