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Patient Details


OPD : 03-Aug-2026 02:38PM Demographic Details Child's Name: Aurav Gupta Age: 3 Year Gender: Male DOB: 2023-07-20 Mother’s occupation: Private job Father’s occupation: Private job Type of family: Joint Number of family members: 6 Number of siblings: 1 Details of siblings (Age and sex): 1.5 years male Address: Lohiya Bazar Contact: 8867185958 Informant: Parents Presenting Concerns Chief concerns: Behavioral concerns, separation anxiety Interaction history: Eye contact: Sustained Quality of Interaction: avoids Behavioral history: Temper tantrums Stubbornness Aggression Academic Concerns: Details:: stand at one corner, cries in school Sensory Concerns: Tactile: Hyposensitive Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Ante partum haemorrhage Oligohydramnios Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Fetal distress Gestational Age: 28-30 weeks Birth Weight: 1.4 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: NICU- 18 days, VLBW, RDS Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Nil 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: 6months Sitting without support: Achieved Age of attainment: 8 months Standing without support: Achieved Age of attainment: 13 months Walking without support: Achieved Age of attainment: 15 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 Drinking from cup: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 12 months Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 9 months Meaningful words: Achieved Age of attainment: 13 months 2 word Phrases: Achieved Age of attainment: 18 months Complete sentences: Achieved Age of attainment: 2.5 years Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 9 months Meaningful words: Achieved Age of attainment: 13 months 2 word Phrases: Achieved Age of attainment: 18 months Complete sentences: Achieved Age of attainment: 2.5 years Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent Drag for needs: Inconsistent Joint attention: Inconsistent Pointing: Inconsistent meaningful pointing Understanding gestures: Consistent Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 3 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: 9 months Comes when called: Achieved Age of attainment: 12 months Copying parents in tasks: Achieved Age of attainment: Asking for food and toilet: Not achieved Response to Name Call Details: 10/10 Sitting tolerance- (in minutes) For interaction: 10-15 minutes For tasks: 15-20 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 3. Needs significant assistance Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 2. Started attempting Details:: Eats dry snacks by is own hands Type of Play : 3. Onlooker Details:: doesnt want to share his toys. Plays with younger sibling Academic History: Is child enrolled in school: Yes Type of school: Regular Additional information: Enrolled in school since 3 months. Doesnt interact in school. Good interaction at home Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours Daily Screen Time Duration: > 5 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 18 Kg Height: 96 cm Head circumference: 49.5 cm 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 Others: Keeps food in mouth pocket Examination summary: Behavioral concerns CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Behavioral concerns Advice Intervention plan: IDP 2/week + PMT 1/week Follow up plan: Every month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 03-Aug-2026 02:38PM Demographic Details

Child's Name: Aurav Gupta
Age: 3 Year
Gender: Male
DOB: 2023-07-20
Mother’s occupation: Private job
Father’s occupation: Private job
Type of family: Joint
Number of family members: 6
Number of siblings: 1
Details of siblings (Age and sex): 1.5 years male
Address: Lohiya Bazar
Contact: 8867185958
Informant: Parents

Presenting Concerns

Chief concerns: Behavioral concerns, separation anxiety

Interaction history:

Eye contact: Sustained
Quality of Interaction: avoids

Behavioral history:

Temper tantrums Stubbornness Aggression Academic Concerns:
Details:: stand at one corner, cries in school
Sensory Concerns:

Tactile: Hyposensitive

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Ante partum haemorrhage
2. Oligohydramnios

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Fetal distress
Gestational Age: 28-30 weeks
Birth Weight: 1.4 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: NICU- 18 days, VLBW, RDS

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Nil 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: 6months
Sitting without support: Achieved

Age of attainment: 8 months
Standing without support: Achieved

Age of attainment: 13 months
Walking without support: Achieved

Age of attainment: 15 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

Drinking from cup: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 12 months
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 9 months

Meaningful words: Achieved

Age of attainment: 13 months

2 word Phrases: Achieved

Age of attainment: 18 months

Complete sentences: Achieved

Age of attainment: 2.5 years

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 9 months

Meaningful words: Achieved

Age of attainment: 13 months

2 word Phrases: Achieved

Age of attainment: 18 months

Complete sentences: Achieved

Age of attainment: 2.5 years

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 3 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment: 9 months
Comes when called: Achieved

Age of attainment: 12 months
Copying parents in tasks: Achieved

Age of attainment:
Asking for food and toilet: Not achieved

Response to Name Call

Details: 10/10

Sitting tolerance- (in minutes)

For interaction: 10-15 minutes
For tasks: 15-20 minutes

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 3. Needs significant assistance
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 2. Started attempting

Details:: Eats dry snacks by is own hands

Type of Play : 3. Onlooker Details:: doesnt want to share his toys. Plays with younger sibling Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Additional information: Enrolled in school since 3 months. Doesnt interact in school. Good interaction at home

Diet History:

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

Sleep History

Total sleep duration (night): 9-10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 hours

Daily Screen Time

Duration: > 5 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 18 Kg Height: 96 cm Head circumference: 49.5 cm

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
Others: Keeps food in mouth pocket

Examination summary: Behavioral concerns CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: Behavioral concerns

Advice

Intervention plan: IDP 2/week + PMT 1/week
Follow up plan: Every month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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