OPD :
11-Apr-2026 02:11PM
Demographic Details
- :
Adika Jha
- :
3 Year 2 Month 10 Days
- :
Female
- :
2023-02-01
- :
36 years
- :
Homemaker
- :
36 years
- :
Pvt job
- :
Nuclear
- :
4
- :
1
- :
8 year old female
- :
Ashok Nagar
- :
6266058872
- :
Doctor
- :
Mother
Presenting Concerns
- :
Delayed development
Interaction history:
Behavioral history:
Hyperactivity
Inattention
Impulsivity
Temper tantrums
Stubbornness
Aggression
Mouthing of objects
Sensory Concerns:
- :
Seeks pressure
Birth & Perinatal History:
Antenatal History
- :
No
- :
Natural
-
High-risk factors in pregnancy:
- PIH
- :
1 spontaneous abortion (12 weeks)
Natal and Postnatal History:
- :
Institutional
- :
NVD
- :
FT
- :
3.2 Kg
- :
No
- :
Yes
- :
? Delayed cry. Admitted for MAS. (under O2)- 11 days
Past history:
:
No
:
No
:
Recurrent cough and cold
:
Syp Cos 3, Syp mentat, Tab rifampicin since 3 months
Investigations done-
:
Not done
:
Not done
Family history:
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
4 months
-
:
Achieved
:
Not sure
-
:
Achieved
:
10 months
-
:
Achieved
:
2 years
-
:
Achieved
:
2.5 years
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
Fine Motor
:
Achieved
:
Not known
:
Achieved
:
Not known
:
Achieved
:
Not known
Language
Receptive:-
-
:
Achieved
:
Not known
-
:
Achieved
:
Not known
-
:
Achieved
:
- :
1-step
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
9 months
:
Achieved
:
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
9 months
:
Achieved
:
:
Started speaking kinship words. Uses gestures for need.
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Consistent
- :
Consistent
- :
Consistent meaningful pointing
Answering Questions:-
Social
-
:
Achieved
:
2 nonths
-
:
Achieved
:
8 months
-
:
Achieved
:
2 years
-
:
Achieved
:
Response to Name Call
Sitting tolerance- (in minutes)
- :
1-2 minutes
ADL Skills (Age-appropriate)-
- :
4. Needs minimal assistance
- :
4. Needs minimal assistance
- :
2. Started attempting
- :
2. Started attempting
:
Indicates by cues. Goes to specified place for toilet
Type of Play : 3. Onlooker
:
Irregular
:
Destructive play
Academic History:
- :
No
Diet History:
- :
No
- :
1-2 /month
Sleep History
- :
6-7 hours
- :
Yes
- :
3-4 hours
Daily Screen Time
-
:
<30 minutes
- :
Mobile
Examination
a. Vitals:
b. Anthropometry:
:
10.3 Kg
:
91 cm
:
43 cm
c. General Examination
:
Prominent ears
:
Absent
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
- :
Proper
- :
Proper
- :
Proper
- :
Improper
:
Prefers sitting in 'w' position :
NAD
:
NAD
:
NAD
:
GDD
Advice
- :
DQ (VSMS, DST), Language and speech evaluation,
- :
MRI Brain, BERA
- :
Review after investigations
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food