OPD :
16-Jul-2026 12:53PM
Demographic Details
- :
Anay Sharma
- :
2 Year 2 Month 2 Days
- :
Male
- :
2024-05-14
- :
31 years
- :
Homemaker
- :
42 years
- :
Contractor
- :
Nuclear
- :
4
- :
1
- :
40 days
- :
Tansen Nagar
- :
7581811100
- :
Doctor
- :
Parents
Presenting Concerns
- :
Speech delay
Interaction history:
- :
Suboptimal
- :
interaction better with known people
- :
limited
Behavioral history:
Hyperactivity
Inattention
Impulsivity
Object obsession
Temper tantrums
Stubbornness
Aggression
Sensory Concerns:
- :
Seeks pressure
Birth & Perinatal History:
Antenatal History
- :
No
- :
Natural
-
High-risk factors in pregnancy:
- Hypothyroidism
- :
thyroid screening of child- normal
Natal and Postnatal History:
- :
Institutional
- :
LSCS
- :
Cord around neck, Fetal distress
- :
36 weeks
- :
2.8 Kg
- :
Cried immediately after birth
- :
No
- :
Yes
- :
Admitted for 7 days in NICU for respiratory distress
Past history:
:
No
:
No
:
Nil
:
Nil
Investigations done-
:
Done
:
OAE - normal
:
Done
:
ROP- normal
Family history:
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
4 months
-
:
Achieved
:
5 months
-
:
Achieved
:
6 months
-
:
Achieved
:
10 months
-
:
Achieved
:
11 months
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
Fine Motor
:
Achieved
:
4months
:
Achieved
:
6 months
:
Achieved
:
12 months
Language
Receptive:-
-
:
Achieved
:
18 months
-
:
Achieved
:
18 months
-
:
Achieved
:
- :
1-step
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Not achieved
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Not achieved
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Absent
- :
Emerging
- :
Emerging
- :
Attempts
- :
Emerging
- :
1-step
Answering Questions:-
:
Absent
Social
-
:
Achieved
:
2 months
-
:
Not achieved
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
Response to Name Call
Sitting tolerance- (in minutes)
- :
doesnt sit
- :
2-3 minutes
ADL Skills (Age-appropriate)-
- :
2. Started attempting
- :
2. Started attempting
- :
2. Started attempting
- :
1. Dependent
- :
1. Dependent
:
Eats dry snacks. Gives cues for urine and stool. Doesnt indicate.
Type of Play : 3. Onlooker
Academic History:
- :
No
Diet History:
- :
Mixed
- :
No
- :
Nil
Sleep History
- :
10-11 hours
- :
Yes
- :
2-3 hours
Daily Screen Time
-
:
< 2 hours
- :
TV
Examination
a. Vitals:
b. Anthropometry:
:
12 Kg
:
86 cm
:
45 cm
c. General Examination
:
ab
:
ab
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
- :
Proper
- :
Proper
- :
Improper
- :
Improper
:
NAD
:
NAD
:
NAD
:
Language delay. M chat- 3 (Moderate risk for ASD)
Advice
- :
Home strategies adviced
- :
Language and speech evaluation
- :
CBC, iron profile, Ca, Vitamin D2, Vitamin B12, TSH, freeT3, free T4
- :
After 15 days
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food
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