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Yesterday
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Patient Details
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OPD :
08-Jul-2026 02:35PM
Demographic Details
Child's Name
:
Daivik Baghel
Age
:
4 Year 11 Month 26 Days
Gender
:
Male
DOB
:
2021-07-12
Mother’s age (years)
:
29 years
Mother’s occupation
:
Homemaker
Father’s age (years)
:
31 years
Father’s occupation
:
Private job
Type of family
:
Joint
Number of family members
:
7
Number of siblings
:
1
Details of siblings (Age and sex)
:
1.5 m male
Address
:
Gole ka mandir
Contact
:
9074645419
Referred By
:
Doctor
Informant
:
Father, Grandmother
Presenting Concerns
Chief concerns
:
Hyperactivity
Duration of symptoms
:
Noticed at 3 years age
Interaction history:
Eye contact
:
Suboptimal
Quality of Interaction
:
limited
Behavioral history:
Hyperactivity
Inattention
Impulsivity
Insisting on sameness
Temper tantrums
Stubbornness
Sensory Concerns:
Proprioception
:
Seeks pressure
Birth & Perinatal History:
Antenatal History
Consanguinity
:
No
Type of conception
:
Natural
Natal and Postnatal History:
Place of Birth
:
Institutional
Mode of Delivery
:
LSCS
Indication for LSCS (if applicable)
:
Fetal distress
Gestational Age
:
FT
Birth Weight
:
2.5 Kg
Cry at birth
:
Delayed cry
Resuscitation required
:
Yes
NICU stay
:
Yes
If yes- Duration & Indication
:
NICU stay- 8 days. On MV -2 days. Neonatal seizures
Past history:
Hospitalization
:
No
Past/Current therapies
:
Nil
Past/Current medications
:
Syp sizodon was given for 1 week
Investigations done-
Hearing assessment
:
Done
Vision assessment
:
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
:
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
:
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
:
Language
Receptive:-
Joint attention
:
Achieved
Age of attainment
:
9 months
Pointing
:
Achieved
Age of attainment
:
18 months
Understanding gestures
:
Achieved
Age of attainment
:
Following commands
:
1-step
Expressive:-
Cooing
:
Achieved
Age of attainment
:
Babbling
:
Achieved
Age of attainment
:
6 months
Meaningful words
:
Achieved
Age of attainment
:
At 4 years
Expressive:-
Cooing
:
Achieved
Age of attainment
:
Babbling
:
Achieved
Age of attainment
:
6 months
Meaningful words
:
Achieved
Age of attainment
:
At 4 years
Details:
:
Patterned speech
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:-
Echolalia
:
Present
Patterned speech
:
Present
Social
Social smile
:
Achieved
Age of attainment
:
2 months
Stranger anxiety
:
Achieved
Age of attainment
:
8 months
Waving bye bye
:
Achieved
Age of attainment
:
18 months
Copying parents in tasks
:
Achieved
Age of attainment
:
Asking for food and toilet
:
Achieved
Age of attainment
:
Response to Name Call
Details
:
9/10
Sitting tolerance- (in minutes)
For interaction
:
Doesnt sit
For tasks
:
1-2 minutes
ADL Skills (Age-appropriate)-
Eating
:
2. Started attempting
Bathing
:
2. Started attempting
Toilet training
:
2. Started attempting
Dressing
:
2. Started attempting
Undressing
:
1. Dependent
Type of Play : 4. Parallel
Details:
:
Wants to play by his rule
Academic History:
Is child enrolled in school
:
No
Diet History:
Food preferences
:
Mixed
Food allergies
:
No
Junk food intake
:
Occasional
Sleep History
Total sleep duration (night)
:
7 hours
Afternoon nap
:
Yes
Duration of Afternoon nap
:
1 hour
Sleep disturbances
:
Yes
Daily Screen Time
Duration
:
> 2 hours
Type of screen
:
Mobile and TV
Examination
a. Vitals:
b. Anthropometry:
Weight
:
17 Kg
Height
:
104 cm
Head circumference
:
48.5 cm
c. General Examination
Dysmorphology
:
Ab
Neurocutaneous markers
:
Cafe au lait macule 2.5*1.5 cm
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
Drooling
:
No
Chewing
:
Proper
Swallowing
:
Proper
Blowing
:
Proper
Sucking
:
Proper
CVS examination
:
NAD
Respiratory System examination
:
NAD
Per abdomen examination
:
NAD
Impression
:
? Poor self regulation
Advice
Intervention plan
:
IDP 2/week + PMT1/week
Evaluation
:
DQ, ISAA, DSM5 ADHD
General recommendation-
Zero Screen Time
Physical interactive play
No Junk food
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