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OPD : 12-May-2026 04:39PM Demographic Details Child's Name: Lovyansh Pal Age: 4 Year 6 Month 24 Days Gender: Male DOB: 2021-10-18 Mother’s age (years): 24 years Mother’s occupation: Homamaker Father’s age (years): 34 years Father’s occupation: Driver Type of family: Joint Number of family members: 5 Number of siblings: 1 Details of siblings (Age and sex): 8 mon females Address: Taraganj, Gwl Contact: 9977486534 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Hyperactivity Interaction history: Eye contact: Suboptimal Behavioral history: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Sensory Concerns: Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 2.4 Kg Cry at birth: Delayed cry Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: 1 mon Past history: Hospitalization: No Seizures: Yes Others: Abnormal body movements (Deviation of neck, eyes, frothing, clenching of teeth,) Started at 18 months age. Past/Current medications: AEDs given for 1 years. Syp Valparin restarted 3 months back. Investigations done- Hearing assessment: Done Details: OAE- normal Vision assessment: Done Details: Adviced follow up Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 6 mon Roll over: Achieved Age of attainment: 6 mon Sitting without support: Achieved Age of attainment: 9 mon Standing without support: Achieved Age of attainment: 16 mon Walking without support: Achieved Age of attainment: 18 mon 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 mon Unidextrous grasp: Achieved Age of attainment: 6 mon Pincer grasp: Achieved Age of attainment: 12 mon Scribbling: Achieved Age of attainment: Drinking from cup: Achieved Age of attainment: Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: Delayed Pointing: Achieved Age of attainment: Delayed Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 2 mon Babbling: Achieved Age of attainment: 6 mon Meaningful words: Achieved Age of attainment: 2.5years 2 word Phrases: Not achieved Complete sentences: Not achieved Expressive:- Cooing: Achieved Age of attainment: 2 mon Babbling: Achieved Age of attainment: 6 mon Meaningful words: Achieved Age of attainment: 2.5years 2 word Phrases: Not achieved Complete sentences: Not achieved Details:: Speaks initial syllables for kinship words Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Drag for needs: Consistent Joint attention: Consistent Pointing: Consistent meaningful pointing Understanding gestures: Consistent Following commands (gesture + verbal): 1-step Answering Questions:- Social Social smile: Achieved Age of attainment: 2 mon Waving bye bye: Achieved Age of attainment: 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: Doesnt sit For tasks: Doesnt sit ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : 4. Parallel Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed diet Food allergies: No Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: Yes Sleep disturbances: No Daily Screen Time Duration: < 2 hours Examination a. Vitals: b. Anthropometry: Weight: 15 Kg Height: 94 cm Head circumference: 46 cm c. General Examination Dysmorphology: Exotropia Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Normal Deep tendon reflexes: KJ 2+/2+, AJ 1+/2+ Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD Advice Evaluation: IQ test (BKT) Investigations: Repeat EEG Follow up plan: after 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 12-May-2026 04:39PM Demographic Details

Child's Name: Lovyansh Pal
Age: 4 Year 6 Month 24 Days
Gender: Male
DOB: 2021-10-18
Mother’s age (years): 24 years
Mother’s occupation: Homamaker
Father’s age (years): 34 years
Father’s occupation: Driver
Type of family: Joint
Number of family members: 5
Number of siblings: 1
Details of siblings (Age and sex): 8 mon females
Address: Taraganj, Gwl
Contact: 9977486534
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Hyperactivity

Interaction history:

Eye contact: Suboptimal

Behavioral history:

Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression
Sensory Concerns:

Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 2.4 Kg
Cry at birth: Delayed cry
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: 1 mon

Past history:

Hospitalization: No Seizures: Yes Others: Abnormal body movements (Deviation of neck, eyes, frothing, clenching of teeth,) Started at 18 months age.

Past/Current medications: AEDs given for 1 years. Syp Valparin restarted 3 months back. Investigations done-

Hearing assessment: Done Details: OAE- normal Vision assessment: Done Details: Adviced follow up

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 6 mon
Roll over: Achieved

Age of attainment: 6 mon
Sitting without support: Achieved

Age of attainment: 9 mon
Standing without support: Achieved

Age of attainment: 16 mon
Walking without support: Achieved

Age of attainment: 18 mon
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 mon

Unidextrous grasp: Achieved

Age of attainment: 6 mon

Pincer grasp: Achieved

Age of attainment: 12 mon

Scribbling: Achieved

Age of attainment:

Drinking from cup: Achieved

Age of attainment:

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: Delayed
Pointing: Achieved

Age of attainment: Delayed
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 2 mon

Babbling: Achieved

Age of attainment: 6 mon

Meaningful words: Achieved

Age of attainment: 2.5years

2 word Phrases: Not achieved

Complete sentences: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 2 mon

Babbling: Achieved

Age of attainment: 6 mon

Meaningful words: Achieved

Age of attainment: 2.5years

2 word Phrases: Not achieved

Complete sentences: Not achieved

Details:: Speaks initial syllables for kinship words

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Drag for needs: Consistent
Joint attention: Consistent
Pointing: Consistent meaningful pointing
Understanding gestures: Consistent
Following commands (gesture + verbal): 1-step

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 mon
Waving bye bye: Achieved

Age of attainment:
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: Doesnt sit
For tasks: Doesnt sit

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 2. Started attempting
Toilet training: 2. Started attempting
Dressing: 2. Started attempting
Undressing: 2. Started attempting

Type of Play : 4. Parallel Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed diet
Food allergies: No

Sleep History

Total sleep duration (night): 9-10 hours
Afternoon nap: Yes
Sleep disturbances: No

Daily Screen Time

Duration: < 2 hours

Examination

a. Vitals:

b. Anthropometry:

Weight: 15 Kg Height: 94 cm Head circumference: 46 cm

c. General Examination

Dysmorphology: Exotropia Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Normal
Deep tendon reflexes: KJ 2+/2+, AJ 1+/2+

Oromotor Examination

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

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

Impression: GDD

Advice

Evaluation: IQ test (BKT)
Investigations: Repeat EEG
Follow up plan: after 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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