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Yesterday
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Patient Details
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OPD :
09-Oct-2026 04:34PM
Demographic Details
Child's Name
:
Amogh Bajpay
Age
:
3 Year 4 Month 11 Days
Gender
:
Male
DOB
:
2023-05-28
Type of family
:
Joint
Number of siblings
:
2
Details of siblings (Age and sex)
:
6 year old, 2nd -twin
Address
:
City centre
Contact
:
9131430076
Referred By
:
Doctor
Informant
:
Parents
Current medications
:
Nil
Presenting Concerns
Chief concerns
:
Speech delay
Duration of symptoms
:
Noted since 4 months
Interaction history:
Eye contact
:
Suboptimal
Interaction
:
Prefers being isolated
Quality of Interaction
:
avoids
Behavioral history:
Inattention
Object obsession
Temper tantrums
Stubbornness
Aggression
Others Emotional History Details
:
Irrelevant laughing, crying
Sensory Concerns:
Auditory
:
Hypersensitive
Visual
:
Seeks visuals
Birth & Perinatal History:
Antenatal History
Consanguinity
:
No
Type of conception
:
Natural
Others:
:
Twin twin transfusion syndrome detected in 5th month ANC
Natal and Postnatal History:
Place of Birth
:
Institutional
Mode of Delivery
:
LSCS
Gestational Age
:
33 weeks
Birth Weight
:
2.9 Kg
Cry at birth
:
Cried immediately after birth
NICU stay
:
Yes
If yes- Duration & Indication
:
PT RD NNHB- 14 days
Past history:
Hospitalization
:
No
Seizures
:
No
Investigations done-
Hearing assessment
:
Not done
Vision assessment
:
Done
Details
:
Adviced follow up
Family history:
Neuropsychiatric condition
:
No
Developmental History:
Gross Motor
Neck holding
:
Achieved
Age of attainment
:
5 months
Roll over
:
Achieved
Age of attainment
:
5 months
Sitting without support
:
Achieved
Age of attainment
:
8 months
Standing without support
:
Achieved
Age of attainment
:
12 months
Walking without support
:
Achieved
Age of attainment
:
14 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
:
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
:
6 months
Expressive:-
Cooing
:
Achieved
Age of attainment
:
4 months
Babbling
:
Achieved
Age of attainment
:
6 months
Details:
:
started speaking kinship words at 2 years.
Communication & Language Assessment
Non-Verbal Communication Grading:-
Need-based communication
:
Emerging
Drag for needs
:
Emerging
Joint attention
:
Emerging
Pointing
:
Attempts
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
:
Achieved
Age of attainment
:
9 months
Waving bye bye
:
Not achieved
Comes when called
:
Not achieved
Asking for food and toilet
:
Not achieved
Response to Name Call
Details
:
3/10
Sitting tolerance- (in minutes)
For interaction
:
5 minutes
For tasks
:
5-7 minutes
ADL Skills (Age-appropriate)-
Eating
:
4. Needs minimal assistance
Bathing
:
2. Started attempting
Toilet training
:
1. Dependent
Dressing
:
1. Dependent
Undressing
:
1. Dependent
Details:
:
Brushing- cooperates. Doesnt indicate for urine and stool
Type of Play : 2. Isolated
Academic History:
Is child enrolled in school
:
Yes
Type of school
:
Regular
Name of School
:
Aditya world
Grade
:
Nursery
Hours spent in school
:
4 hours
Diet History:
Food preferences
:
Mixed
Food allergies
:
No
Sleep History
Total sleep duration (night)
:
10 hours
Afternoon nap
:
No
Duration of Afternoon nap
:
1-1.5 hours
Sleep disturbances
:
No
Daily Screen Time
Duration
:
Zero
Examination
a. Vitals:
b. Anthropometry:
c. General Examination
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
Impression
:
? ASD
Advice
Intervention plan
:
IDP 2/week + PMT 1/week
Evaluation
:
DQ, ISAA, DSM 5 ASD
Follow up plan
:
Next month
General recommendation-
Zero Screen Time
Physical interactive play
No Junk food
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