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Welcome to Otika template!
Yesterday
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Patient Details
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OPD :
06-Oct-2026 05:01PM
Demographic Details
Child's Name
:
Arnav yadav
Age
:
5 Year 9 Month 12 Days
Gender
:
Male
DOB
:
2020-12-24
Mother’s age (years)
:
31 years
Mother’s occupation
:
Homemaker
Father’s age (years)
:
35 years
Father’s occupation
:
Govt job
Type of family
:
Joint
Number of family members
:
10
Number of siblings
:
1
Details of siblings (Age and sex)
:
3 year old male
Address
:
Nai sadak
Contact
:
9993491990
Referred By
:
Doctor
Informant
:
Parents
Current medications
:
Tab Arkamin 100mcg 1/4th, tab Arip MT 2mg 1/2 tab OD, syp melatonin 5 ml OD4
Interaction history:
Eye contact
:
Fleeting
Quality of Interaction
:
limited
Behavioral history:
Repetitive behaviors (RRBs):
Patterned behavior or activities:
Hyperactivity
Inattention
Impulsivity
Object obsession
Stubbornness
Aggression
Mouthing of objects
Others Emotional History Details
:
Irrelevant laughing and crying
Sensory Concerns:
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
:
LSCS
Indication for LSCS (if applicable)
:
Non progression of labor
Gestational Age
:
FT
Birth Weight
:
2.5 kg
Cry at birth
:
Cried immediately after birth
Resuscitation required
:
No
NICU stay
:
No
Past history:
Hospitalization
:
No
Seizures
:
No
Others
:
Syp Valprol
Past/Current therapies
:
Started OT since 3.5 years age
Investigations done-
Hearing assessment
:
Done
Details
:
Normal
Vision assessment
:
Done
Details
:
normal
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
:
6 months
Standing without support
:
Achieved
Age of attainment
:
9 months
Walking without support
:
Achieved
Age of attainment
:
10 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
Scribbling
:
Achieved
Age of attainment
:
Drinking from cup
:
Achieved
Age of attainment
:
Buttoning / Unbuttoning
:
Not achieved
Language
Receptive:-
Joint attention
:
Achieved
Age of attainment
:
4 years
Pointing
:
Achieved
Age of attainment
:
4.5 years
Understanding gestures
:
Achieved
Age of attainment
:
Following commands
:
1-step
Expressive:-
Cooing
:
Achieved
Age of attainment
:
4 months
Babbling
:
Achieved
Age of attainment
:
4 years
Meaningful words
:
Not achieved
2 word Phrases
:
Not achieved
Expressive:-
Cooing
:
Achieved
Age of attainment
:
4 months
Babbling
:
Achieved
Age of attainment
:
4 years
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
:
Emerging
Pointing
:
Inconsistent meaningful pointing
Understanding gestures
:
Emerging
Following commands (gesture + verbal)
:
1-step
Answering Questions:-
Echolalia
:
Present
Patterned speech
:
Present
Social
Social smile
:
Achieved
Age of attainment
:
2 months
Stranger anxiety
:
Not achieved
Waving bye bye
:
Not achieved
Comes when called
:
Achieved
Age of attainment
:
Response to Name Call
Details
:
7/10
Sitting tolerance- (in minutes)
For interaction
:
5 minutes
For tasks
:
5-20 minutes
ADL Skills (Age-appropriate)-
Eating
:
3. Needs significant assistance
Bathing
:
2. Started attempting
Toilet training
:
3. Needs significant assistance
Dressing
:
2. Started attempting
Undressing
:
2. Started attempting
Details:
:
Indicates for toilet needs non verbally
Type of Play : 2. Isolated
Academic History:
Is child enrolled in school
:
No
Diet History:
Food preferences
:
Mixed
Food allergies
:
No
Junk food intake
:
nil. Doesnt eat fruits
Sleep History
Total sleep duration (night)
:
10 hours
Afternoon nap
:
Yes
Duration of Afternoon nap
:
1 hour
Daily Screen Time
Duration
:
Zero
Examination
a. Vitals:
b. Anthropometry:
c. General Examination
Dysmorphology
:
Ab
Neurocutaneous markers
:
Ab
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
Drooling
:
No
Chewing
:
Proper
Swallowing
:
Proper
Blowing
:
Proper
Sucking
:
Proper
Advice
Intervention plan
:
IDP + PT 2/week + PMT 1/week
Medications
:
Continue medications
Follow up plan
:
Next month
General recommendation-
Zero Screen Time
Physical interactive play
No Junk food
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