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Welcome to Otika template!
Yesterday
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Patient Details
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OPD :
07-Sep-2026 05:08PM
Demographic Details
Child's Name
:
Vidushi Pal
Age
:
3 Year 1 Month 24 Days
Gender
:
Female
DOB
:
2023-07-14
Mother’s age (years)
:
45 years
Mother’s occupation
:
Homemaker
Father’s age (years)
:
45 years
Father’s occupation
:
Wendy School
Type of family
:
Nuclear
Number of family members
:
4
Number of siblings
:
1
Address
:
Vinay Nagar
Contact
:
7415456389
Referred By
:
Doctor
Informant
:
Parents
Presenting Concerns
Chief concerns
:
Poor response to name call
Interaction history:
Eye contact
:
Poor
Quality of Interaction
:
limited
Behavioral history:
Repetitive behaviors (RRBs):
Hand flapping, loooking from corner of eyesw
Patterned behavior or activities:
Inattention
Insisting on sameness
Object obsession
Stubbornness
Aggression
Mouthing of objects
Others Emotional History Details
:
lrrelevant laughing
Sensory Concerns:
Auditory
:
Fear of loud sounds
Details:
:
Sits on soft surface only.
Birth & Perinatal History:
Antenatal History
Consanguinity
:
No
Type of conception
:
IVF
Others:
:
Gestational hypothyroidism in mother. Neonatal screening normal
Natal and Postnatal History:
Place of Birth
:
Institutional
Mode of Delivery
:
LSCS
Gestational Age
:
FT
Birth Weight
:
Not known
Cry at birth
:
Cried immediately after birth
Resuscitation required
:
No
NICU stay
:
No
Past history:
Hospitalization
:
No
Seizures
:
No
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
:
6months
Roll over
:
Achieved
Age of attainment
:
Sitting without support
:
Achieved
Age of attainment
:
12 months
Standing without support
:
Achieved
Age of attainment
:
18 months
Walking without support
:
Achieved
Age of attainment
:
2 years
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
:
4 months
Unidextrous grasp
:
Achieved
Age of attainment
:
6 months
Pincer grasp
:
Achieved
Age of attainment
:
12 months
Scribbling
:
Not achieved
Drinking from cup
:
Not achieved
Buttoning / Unbuttoning
:
Not achieved
Language
Receptive:-
Joint attention
:
Not achieved
Pointing
:
Not achieved
Understanding gestures
:
Not achieved
Following commands
:
Not following
Expressive:-
Cooing
:
Achieved
Age of attainment
:
4 months
Babbling
:
Achieved
Age of attainment
:
18 months
Meaningful words
:
Not achieved
2 word Phrases
:
Not achieved
Expressive:-
Cooing
:
Achieved
Age of attainment
:
4 months
Babbling
:
Achieved
Age of attainment
:
18 months
Meaningful words
:
Not achieved
2 word Phrases
:
Not achieved
Communication & Language Assessment
Non-Verbal Communication Grading:-
Need-based communication
:
Emerging
Drag for needs
:
Emerging
Joint attention
:
Absent
Pointing
:
Absent
Understanding gestures
:
Absent
Following commands (gesture + verbal)
:
Nil
Answering Questions:-
Echolalia
:
Present
Social
Social smile
:
Achieved
Age of attainment
:
3 months
Stranger anxiety
:
Achieved
Age of attainment
:
12 months
Waving bye bye
:
Not achieved
Copying parents in tasks
:
Not achieved
Asking for food and toilet
:
Not achieved
Response to Name Call
Details
:
2/10
Sitting tolerance- (in minutes)
For interaction
:
5 minutes
For tasks
:
5-7 minutes
ADL Skills (Age-appropriate)-
Eating
:
2. Started attempting
Bathing
:
2. Started attempting
Toilet training
:
1. Dependent
Dressing
:
1. Dependent
Undressing
:
1. Dependent
Details:
:
Doesnt indicate consistently
Type of Play : 2. Isolated
Academic History:
Is child enrolled in school
:
Yes
Type of school
:
Regular
Name of School
:
Xavier international Playschool
Grade
:
Playgroup
Hours spent in school
:
2
Diet History:
Food preferences
:
Picky eater
Food allergies
:
No
Junk food intake
:
No
Sleep History
Total sleep duration (night)
:
10 hours
Afternoon nap
:
Yes
Duration of Afternoon nap
:
1-2 hours
Daily Screen Time
Duration
:
< 2 hours
Type of screen
:
Mobile and TV
Examination
a. Vitals:
b. Anthropometry:
Weight
:
14 Kg
c. General Examination
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
Chewing
:
Proper
Swallowing
:
Proper
CVS examination
:
NAD
Respiratory System examination
:
NAD
Per abdomen examination
:
NAD
Impression
:
? ASD
Advice
Intervention plan
:
IDP 2/week + PMT 1/week
Evaluation
:
DQ, ISAA, DSM5 ASD
Follow up plan
:
Next month
General recommendation-
Zero Screen Time
Physical interactive play
No Junk food
No focus on academics at present
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