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Patient Details
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OPD :
10-Sep-2026 04:27PM
Demographic Details
Child's Name
:
Abhyudaya
Age
:
4 Year 10 Month 3 Days
Gender
:
Male
DOB
:
2021-11-07
Type of family
:
Nuclear
Number of family members
:
5
Number of siblings
:
2
Details of siblings (Age and sex)
:
1-18 year old female, 2-12 year old female
Address
:
Maharajpura
Contact
:
8148779237
Referred By
:
Doctor
Informant
:
Parents
Investigations done
:
ISAA- 117. CBCL- s/o withdrawal related difficulties
Presenting Concerns
Chief concerns
:
Speech delay, doesnt initiate
Duration of symptoms
:
Since early childhood
Interaction history:
Eye contact
:
Suboptimal
Quality of Interaction
:
limited
Behavioral history:
Hyperactivity
Inattention
Stubbornness
Aggression
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)
:
Cord around neck
Gestational Age
:
FT
Birth Weight
:
2.5 Kg
Cry at birth
:
Cried immediately after birth
Resuscitation required
:
No
NICU stay
:
No
If yes- Duration & Indication
:
3 MTPs
Past history:
Hospitalization
:
No
Seizures
:
No
Investigations done-
Hearing assessment
:
Done
Details
:
Reports not there
Vision assessment
:
Done
Details
:
Reports not there
Family history:
Neuropsychiatric condition
:
No
Developmental History:
Gross Motor
Neck holding
:
Achieved
Age of attainment
:
6 months
Roll over
:
Achieved
Age of attainment
:
6 months
Sitting without support
:
Achieved
Age of attainment
:
7 months
Standing without support
:
Achieved
Age of attainment
:
16 months
Walking without support
:
Achieved
Age of attainment
:
18 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
:
Language
Receptive:-
Joint attention
:
Achieved
Age of attainment
:
Delayed
Pointing
:
Achieved
Age of attainment
:
Delayed
Understanding gestures
:
Achieved
Age of attainment
:
Following commands
:
1-step
Expressive:-
Cooing
:
Achieved
Age of attainment
:
4 months
Babbling
:
Achieved
Age of attainment
:
12 months
Meaningful words
:
Achieved
Age of attainment
:
3 years
Expressive:-
Cooing
:
Achieved
Age of attainment
:
4 months
Babbling
:
Achieved
Age of attainment
:
12 months
Meaningful words
:
Achieved
Age of attainment
:
3 years
Details:
:
Patterned speech
Communication & Language Assessment
Non-Verbal Communication Grading:-
Need-based communication
:
Consistent
Drag for needs
:
Consistent
Joint attention
:
Consistent
Pointing
:
Consistent meaningful pointing
Understanding gestures
:
Emerging
Following commands (gesture + verbal)
:
1-step
Answering Questions:-
What
Echolalia
:
Present
Patterned speech
:
Present
Social
Social smile
:
Achieved
Age of attainment
:
2 months
Stranger anxiety
:
Achieved
Age of attainment
:
8 months
Waving bye bye
:
Not achieved
Asking for food and toilet
:
Achieved
Age of attainment
:
Response to Name Call
Details
:
7/10
Sitting tolerance- (in minutes)
For interaction
:
Doesnt sit
For tasks
:
Better for tasks
ADL Skills (Age-appropriate)-
Eating
:
2. Started attempting
Bathing
:
2. Started attempting
Toilet training
:
2. Started attempting
Dressing
:
1. Dependent
Undressing
:
1. Dependent
Details:
:
Eats preferred food by himself
Type of Play : 2. Isolated
Academic History:
Is child enrolled in school
:
Yes
Type of school
:
Regular
Name of School
:
No.2 Air force school
Grade
:
LKG
Hours spent in school
:
4
Location
:
Maharajpura
Diet History:
Food preferences
:
Mixed
Food allergies
:
No
Junk food intake
:
Occasional
Sleep History
Total sleep duration (night)
:
10 hours
Afternoon nap
:
No
Duration of Afternoon nap
:
2 hours
Daily Screen Time
Duration
:
< 2 hours
Type of screen
:
Mobile and TV
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
CVS examination
:
NAD
Respiratory System examination
:
NAD
Per abdomen examination
:
NAD
Impression
:
ASD
Advice
Intervention plan
:
IDP 2/week + PMT 1/week
Follow up plan
:
Next month
General recommendation-
Zero Screen Time
Physical interactive play
No focus on academics at present
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