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Welcome to Otika template!
Yesterday
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Patient Details
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OPD :
22-Sep-2026 10:37AM
Demographic Details
Child's Name
:
Atharva Pathak
Age
:
6 Year 1 Month 9 Days
Gender
:
Male
DOB
:
2020-08-12
Mother’s age (years)
:
35 years
Mother’s occupation
:
Homemaker
Father’s age (years)
:
36 years
Father’s occupation
:
Government job
Type of family
:
Nuclear
Number of siblings
:
1
Details of siblings (Age and sex)
:
10 year old female
Contact
:
8114420516
Referred By
:
Doctor
Informant
:
Parents
Presenting Concerns
Chief concerns
:
Speech delay, behavioral concerns
Interaction history:
Eye contact
:
Fleeting
Quality of Interaction
:
limited
Behavioral history:
Repetitive behaviors (RRBs):
Looking from corner pf eyes
Patterned behavior or activities:
Hyperactivity
Inattention
Insisting on sameness
Object obsession
Temper tantrums
Stubbornness
Aggression
Others Emotional History Details
:
Irrelevant laughing
Sensory Concerns:
Proprioception
:
Seeks pressure
Vestibular
:
Avoids swings
Birth & Perinatal History:
Antenatal History
Consanguinity
:
No
High-risk factors in pregnancy:
GDM
Natal and Postnatal History:
Place of Birth
:
Institutional
Mode of Delivery
:
LSCS
Gestational Age
:
FT
Birth Weight
:
3.75 Kg
Cry at birth
:
Cried immediately after birth
Resuscitation required
:
No
NICU stay
:
No
Past history:
Hospitalization
:
No
Seizures
:
No
Past/Current therapies
:
From 4 years age- daily OT/speech
Investigations done-
Hearing assessment
:
Not done
Vision assessment
:
Not done
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
:
9 months
Standing without support
:
Achieved
Age of attainment
:
14 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
:
Inconsistent
Pointing
:
Not achieved
Understanding gestures
:
Not achieved
Following commands
:
1-step
Expressive:-
Cooing
:
Achieved
Age of attainment
:
6 months
Babbling
:
Achieved
Age of attainment
:
2 years
Meaningful words
:
Not achieved
Expressive:-
Cooing
:
Achieved
Age of attainment
:
6 months
Babbling
:
Achieved
Age of attainment
:
2 years
Meaningful words
:
Not achieved
Communication & Language Assessment
Non-Verbal Communication Grading:-
Need-based communication
:
Inconsistent
Drag for needs
:
Inconsistent
Joint attention
:
Emerging
Pointing
:
Attempts
Understanding gestures
:
Absent
Following commands (gesture + verbal)
:
1-step
Answering Questions:-
Echolalia
:
Present
Social
Social smile
:
Achieved
Age of attainment
:
2 months
Stranger anxiety
:
Achieved
Age of attainment
:
8 months
Waving bye bye
:
Not achieved
Response to Name Call
Details
:
8/10
Sitting tolerance- (in minutes)
For interaction
:
Doesnt sit
For tasks
:
Better for tasks
ADL Skills (Age-appropriate)-
Eating
:
4. Needs minimal assistance
Bathing
:
3. Needs significant assistance
Toilet training
:
3. Needs significant assistance
Dressing
:
2. Started attempting
Undressing
:
3. Needs significant assistance
Details:
:
Doesnt indicate for urine and stool. Goes for himself
Type of Play : 2. Isolated
Academic History:
Is child enrolled in school
:
No
Additional information
:
Discontinued
Diet History:
Food preferences
:
Mixed
Food allergies
:
No
Junk food intake
:
Toast daily
Sleep History
Total sleep duration (night)
:
7 hours
Afternoon nap
:
No
Sleep disturbances
:
No
Daily Screen Time
Duration
:
> 2 hours
Examination
a. Vitals:
b. Anthropometry:
Weight
:
23 Kg
Height
:
119 cm
Head circumference
:
54 cm
c. General Examination
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
CVS examination
:
NAD
Respiratory System examination
:
NAD
Per abdomen examination
:
NAD
Impression
:
ASD
Advice
Intervention plan
:
IDP 2/Week + PMT 1/week
Investigations
:
CBC, Thyroid profile, Calcium, S vitamin D, S vitamin B12, S . Homocysteine
Follow up plan
:
Next month
General recommendation-
Zero Screen Time
Physical interactive play
No Junk food
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