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OPD : 21-Oct-2026 02:27PM Demographic Details Child's Name: Nitya Tripathi Age: 3 Year 3 Month 9 Days Gender: Female DOB: 2023-07-12 Mother’s age (years): 33 years Mother’s occupation: Homemaker Father’s age (years): 37 years Father’s occupation: Air force Type of family: Nuclear Number of family members: 4 Number of siblings: 1 Details of siblings (Age and sex): 10 year old female Address: Hashimara Contact: 8602448008 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Handflapping Patterned behavior or activities: Hyperactivity Inattention Temper tantrums Stubbornness Aggression Emotional history: Irritability Sensory Concerns: Tactile: Hypersensitive Auditory: Hypersensitive Proprioception: Seeks pressure 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: 3.2 Kg Cry at birth: Cried immediately after birth NICU stay: No Past history: Hospitalization: Yes Seizures: No Others: At age 2 years- admitted for AGE, muscle spasms in winters Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Not done Vision assessment: Done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 months Roll over: Achieved Age of attainment: 6 months Sitting without support: Achieved Age of attainment: 6 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: 4 months Unidextrous grasp: Achieved Age of attainment: 6 months Pincer grasp: Achieved Age of attainment: 12 months Language Receptive:- Joint attention: Achieved Age of attainment: Inoconsistent Pointing: Achieved Age of attainment: Inconsitent Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 2.5 years Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 2.5 years Details:: Speaks kinship words meaningfully Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent Drag for needs: Inconsistent Joint attention: Inconsistent Pointing: Inconsistent meaningful pointing Understanding gestures: Emerging Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 9 months Comes when called: Achieved Age of attainment: Response to Name Call Details: 5/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: 2-3 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 2. Started attempting Undressing: 2. Started attempting Details:: Indicates for urine and stool Type of Play : 2. Isolated Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Playschool Hours spent in school: 3 hours Location: Hashimara Diet History: Food preferences: Picky eater Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 8-10 hours Afternoon nap: No Daily Screen Time Duration: > 2 hours Examination a. Vitals: b. Anthropometry: Head circumference: 46 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper Examination summary: ISAA, DSM5 ASD CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Social communication delay Advice Intervention plan: IDP 3/week + PMT 1/week Evaluation: ISAA, DSM5 ASD Medications: Syp autinorm 5 ml OD Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 21-Oct-2026 02:27PM Demographic Details

Child's Name: Nitya Tripathi
Age: 3 Year 3 Month 9 Days
Gender: Female
DOB: 2023-07-12
Mother’s age (years): 33 years
Mother’s occupation: Homemaker
Father’s age (years): 37 years
Father’s occupation: Air force
Type of family: Nuclear
Number of family members: 4
Number of siblings: 1
Details of siblings (Age and sex): 10 year old female
Address: Hashimara
Contact: 8602448008
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Handflapping Patterned behavior or activities: Hyperactivity Inattention Temper tantrums Stubbornness Aggression Emotional history:
Irritability
Sensory Concerns:

Tactile: Hypersensitive
Auditory: Hypersensitive
Proprioception: Seeks pressure
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: 3.2 Kg
Cry at birth: Cried immediately after birth
NICU stay: No

Past history:

Hospitalization: Yes Seizures: No Others: At age 2 years- admitted for AGE, muscle spasms in winters

Past/Current therapies: Nil Past/Current medications: Nil Investigations done-

Hearing assessment: Not done Vision assessment: Done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 months
Roll over: Achieved

Age of attainment: 6 months
Sitting without support: Achieved

Age of attainment: 6 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: 4 months

Unidextrous grasp: Achieved

Age of attainment: 6 months

Pincer grasp: Achieved

Age of attainment: 12 months

Language

Receptive:-

Joint attention: Achieved

Age of attainment: Inoconsistent
Pointing: Achieved

Age of attainment: Inconsitent
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 2.5 years

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 2.5 years

Details:: Speaks kinship words meaningfully

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Inconsistent
Drag for needs: Inconsistent
Joint attention: Inconsistent
Pointing: Inconsistent meaningful pointing
Understanding gestures: Emerging
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 9 months
Comes when called: Achieved

Age of attainment:

Response to Name Call

Details: 5/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: 2-3 minutes

ADL Skills (Age-appropriate)-

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

Details:: Indicates for urine and stool

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Playschool
Hours spent in school: 3 hours
Location: Hashimara

Diet History:

Food preferences: Picky eater
Food allergies: No
Junk food intake: Occasional

Sleep History

Total sleep duration (night): 8-10 hours
Afternoon nap: No

Daily Screen Time

Duration: > 2 hours

Examination

a. Vitals:

b. Anthropometry:

Head circumference: 46 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Proper
Sucking: Proper

Examination summary: ISAA, DSM5 ASD CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: Social communication delay

Advice

Intervention plan: IDP 3/week + PMT 1/week
Evaluation: ISAA, DSM5 ASD
Medications: Syp autinorm 5 ml OD
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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