OPD :
01-Sep-2026 11:08AM
Demographic Details
- :
Prince Ojha
- :
10 Year 2 Month 23 Days
- :
Male
- :
2016-06-09
- :
Joint
- :
12
- :
2
- :
8 year female, 6 year male
- :
6353517687
- :
Doctor
- :
Father, maternal uncle
- :
Tab Risdone 0.5 mg
- :
MRI Brain- (9yr): normal
Presenting Concerns
- :
Poor understanding
Interaction history:
- :
Sustained
- :
age-appropriate
Behavioral history:
Inattention
Stubbornness
Aggression
:
Screamin, 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:
:
Yes
:
No
:
? Meningitis during early childhood
:
Nil
Investigations done-
:
Not done
:
Not done
Family history:
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
4 months
-
:
Achieved
:
5 months
-
:
Achieved
:
6 months
-
:
Achieved
:
9 months
-
:
Achieved
:
13 months
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
Fine Motor
:
Achieved
:
4 months
:
Not achieved
:
Achieved
:
12 months
:
Achieved
:
:
Achieved
:
Language
Receptive:-
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
5 years
:
Achieved
:
9 years
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
5 years
:
Achieved
:
9 years
:
Unclear speech
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Inconsistent
- :
Inconsistent
- :
Inconsistent
- :
Inconsistent meaningful pointing
- :
Emerging
- :
1-step
Answering Questions:-
:
Present
Social
-
:
Achieved
:
2 months
-
:
Achieved
:
8 months
-
:
Not achieved
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
Response to Name Call
Sitting tolerance- (in minutes)
ADL Skills (Age-appropriate)-
- :
5. Independent
- :
3. Needs significant assistance
- :
3. Needs significant assistance
- :
2. Started attempting
- :
2. Started attempting
Type of Play : 4. Parallel
:
Doesnt understand rules of simple games
Academic History:
- :
No
- :
Went to school for 2 years. Discontinued
Diet History:
- :
Mixed
- :
No
- :
Occasional
Sleep History
- :
5-6 hours
- :
No
Daily Screen Time
Examination
a. Vitals:
b. Anthropometry:
:
17 Kg
:
122 cm
:
49 cm
c. General Examination
:
Ab
:
Ab
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
- :
Normal
- :
KJ-2 +/2+, AJ-2+/2+
- :
Plantars- B/l flexors
Oromotor Examination
- :
No
- :
Proper
- :
Proper
- :
Proper
- :
Proper
:
?ID
Advice
- :
Home strategies adviced
- :
IQ/ DQ
- :
Continue Tab Risdone 0.5 mg HS
- :
After evaluation
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food