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OPD : 06-Jul-2026 12:24PM Demographic Details Child's Name: Vedant Panchkar Age: 10 Year 3 Month 3 Days Gender: Male DOB: 2016-04-03 Mother’s age (years): 28 years Mother’s occupation: Homemaker Father’s age (years): 30 years Father’s occupation: Labourer Type of family: Joint Number of family members: 5 Number of siblings: 3 Details of siblings (Age and sex): 7yf,4yf,3mM Address: Damoh Contact: 8839644663 Referred By: Doctor Informant: Father Presenting Concerns Chief concerns: Poor understanding Duration of symptoms: Realized at 4 years age Interaction history: Eye contact: Sustained Interaction: Wants to interact but inappropriate approach Behavioral history: Repetitive behaviors (RRBs): Hand flapping Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Emotional history: Irritability Others Emotional History Details: Irrelevant laughing Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Pre-eclampsia Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: Not known Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: Admitted in NICU for 16 days for MAS, HIE Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Medications stopped 1 yr back 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: 7 months Standing without support: Achieved Age of attainment: 16 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: 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: Not achieved Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: Delay Pointing: Achieved Age of attainment: Delay Understanding gestures: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 18 months 2 word Phrases: Achieved Age of attainment: 24 months Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 18 months 2 word Phrases: Achieved Age of attainment: 24 months Details:: Misarticulation (Tongue tie+) Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent 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: 2 months Stranger anxiety: Achieved Age of attainment: 12 months Waving bye bye: Achieved Age of attainment: Delayed Response to Name Call Sitting tolerance- (in minutes) For interaction: doesnt sit ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Doesnt indicate for urine and stool Type of Play : 2. Isolated Academic History: Is child enrolled in school: Yes Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Frequent Sleep History Total sleep duration (night): 8-9 hours Afternoon nap: No Duration of Afternoon nap: Occasional naps Sleep disturbances: Yes Daily Screen Time Duration: < 1 hour Type of screen: Mobile Examination a. Vitals: b. Anthropometry: Weight: 35 Kg Height: 140 cm Head circumference: 51 cm c. General Examination Neurocutaneous markers: Hypopigmented patch over left forearm d. CNS: Higher Mental Functions Consciousness: Awake Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypertonia Deep tendon reflexes: KJ-2+/2+, AJ-2+/2+ Superficial reflexes: Plantars- withdrawal Oromotor Examination Drooling: Yes Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper Examination summary: Tone increased (UL), Angle of mouth deviates to Left side, misarticulation, restricted tongue movements CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ID Advice Intervention plan: IQ/DQ evaluation Investigations: MRI Brain, Pediatric surgeon opinion General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 06-Jul-2026 12:24PM Demographic Details

Child's Name: Vedant Panchkar
Age: 10 Year 3 Month 3 Days
Gender: Male
DOB: 2016-04-03
Mother’s age (years): 28 years
Mother’s occupation: Homemaker
Father’s age (years): 30 years
Father’s occupation: Labourer
Type of family: Joint
Number of family members: 5
Number of siblings: 3
Details of siblings (Age and sex): 7yf,4yf,3mM
Address: Damoh
Contact: 8839644663
Referred By: Doctor
Informant: Father

Presenting Concerns

Chief concerns: Poor understanding
Duration of symptoms: Realized at 4 years age

Interaction history:

Eye contact: Sustained
Interaction: Wants to interact but inappropriate approach

Behavioral history:

Repetitive behaviors (RRBs): Hand flapping Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Emotional history:
Irritability Others Emotional History Details: Irrelevant laughing

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Pre-eclampsia

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: Not known
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: Admitted in NICU for 16 days for MAS, HIE

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Medications stopped 1 yr back 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: 7 months
Standing without support: Achieved

Age of attainment: 16 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:

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: Not achieved

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: Delay
Pointing: Achieved

Age of attainment: Delay
Understanding gestures: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 18 months

2 word Phrases: Achieved

Age of attainment: 24 months

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 18 months

2 word Phrases: Achieved

Age of attainment: 24 months

Details:: Misarticulation (Tongue tie+)

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Inconsistent
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: 2 months
Stranger anxiety: Achieved

Age of attainment: 12 months
Waving bye bye: Achieved

Age of attainment: Delayed

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: doesnt sit

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Details:: Doesnt indicate for urine and stool

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: Yes

Diet History:

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

Sleep History

Total sleep duration (night): 8-9 hours
Afternoon nap: No
Duration of Afternoon nap: Occasional naps
Sleep disturbances: Yes

Daily Screen Time

Duration: < 1 hour
Type of screen: Mobile

Examination

a. Vitals:

b. Anthropometry:

Weight: 35 Kg Height: 140 cm Head circumference: 51 cm

c. General Examination

Neurocutaneous markers: Hypopigmented patch over left forearm

d. CNS: Higher Mental Functions

Consciousness: Awake

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypertonia
Deep tendon reflexes: KJ-2+/2+, AJ-2+/2+
Superficial reflexes: Plantars- withdrawal

Oromotor Examination

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

Examination summary: Tone increased (UL), Angle of mouth deviates to Left side, misarticulation, restricted tongue movements CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: ID

Advice

Intervention plan: IQ/DQ evaluation
Investigations: MRI Brain, Pediatric surgeon opinion
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

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