Create - Child Development Centre

Patient Details


OPD : 05-May-2026 03:48PM Demographic Details Child's Name: Abir Gupta Age: 3 Year 6 Month 21 Days Gender: Male DOB: 2022-10-14 Mother’s age (years): 35 years Mother’s occupation: Homemaker Father’s age (years): 35 years Father’s occupation: Jewellery business Type of family: Joint Number of family members: 6 Number of siblings: 1 Details of siblings (Age and sex): 5.5 year old female Address: Kampoo Contact: 8130023717 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: interaction age appropriate Interaction history: Eye contact: Suboptimal Quality of Interaction: avoids Behavioral history: Patterned behavior or activities: spins wheels of Hyperactivity Object obsession Temper tantrums Sensory Concerns: Auditory: Hypersensitive Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Pre-eclampsia Others:: 2 MTPs for personal reason Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Fetal distress Gestational Age: 28+-2 weeks Birth Weight: 1.2 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No If yes- Duration & Indication: Total NICU stay- 40 days. 5 days on ventilator Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Investigations done- Hearing assessment: Done Details: OAE- pass Vision assessment: Done Details: Squint- Doing patching. Refractive errors (-8D lt eye) Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 months Roll over: Achieved Age of attainment: 6 months Sitting without support: Achieved Age of attainment: 12 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: 12 months Unidextrous grasp: Achieved Age of attainment: 13 months Pincer grasp: Achieved Age of attainment: 14 months Scribbling: Achieved Age of attainment: Drinking from cup: Achieved Age of attainment: Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: Inconsistent Pointing: Achieved Age of attainment: 2 years Understanding gestures: Achieved Age of attainment: Inconsistent Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 12 months Babbling: Achieved Age of attainment: 18 months Meaningful words: Achieved Age of attainment: 24 months Expressive:- Cooing: Achieved Age of attainment: 12 months Babbling: Achieved Age of attainment: 18 months Meaningful words: Achieved Age of attainment: 24 months Details:: Started speaking kinship words and few meaningful words Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Drag for needs: Consistent Joint attention: Inconsistent Pointing: Inconsistent meaningful pointing Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 12 months Stranger anxiety: Not achieved Response to Name Call Details: 5/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: Sits for longer period ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 2. Started attempting Type of Play : 2. Isolated Outdoor play duration: 1-2 hours Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: LAHS Grade: Nursery Hours spent in school: 5 hours Additional information: Doesnt sits in class, doesnt interact with kids Diet History: Food preferences: Mixed diet. Botttlefeeding 4 times Food allergies: No Junk food intake: Biscuits occasional. No sugar Sleep History Total sleep duration (night): 6-7 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Daily Screen Time Duration: < 2 hours Type of screen: TV Examination a. Vitals: b. Anthropometry: Weight: 14.4 Kg Height: 98 cm Head circumference: 49 cm c. General Examination Neurocutaneous markers: 2 cafe au lait macule- 1 at neck11 cm, 2- at lt side abd- 0.5 2 cm 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: M chat R score- 11 (High risk) Advice Intervention plan: IDP 2/week +PMT 1/week Evaluation: DQ, ISAA, DSM 5ASD (Later) Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 05-May-2026 03:48PM Demographic Details

Child's Name: Abir Gupta
Age: 3 Year 6 Month 21 Days
Gender: Male
DOB: 2022-10-14
Mother’s age (years): 35 years
Mother’s occupation: Homemaker
Father’s age (years): 35 years
Father’s occupation: Jewellery business
Type of family: Joint
Number of family members: 6
Number of siblings: 1
Details of siblings (Age and sex): 5.5 year old female
Address: Kampoo
Contact: 8130023717
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: interaction age appropriate

Interaction history:

Eye contact: Suboptimal
Quality of Interaction: avoids

Behavioral history:

Patterned behavior or activities: spins wheels of Hyperactivity Object obsession Temper tantrums
Sensory Concerns:

Auditory: Hypersensitive

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Pre-eclampsia
Others:: 2 MTPs for personal reason

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Fetal distress
Gestational Age: 28+-2 weeks
Birth Weight: 1.2 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No
If yes- Duration & Indication: Total NICU stay- 40 days. 5 days on ventilator

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Investigations done-

Hearing assessment: Done Details: OAE- pass Vision assessment: Done Details: Squint- Doing patching. Refractive errors (-8D lt eye)

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 months
Roll over: Achieved

Age of attainment: 6 months
Sitting without support: Achieved

Age of attainment: 12 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: 12 months

Unidextrous grasp: Achieved

Age of attainment: 13 months

Pincer grasp: Achieved

Age of attainment: 14 months

Scribbling: Achieved

Age of attainment:

Drinking from cup: Achieved

Age of attainment:

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: Inconsistent
Pointing: Achieved

Age of attainment: 2 years
Understanding gestures: Achieved

Age of attainment: Inconsistent
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 12 months

Babbling: Achieved

Age of attainment: 18 months

Meaningful words: Achieved

Age of attainment: 24 months

Expressive:-

Cooing: Achieved

Age of attainment: 12 months

Babbling: Achieved

Age of attainment: 18 months

Meaningful words: Achieved

Age of attainment: 24 months

Details:: Started speaking kinship words and few meaningful words

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 12 months
Stranger anxiety: Not achieved

Response to Name Call

Details: 5/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: Sits for longer period

ADL Skills (Age-appropriate)-

Eating: 5. Independent
Bathing: 2. Started attempting
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 2. Started attempting

Type of Play : 2. Isolated Outdoor play duration: 1-2 hours Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: LAHS
Grade: Nursery
Hours spent in school: 5 hours
Additional information: Doesnt sits in class, doesnt interact with kids

Diet History:

Food preferences: Mixed diet. Botttlefeeding 4 times
Food allergies: No
Junk food intake: Biscuits occasional. No sugar

Sleep History

Total sleep duration (night): 6-7 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours

Daily Screen Time

Duration: < 2 hours
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 14.4 Kg Height: 98 cm Head circumference: 49 cm

c. General Examination

Neurocutaneous markers: 2 cafe au lait macule- 1 at neck1*1 cm, 2- at lt side abd- 0.5* 2 cm

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: M chat R score- 11 (High risk)

Advice

Intervention plan: IDP 2/week +PMT 1/week
Evaluation: DQ, ISAA, DSM 5ASD (Later)
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

Setting Panel

Select Layout

Light Dark

Sidebar Color

Color Theme

Mini Sidebar

Sticky Header

Patient Details print

Select Layout

Sidebar Color

Color Theme

Patient Details