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OPD : 06-Oct-2026 02:04PM Demographic Details Child's Name: Saksham Choubey Age: 3 Year 8 Month 15 Days Gender: Male DOB: 2023-01-21 Mother’s age (years): 22 Mother’s occupation: Homemaker Father’s age (years): 28 Father’s occupation: Private job Type of family: Joint Number of family members: 5 Number of siblings: 0 Address: Tikamgarh Contact: 7999882384 Referred By: Doctor Informant: Father, grandfather Presenting Concerns Chief concerns: Hyperactivity, inattention Strengths of child: Interaction Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Sensory Concerns: Auditory: Hyposensitive 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: 4 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Admitted on day 2 of life for NNHB for 1-2 days under PT Past history: Hospitalization: Yes Seizures: Yes Others: Febrile seizures 2 episodes last year 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: 7 months Standing without support: Achieved Age of attainment: 9 months Walking without support: Achieved Age of attainment: 12 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: 6 months Unidextrous grasp: Achieved Age of attainment: 9 months Pincer grasp: Achieved Age of attainment: 12 months Scribbling: Achieved Age of attainment: Drinking from cup: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: 1.5 years Pointing: Achieved Age of attainment: 2 years Understanding gestures: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 3 years 2 word Phrases: Not achieved Complete sentences: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 3 years 2 word Phrases: Not achieved Complete sentences: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Drag for needs: Consistent Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 9 months Waving bye bye: Achieved Age of attainment: Comes when called: Achieved Age of attainment: Response to Name Call Details: 8/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: 1-2 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 1. Dependent Undressing: 2. Started attempting Type of Play : 4. Parallel Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Biscuits Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours Daily Screen Time Duration: <30 minutes Examination a. Vitals: b. Anthropometry: Head circumference: 49 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Poor self regulation. Advice Intervention plan: IDP + PT/ Home Based Program Evaluation: DSM5 ADHD Investigations: CBC, S vitamin D, vitamin B12, thyroid profile, s urea, RBS Medications: Tab atomoxetine (10mg) 1/4th tab OD after breakfast. after 2 weeks 1/2 tab OD Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 06-Oct-2026 02:04PM Demographic Details

Child's Name: Saksham Choubey
Age: 3 Year 8 Month 15 Days
Gender: Male
DOB: 2023-01-21
Mother’s age (years): 22
Mother’s occupation: Homemaker
Father’s age (years): 28
Father’s occupation: Private job
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Address: Tikamgarh
Contact: 7999882384
Referred By: Doctor
Informant: Father, grandfather

Presenting Concerns

Chief concerns: Hyperactivity, inattention

Strengths of child: Interaction

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression
Sensory Concerns:

Auditory: Hyposensitive

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: 4 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Admitted on day 2 of life for NNHB for 1-2 days under PT

Past history:

Hospitalization: Yes Seizures: Yes Others: Febrile seizures 2 episodes last year

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: 7 months
Standing without support: Achieved

Age of attainment: 9 months
Walking without support: Achieved

Age of attainment: 12 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: 6 months

Unidextrous grasp: Achieved

Age of attainment: 9 months

Pincer grasp: Achieved

Age of attainment: 12 months

Scribbling: Achieved

Age of attainment:

Drinking from cup: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 1.5 years
Pointing: Achieved

Age of attainment: 2 years
Understanding gestures: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 3 years

2 word Phrases: Not achieved

Complete sentences: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 3 years

2 word Phrases: Not achieved

Complete sentences: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Drag for needs: Consistent

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 9 months
Waving bye bye: Achieved

Age of attainment:
Comes when called: Achieved

Age of attainment:

Response to Name Call

Details: 8/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: 1-2 minutes

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 2. Started attempting
Toilet training: 2. Started attempting
Dressing: 1. Dependent
Undressing: 2. Started attempting

Type of Play : 4. Parallel Academic History:

Is child enrolled in school: No

Diet History:

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

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours

Daily Screen Time

Duration: <30 minutes

Examination

a. Vitals:

b. Anthropometry:

Head circumference: 49 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

Chewing: Proper
Swallowing: Proper
Blowing: Proper
Sucking: Proper

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

Impression: Poor self regulation.

Advice

Intervention plan: IDP + PT/ Home Based Program
Evaluation: DSM5 ADHD
Investigations: CBC, S vitamin D, vitamin B12, thyroid profile, s urea, RBS
Medications: Tab atomoxetine (10mg) 1/4th tab OD after breakfast. after 2 weeks 1/2 tab OD
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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