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OPD : 01-Jun-2026 12:44PM Demographic Details Child's Name: Mohammad Roman Age: 3 Year 6 Month 8 Days Gender: Male DOB: 2022-11-24 Mother’s age (years): 26 years Mother’s occupation: Homemaker Father’s age (years): 29 years Father’s occupation: Tailor Type of family: Joint Number of family members: 4 Number of siblings: 1 Details of siblings (Age and sex): 1.5 year male Address: Guda gudi ka naka Contact: 9131164576 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Poor response to name call Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Handflapping, running to and fro, stimming Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Others Emotional History Details: Irrelevant laughing, crying Sensory Concerns: Tactile: Hyposensitive Auditory: Hypersensitive Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Seeks movement Details:: doesnt cooperate for haircut and nailcut Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Indication for LSCS (if applicable): Leaking PV for 3 days, PROM. Episiotomy Gestational Age: FT Birth Weight: 2.8 Kg Cry at birth: Delayed cry Resuscitation required: No Details of Resuscitation: Intubated NICU stay: Yes If yes- Duration & Indication: NICU stay- 12 days. HIE 3, MSL Past history: Hospitalization: Yes Seizures: Yes Others: At Investigations done- Hearing assessment: Done Vision assessment: Done Details: Fundus normal Family history: Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 3 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: 15 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: Hopping: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Achieved Age of attainment: 6 months Pincer grasp: Achieved Age of attainment: 9 months Scribbling: Achieved Age of attainment: Drinking from cup: Achieved Age of attainment: Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: 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 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:- Need-based communication: Inconsistent Drag for needs: Inconsistent Joint attention: Absent Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Echolalia: Absent 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: 3/10 Sitting tolerance- (in minutes) For interaction: Doesnt prefers sitting For tasks: Sits for 1-2 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 2. Started attempting Undressing: 2. Started attempting Details:: Gives cues by removing pant, drags to toilet Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed. Prefers mashed food Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 2- 3 hours Daily Screen Time Duration: > 2 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Height: 90 cm Head circumference: 49 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Proper Examination summary: Mild hypotonia+ CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ASD. HIE sequelae Advice Intervention plan: IDP 2/week + PMT 1/week Investigations: Fragile X TP PCR (Later), MRI Brain Medications: As adviced by pediatrician Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 01-Jun-2026 12:44PM Demographic Details

Child's Name: Mohammad Roman
Age: 3 Year 6 Month 8 Days
Gender: Male
DOB: 2022-11-24
Mother’s age (years): 26 years
Mother’s occupation: Homemaker
Father’s age (years): 29 years
Father’s occupation: Tailor
Type of family: Joint
Number of family members: 4
Number of siblings: 1
Details of siblings (Age and sex): 1.5 year male
Address: Guda gudi ka naka
Contact: 9131164576
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Poor response to name call

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Handflapping, running to and fro, stimming Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Others Emotional History Details: Irrelevant laughing, crying
Sensory Concerns:

Tactile: Hyposensitive
Auditory: Hypersensitive
Visual: Seeks visuals
Proprioception: Seeks pressure
Vestibular: Seeks movement

Details:: doesnt cooperate for haircut and nailcut

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Indication for LSCS (if applicable): Leaking PV for 3 days, PROM. Episiotomy
Gestational Age: FT
Birth Weight: 2.8 Kg
Cry at birth: Delayed cry
Resuscitation required: No
Details of Resuscitation: Intubated
NICU stay: Yes
If yes- Duration & Indication: NICU stay- 12 days. HIE 3, MSL

Past history:

Hospitalization: Yes Seizures: Yes Others: At

Investigations done-

Hearing assessment: Done Vision assessment: Done Details: Fundus normal

Family history:

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 3 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: 15 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:
Hopping: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp: Achieved

Age of attainment: 6 months

Pincer grasp: Achieved

Age of attainment: 9 months

Scribbling: Achieved

Age of attainment:

Drinking from cup: Achieved

Age of attainment:

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: 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

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:-

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

Answering Questions:-

Echolalia: Absent

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: 3/10

Sitting tolerance- (in minutes)

For interaction: Doesnt prefers sitting
For tasks: Sits for 1-2 minutes

ADL Skills (Age-appropriate)-

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

Details:: Gives cues by removing pant, drags to toilet

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed. Prefers mashed food
Food allergies: No
Junk food intake: Occasional

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2- 3 hours

Daily Screen Time

Duration: > 2 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Height: 90 cm Head circumference: 49 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

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

Examination summary: Mild hypotonia+ CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: ASD. HIE sequelae

Advice

Intervention plan: IDP 2/week + PMT 1/week
Investigations: Fragile X TP PCR (Later), MRI Brain
Medications: As adviced by pediatrician
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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