OPD :
22-May-2026 11:54AM
Demographic Details
- :
Ashika Lodhi
- :
11 Year 4 Month 21 Days
- :
Female
- :
2015-01-01
- :
Joint
- :
11
- :
4
- :
14y, 8y females, 5 year male
- :
Karera, Shivpuri
- :
9340827107
- :
Doctor
- :
Father, cousin
Presenting Concerns
- :
Poor understanding
- :
from early infancy
Interaction history:
Behavioral history:
Inattention
Stubbornness
Aggression
:
Irrelevant laughing
Birth & Perinatal History:
Antenatal History
- :
No
- :
Natural
Natal and Postnatal History:
- :
Institutional
- :
NVD
- :
FT
- :
Not known
- :
Cried immediately after birth
- :
No
- :
No
Past history:
:
No
:
Nil
:
Nil
Investigations done-
:
Done
:
PTA-b/l minimal HL with high frequency comp. BERA- normal
:
Not done
Family history:
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
4 months
-
:
Achieved
:
5 months
-
:
Achieved
:
7 months
-
:
Achieved
:
9 months
-
:
Achieved
:
12 months
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
Fine Motor
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
12 months
:
Achieved
:
:
Achieved
:
Frequently spils
:
Not achieved
Language
Receptive:-
-
:
Achieved
:
Not known
-
:
Achieved
:
Not known
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
3 years
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
3 years
:
Says mumuum when needs water.
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Inconsistent
- :
Inconsistent
- :
Inconsistent
- :
Inconsistent meaningful pointing
- :
Emerging
- :
1-step
Answering Questions:-
:
No
:
Present
Social
-
:
Achieved
:
2 months
-
:
Achieved
:
9 months
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
Response to Name Call
Sitting tolerance- (in minutes)
- :
can sit for longe periods, fidgetiness+
ADL Skills (Age-appropriate)-
- :
5. Independent
- :
5. Independent
- :
5. Independent
- :
4. Needs minimal assistance
- :
4. Needs minimal assistance
Type of Play : 3. Onlooker
:
Doesnt understand simple rules of games
Academic History:
- :
Yes
- :
Regular
- :
Sashkiya Vidyalaya
- :
3
- :
4 hours
- :
MP
- :
Shivpuri
Diet History:
- :
Mixed
- :
No
- :
Occasional
Sleep History
- :
9 hours
- :
Yes
- :
2-3 hours
Daily Screen Time
-
:
< 2 hours
- :
Mobile and TV
Examination
a. Vitals:
b. Anthropometry:
:
44 Kg
:
149 cm
:
53.5 cm
c. General Examination
:
Maxillary prominence
:
Ab
d. CNS:
Higher Mental Functions
- :
Awake
- :
to person
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
- :
Gross motor and Fine motor
- :
Normal
- :
KJ- 2+/2+, AJ 2+/2+
- :
Plantars- B/l flexors
- :
NAD
- :
NAD
:
Difficulty in performing finger nose test, heel shin test. Dysdiadokinesia+
:
Absent
Oromotor Examination
- :
No
- :
Proper
- :
Proper
- :
Proper
- :
Proper
:
Cognitive impairment. Fine motor difficulties. Speech delay. :
NAD
:
NAD
:
NAD
:
? ID with Language delay (Expressive> receptive) ? Genetic
:
Improvement in basic understanding
Advice
- :
after evaluation
- :
IQ/ DQ
- :
CBC, LFT, RFT thyroid profile, Calcium, Vitamin D, Vitamin B12, RBS. MRI Brain.
- :
After evaluations
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food
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