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Patient Details


OPD : 15-Sep-2026 04:02PM Demographic Details Child's Name: Atharva Age: 1 Year 6 Month 28 Days Gender: Male DOB: 2025-02-18 Mother’s age (years): 26 years Mother’s occupation: Homemaker Father’s age (years): 28 years Father’s occupation: Air force Type of family: Joint Number of family members: 2 Number of siblings: 0 Address: Pinto Park Contact: 8905207365 Referred By: Doctor Informant: Mother Current medications: Nil Presenting Concerns Chief concerns: Poor response to name call Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Running to and fro, spinning Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Sensory Concerns: Vestibular: Seeks movement Details:: Doesnt cooperate for haircut 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): Oligo, Cord around neck Gestational Age: Late PT Birth Weight: 2.4 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Done Details: OAE- B/l 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 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: 6 months Meaningful words: Not achieved 2 word Phrases: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved 2 word Phrases: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Social smile: Achieved Age of attainment: 4 months Stranger anxiety: Achieved Age of attainment: 9 months Waving bye bye: Not achieved Comes when called: Achieved Age of attainment: Copying parents in tasks: Not achieved Asking for food and toilet: Not achieved Response to Name Call Details: 4/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: 1-2 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: sits at one place to pass stool. Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Picky eating Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 10 hours Afternoon nap: No Duration of Afternoon nap: 2-2.5 hours Daily Screen Time Duration: < 1 hour Type of screen: Mobile Examination a. Vitals: b. Anthropometry: c. General Examination Dysmorphology: Triangular facies, increased hair growth over body Neurocutaneous markers: Absent d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: M chat -13. ? ASD Advice Intervention plan: IDP 2/week + PMT 1/week Investigations: Fragile X TP PCR, WES (Later) Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 15-Sep-2026 04:02PM Demographic Details

Child's Name: Atharva
Age: 1 Year 6 Month 28 Days
Gender: Male
DOB: 2025-02-18
Mother’s age (years): 26 years
Mother’s occupation: Homemaker
Father’s age (years): 28 years
Father’s occupation: Air force
Type of family: Joint
Number of family members: 2
Number of siblings: 0
Address: Pinto Park
Contact: 8905207365
Referred By: Doctor
Informant: Mother
Current medications: Nil

Presenting Concerns

Chief concerns: Poor response to name call

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Running to and fro, spinning Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects
Sensory Concerns:

Vestibular: Seeks movement

Details:: Doesnt cooperate for haircut

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): Oligo, Cord around neck
Gestational Age: Late PT
Birth Weight: 2.4 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

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

Hearing assessment: Done Details: OAE- B/l 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

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: 6 months

Meaningful words: Not achieved

2 word Phrases: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

2 word Phrases: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 4 months
Stranger anxiety: Achieved

Age of attainment: 9 months
Waving bye bye: Not achieved
Comes when called: Achieved

Age of attainment:
Copying parents in tasks: Not achieved
Asking for food and toilet: Not achieved

Response to Name Call

Details: 4/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: 1-2 minutes

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 2. Started attempting
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Details:: sits at one place to pass stool.

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Picky eating
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: No
Duration of Afternoon nap: 2-2.5 hours

Daily Screen Time

Duration: < 1 hour
Type of screen: Mobile

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

Dysmorphology: Triangular facies, increased hair growth over body Neurocutaneous markers: Absent

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

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

CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: M chat -13. ? ASD

Advice

Intervention plan: IDP 2/week + PMT 1/week
Investigations: Fragile X TP PCR, WES (Later)
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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