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OPD : 29-Apr-2026 12:57PM Demographic Details Child's Name: Vivan Baghel Age: 2 Year 7 Month 8 Days Gender: Male DOB: 2023-09-21 Mother’s age (years): 28 years Mother’s occupation: Homemaker Father’s age (years): 29 years Father’s occupation: MP Police Type of family: Joint Number of family members: 5 Number of siblings: 0 Contact: 9617090649 Referred By: Doctor Informant: Shatapdipuram Presenting Concerns Chief concerns: Hyperactivity, repetitive behaviors Duration of symptoms: since early infancy Interaction history: Eye contact: Poor Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): toe walking, running to and fro, spinning, hand flapping Patterned behavior or activities: Arranges objects in line, obsessed with plastic caps Hyperactivity Inattention Impulsivity Insisting on sameness Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Encopresis Sensory Concerns: Tactile: Hyposensitive Auditory: Hypersensitive Proprioception: Seeks pressure Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Hypothyroidism Others:: Neonatal screening of thyroid- normal Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Gestational Age: FT Birth Weight: 2.8 Kg Cry at birth: Cried immediately after birth NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Nil 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: 6 months Standing without support: Achieved Age of attainment: 9 months Walking without support: Achieved Age of attainment: 14 months Running: Achieved Age of attainment: Climbing upstairs: 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 Drinking from cup: Achieved Age of attainment: Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Not achieved Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Expressive:- Cooing: Not achieved Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Drag for needs: Emerging Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 6 months Stranger anxiety: Not achieved Waving bye bye: Not achieved Response to Name Call Sitting tolerance- (in minutes) For interaction: Doesnt sit for interaction For tasks: Better for tasks ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Picky eater. Predominantly bottlefeeding Food allergies: No Junk food intake: Occasional biscuits Sleep History Total sleep duration (night): 8 hours Afternoon nap: Yes Duration of Afternoon nap: 1- 2 hours Sleep disturbances: No Daily Screen Time Duration: <30 minutes Examination a. Vitals: b. Anthropometry: Weight: 16 Kg Height: 96 cm Head circumference: 51 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: 1 cafe au lait macule 3*2 cm d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Normal Deep tendon reflexes: KJ- 2+/2+, AJ- 1+/1+ Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: M chat R score- 16 (High risk) Advice Intervention plan: IDP 2/week + PMT 1/week Investigations: MRI Brain (later in view of cafe au lait macule). CBC, S. Calcium, Vitamin D2, Vitamin B12, S Lead Medications: Syp IQ norm 5 ml OD Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 29-Apr-2026 12:57PM Demographic Details

Child's Name: Vivan Baghel
Age: 2 Year 7 Month 8 Days
Gender: Male
DOB: 2023-09-21
Mother’s age (years): 28 years
Mother’s occupation: Homemaker
Father’s age (years): 29 years
Father’s occupation: MP Police
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Contact: 9617090649
Referred By: Doctor
Informant: Shatapdipuram

Presenting Concerns

Chief concerns: Hyperactivity, repetitive behaviors
Duration of symptoms: since early infancy

Interaction history:

Eye contact: Poor
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): toe walking, running to and fro, spinning, hand flapping Patterned behavior or activities: Arranges objects in line, obsessed with plastic caps Hyperactivity Inattention Impulsivity Insisting on sameness Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Encopresis
Sensory Concerns:

Tactile: Hyposensitive
Auditory: Hypersensitive
Proprioception: Seeks pressure
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Hypothyroidism
Others:: Neonatal screening of thyroid- normal

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Gestational Age: FT
Birth Weight: 2.8 Kg
Cry at birth: Cried immediately after birth
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Nil 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: 6 months
Standing without support: Achieved

Age of attainment: 9 months
Walking without support: Achieved

Age of attainment: 14 months
Running: Achieved

Age of attainment:
Climbing upstairs: 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

Drinking from cup: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Not achieved

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Expressive:-

Cooing: Not achieved

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent
Drag for needs: Emerging

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 6 months
Stranger anxiety: Not achieved
Waving bye bye: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: Doesnt sit for interaction
For tasks: Better for tasks

ADL Skills (Age-appropriate)-

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

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Picky eater. Predominantly bottlefeeding
Food allergies: No
Junk food intake: Occasional biscuits

Sleep History

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

Daily Screen Time

Duration: <30 minutes

Examination

a. Vitals:

b. Anthropometry:

Weight: 16 Kg Height: 96 cm Head circumference: 51 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: 1 cafe au lait macule 3*2 cm

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

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

Oromotor Examination

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

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

Impression: M chat R score- 16 (High risk)

Advice

Intervention plan: IDP 2/week + PMT 1/week
Investigations: MRI Brain (later in view of cafe au lait macule). CBC, S. Calcium, Vitamin D2, Vitamin B12, S Lead
Medications: Syp IQ norm 5 ml OD
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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