OPD :
01-Jul-2026 02:57PM
Demographic Details
- :
Ursiya Khan
- :
4 Year 7 Month 14 Days
- :
Female
- :
2021-11-17
- :
30 years
- :
homemaker
- :
35 years
- :
shop
- :
Joint
- :
7
- :
0
- :
Karaira, Shivpuri
- :
9074180020
- :
Doctor
- :
Parents
- :
CT Brain- WNL, EEG- Normal, TSH- 0.76
Interaction history:
- :
Sustained
- :
age-appropriate
Behavioral history:
Birth & Perinatal History:
Antenatal History
- :
Yes
- :
3
- :
Natural
- :
H/o miscarriages- 4 times (7month, 3 month, 5 month, 3 month). Conceived after infertility treatment
Natal and Postnatal History:
- :
Institutional
- :
LSCS
- :
Non progression of labor
- :
FT
- :
Not known
- :
Cried immediately after birth
- :
No
- :
No
Past history:
:
No
:
No
:
UTI at 1 year age. AEDs given for 2 years for paroxysmal events.
:
Nil
Investigations done-
Family history:
:
Yes
:
Some behavioral issues in distant relative
Developmental History:
Gross Motor
-
:
Achieved
:
4 months
-
:
Achieved
:
6 months
-
:
Achieved
:
8 months
-
:
Achieved
:
2.4 years
-
:
Achieved
:
2.5 years
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
4.5 years
Fine Motor
:
Achieved
:
4 months
:
Achieved
:
12 months
:
Achieved
:
:
Achieved
:
:
Achieved
:
4 years
:
Achieved
:
Language
Receptive:-
-
:
Achieved
:
9 months
-
:
Achieved
:
12 months
-
:
Achieved
:
- :
1-step
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
2 years
:
Achieved
:
2.5 years
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
2 years
:
Achieved
:
2.5 years
:
Kinship words and few common objects
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Consistent
- :
Consistent
- :
Consistent
- :
Consistent meaningful pointing
- :
Emerging
- :
1-step
Answering Questions:-
:
Absent
Social
-
:
Achieved
:
2 months
-
:
Achieved
:
8 months
-
:
Achieved
:
2.5 years
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
Response to Name Call
Sitting tolerance- (in minutes)
ADL Skills (Age-appropriate)-
- :
4. Needs minimal assistance
- :
4. Needs minimal assistance
- :
4. Needs minimal assistance
- :
3. Needs significant assistance
- :
4. Needs minimal assistance
:
Understands front and back of cloth
Type of Play : 4. Parallel
:
Doesnt understands rules of games
Academic History:
- :
No
Diet History:
- :
Mixed
- :
No
- :
Frequently
Sleep History
- :
10 hours
- :
Yes
- :
1-2 hours
Daily Screen Time
-
:
<30 minutes
- :
Mobile and TV
Examination
a. Vitals:
b. Anthropometry:
:
96 cm
:
48 cm
c. General Examination
:
Ab
:
Ab
d. CNS:
Higher Mental Functions
- :
Conscious, playful
- :
Oriented to persons
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
- :
No
- :
Proper
- :
Proper
- :
Proper
- :
Improper
:
NAD
:
NAD
:
NAD
:
GDD
Advice
- :
After evaluation
- :
VSMS, DST
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food
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