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Patient Details


OPD : 04-Aug-2026 12:21PM Demographic Details Child's Name: Varun Kushwah Age: 7 Year 7 Month 14 Days Gender: Male DOB: 2018-12-21 Mother’s age (years): 30 years Mother’s occupation: Homemaker Father’s age (years): 30 years Father’s occupation: Private Type of family: Joint Number of family members: 4 Number of siblings: 2 Details of siblings (Age and sex): 1- 10 year old female, 2- 4 year old female Contact: 9098900525 Referred By: Doctor Informant: Father, grandmother Presenting Concerns Chief concerns: Speech delay, poor understanding Interaction history: Eye contact: Sustained Quality of Interaction: avoids Behavioral history: Repetitive behaviors (RRBs): Hand flapping Inattention Stubbornness Aggression Sensory Concerns: Vestibular: Seeks movement 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: Not known Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: Admitted for 20 days in SNCU for Resp distress, perinatal asphyxia Past history: Hospitalization: Yes Seizures: No Others: at age 2 years admitted for pneumonia 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: 12 months Roll over: Achieved Age of attainment: 15 months Sitting without support: Achieved Age of attainment: 18 months Standing without support: Achieved Age of attainment: 20 months Walking without support: Achieved Age of attainment: 24 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: 10 months Unidextrous grasp: Achieved Age of attainment: 12 months Pincer grasp: Achieved Age of attainment: Scribbling: Not achieved Drinking from cup: Not achieved Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: Delayed Pointing: Achieved Age of attainment: Delayed Understanding gestures: Achieved Age of attainment: Delayed Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Achieved Age of attainment: 24 months 2 word Phrases: Achieved Age of attainment: 4 years Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Achieved Age of attainment: 24 months 2 word Phrases: Achieved Age of attainment: 4 years Details:: 2-3 word phrases for needs, doesnt converse with strangers 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: 12 months Stranger anxiety: Achieved Age of attainment: Delayed Waving bye bye: Achieved Age of attainment: Delayed Comes when called: Achieved Age of attainment: Delayed Copying parents in tasks: Achieved Age of attainment: Delayed Asking for food and toilet: Achieved Age of attainment: Delayed Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 3. Needs significant assistance Toilet training: 5. Independent Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : 4. Parallel Details:: Doesnt understand rules of games Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Government school Grade: 1 Hours spent in school: 3 hours Board: MP Additional information: Tuitions- 2.5 hours. follows simple commands. sits at one place. Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 10 hours Afternoon nap: No Duration of Afternoon nap: Occasional naps Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 12.8 kg Height: 109 cm Head circumference: 46. 5 cm (Microcephaly) c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Drooling: Yes Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ID Advice Intervention plan: Home strategies adviced Medications: Syp Cos 3 5 ml BD, Syp Multivitamin A to Z Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 04-Aug-2026 12:21PM Demographic Details

Child's Name: Varun Kushwah
Age: 7 Year 7 Month 14 Days
Gender: Male
DOB: 2018-12-21
Mother’s age (years): 30 years
Mother’s occupation: Homemaker
Father’s age (years): 30 years
Father’s occupation: Private
Type of family: Joint
Number of family members: 4
Number of siblings: 2
Details of siblings (Age and sex): 1- 10 year old female, 2- 4 year old female
Contact: 9098900525
Referred By: Doctor
Informant: Father, grandmother

Presenting Concerns

Chief concerns: Speech delay, poor understanding

Interaction history:

Eye contact: Sustained
Quality of Interaction: avoids

Behavioral history:

Repetitive behaviors (RRBs): Hand flapping Inattention Stubbornness Aggression
Sensory Concerns:

Vestibular: Seeks movement

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: Not known
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: Admitted for 20 days in SNCU for Resp distress, perinatal asphyxia

Past history:

Hospitalization: Yes Seizures: No Others: at age 2 years admitted for pneumonia

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: 12 months
Roll over: Achieved

Age of attainment: 15 months
Sitting without support: Achieved

Age of attainment: 18 months
Standing without support: Achieved

Age of attainment: 20 months
Walking without support: Achieved

Age of attainment: 24 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: 10 months

Unidextrous grasp: Achieved

Age of attainment: 12 months

Pincer grasp: Achieved

Age of attainment:

Scribbling: Not achieved

Drinking from cup: Not achieved

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: Delayed
Pointing: Achieved

Age of attainment: Delayed
Understanding gestures: Achieved

Age of attainment: Delayed
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Achieved

Age of attainment: 24 months

2 word Phrases: Achieved

Age of attainment: 4 years

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Achieved

Age of attainment: 24 months

2 word Phrases: Achieved

Age of attainment: 4 years

Details:: 2-3 word phrases for needs, doesnt converse with strangers

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: 12 months
Stranger anxiety: Achieved

Age of attainment: Delayed
Waving bye bye: Achieved

Age of attainment: Delayed
Comes when called: Achieved

Age of attainment: Delayed
Copying parents in tasks: Achieved

Age of attainment: Delayed
Asking for food and toilet: Achieved

Age of attainment: Delayed

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 5. Independent
Bathing: 3. Needs significant assistance
Toilet training: 5. Independent
Dressing: 2. Started attempting
Undressing: 2. Started attempting

Type of Play : 4. Parallel Details:: Doesnt understand rules of games Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Government school
Grade: 1
Hours spent in school: 3 hours
Board: MP
Additional information: Tuitions- 2.5 hours. follows simple commands. sits at one place.

Diet History:

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

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: No
Duration of Afternoon nap: Occasional naps

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 12.8 kg Height: 109 cm Head circumference: 46. 5 cm (Microcephaly)

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Drooling: Yes
Chewing: Proper
Swallowing: Proper
Blowing: Proper
Sucking: Improper

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

Impression: ID

Advice

Intervention plan: Home strategies adviced
Medications: Syp Cos 3 5 ml BD, Syp Multivitamin A to Z
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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