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Patient Details


OPD : 29-Jun-2026 01:48PM Demographic Details Child's Name: Yashvi Age: 8 Year 6 Month 17 Days Gender: Female DOB: 2017-12-12 Type of family: Joint Number of family members: 6 Number of siblings: 1 Details of siblings (Age and sex): 6 year old male Contact: 7804083732 Referred By: Doctor Informant: Mother Presenting Concerns Chief concerns: Nocturnal enuresis Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Emotional history: Irritability Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Investigations done- Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: Roll over: Achieved Age of attainment: Sitting without support: Achieved Age of attainment: Standing without support: Achieved Age of attainment: Walking without support: Achieved Age of attainment: Running: Achieved Age of attainment: Climbing upstairs: Achieved Age of attainment: Climbing downstairs: Achieved Age of attainment: Hopping: Achieved Age of attainment: Standing on one foot: Achieved Age of attainment: Skipping: Achieved Age of attainment: Fine Motor Bidextrous grasp: Achieved Age of attainment: Unidextrous grasp: Achieved Age of attainment: Pincer grasp: Achieved Age of attainment: Scribbling: Achieved Age of attainment: Drinking from cup: Achieved Age of attainment: Buttoning / Unbuttoning: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: Pointing: Achieved Age of attainment: Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: Babbling: Achieved Age of attainment: Meaningful words: Achieved Age of attainment: 2 word Phrases: Achieved Age of attainment: Complete sentences: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: Babbling: Achieved Age of attainment: Meaningful words: Achieved Age of attainment: 2 word Phrases: Achieved Age of attainment: Complete sentences: Achieved Age of attainment: Details:: Milestones age appropriate. Forgets 2 steps commands 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: Stranger anxiety: Achieved Age of attainment: 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) ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 5. Independent Toilet training: 5. Independent Dressing: 5. Independent Undressing: 5. Independent Details:: Requires nagging Type of Play : 6. Cooperative Details:: Gets irritated while playing Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Narayan e techno Grade: 3 Hours spent in school: 5.5 hours Board: CBSE Location: Anand Nagar Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 8-9 hours Afternoon nap: No Duration of Afternoon nap: 1-2 hours somemtimes Sleep disturbances: Daily Screen Time Duration: > 5 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 28.30Kg Height: 134 cm Head circumference: 52 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab 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 Advice Investigations: CBC, Iron profile, Calcium, Vitamin D, Vitamin B12, RFT, Thyroid profile, RBS, Urine R/M Follow up plan: Review with reports General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 29-Jun-2026 01:48PM Demographic Details

Child's Name: Yashvi
Age: 8 Year 6 Month 17 Days
Gender: Female
DOB: 2017-12-12
Type of family: Joint
Number of family members: 6
Number of siblings: 1
Details of siblings (Age and sex): 6 year old male
Contact: 7804083732
Referred By: Doctor
Informant: Mother

Presenting Concerns

Chief concerns: Nocturnal enuresis

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Emotional history:
Irritability

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Investigations done-

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment:
Roll over: Achieved

Age of attainment:
Sitting without support: Achieved

Age of attainment:
Standing without support: Achieved

Age of attainment:
Walking without support: Achieved

Age of attainment:
Running: Achieved

Age of attainment:
Climbing upstairs: Achieved

Age of attainment:
Climbing downstairs: Achieved

Age of attainment:
Hopping: Achieved

Age of attainment:
Standing on one foot: Achieved

Age of attainment:
Skipping: Achieved

Age of attainment:

Fine Motor

Bidextrous grasp: Achieved

Age of attainment:

Unidextrous grasp: Achieved

Age of attainment:

Pincer grasp: Achieved

Age of attainment:

Scribbling: Achieved

Age of attainment:

Drinking from cup: Achieved

Age of attainment:

Buttoning / Unbuttoning: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment:
Pointing: Achieved

Age of attainment:
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment:

Babbling: Achieved

Age of attainment:

Meaningful words: Achieved

Age of attainment:

2 word Phrases: Achieved

Age of attainment:

Complete sentences: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment:

Babbling: Achieved

Age of attainment:

Meaningful words: Achieved

Age of attainment:

2 word Phrases: Achieved

Age of attainment:

Complete sentences: Achieved

Age of attainment:

Details:: Milestones age appropriate. Forgets 2 steps commands

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:
Stranger anxiety: Achieved

Age of attainment:
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)

ADL Skills (Age-appropriate)-

Eating: 5. Independent
Bathing: 5. Independent
Toilet training: 5. Independent
Dressing: 5. Independent
Undressing: 5. Independent

Details:: Requires nagging

Type of Play : 6. Cooperative Details:: Gets irritated while playing Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Narayan e techno
Grade: 3
Hours spent in school: 5.5 hours
Board: CBSE
Location: Anand Nagar

Diet History:

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

Sleep History

Total sleep duration (night): 8-9 hours
Afternoon nap: No
Duration of Afternoon nap: 1-2 hours somemtimes
Sleep disturbances:

Daily Screen Time

Duration: > 5 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 28.30Kg Height: 134 cm Head circumference: 52 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

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

Advice

Investigations: CBC, Iron profile, Calcium, Vitamin D, Vitamin B12, RFT, Thyroid profile, RBS, Urine R/M
Follow up plan: Review with reports
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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