Create - Child Development Centre

Patient Details


OPD : 21-May-2026 11:25AM Demographic Details Child's Name: Nihal Joshi Age: 2 Year 8 Month 26 Days Gender: Male DOB: 2023-08-25 Mother’s age (years): 33 years Mother’s occupation: Homemaker Father’s age (years): 33 years Father’s occupation: Teacher Type of family: Joint Number of family members: 7 Number of siblings: 0 Address: Dabra Contact: 9753556879 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Hyperactivity, speech delay Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): stimming, running to and fro Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Emotional history: Irritability Excessive crying episodes Others Emotional History Details: Irrelevant laughing episodes Sensory Concerns: Tactile: Hypersensitive Auditory: Hypersensitive Visual: Seeks visuals Proprioception: Seeks pressure Details:: afraid of balloon Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 1.75 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Others: At 1 year H/o Kochs. Took treatment for 1 year Past/Current therapies: Nil Past/Current medications: Nil 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: 7 months Standing without support: Achieved Age of attainment: 10 months Walking without support: Achieved Age of attainment: 12 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 Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Drag for needs: Emerging Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Not achieved Comes when called: Not achieved Copying parents in tasks: Not achieved Asking for food and toilet: Not achieved Response to Name Call Details: 4/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: Doesnt hit ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Doesnt indicate for urine and stool Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed diet. bottlefeeding Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 6 hours Afternoon nap: Yes Duration of Afternoon nap: 3 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 12 Kg Height: 90cm Head circumference: 50 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Normal Deep tendon reflexes: KJ 2+/2+, AJ 2+/2+ Superficial reflexes: Present 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 Evaluation: ISAA, DSM5 ASD (Later) Investigations: Repeat EEG. CBC, S calcium, Vitamin D, Vitamin B12, S Homeocysteine Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 21-May-2026 11:25AM Demographic Details

Child's Name: Nihal Joshi
Age: 2 Year 8 Month 26 Days
Gender: Male
DOB: 2023-08-25
Mother’s age (years): 33 years
Mother’s occupation: Homemaker
Father’s age (years): 33 years
Father’s occupation: Teacher
Type of family: Joint
Number of family members: 7
Number of siblings: 0
Address: Dabra
Contact: 9753556879
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Hyperactivity, speech delay

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): stimming, running to and fro Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Emotional history:
Irritability Excessive crying episodes Others Emotional History Details: Irrelevant laughing episodes
Sensory Concerns:

Tactile: Hypersensitive
Auditory: Hypersensitive
Visual: Seeks visuals
Proprioception: Seeks pressure

Details:: afraid of balloon

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 1.75 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No Others: At 1 year H/o Kochs. Took treatment for 1 year

Past/Current therapies: Nil Past/Current medications: Nil 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: 7 months
Standing without support: Achieved

Age of attainment: 10 months
Walking without support: Achieved

Age of attainment: 12 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

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Emerging
Drag for needs: Emerging

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Not achieved
Comes when called: Not achieved
Copying parents in tasks: Not achieved
Asking for food and toilet: Not achieved

Response to Name Call

Details: 4/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: Doesnt hit

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Details:: Doesnt indicate for urine and stool

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed diet. bottlefeeding
Food allergies: No
Junk food intake: Occasional

Sleep History

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

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 12 Kg Height: 90cm Head circumference: 50 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Normal
Deep tendon reflexes: KJ 2+/2+, AJ 2+/2+
Superficial reflexes: Present

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
Evaluation: ISAA, DSM5 ASD (Later)
Investigations: Repeat EEG. CBC, S calcium, Vitamin D, Vitamin B12, S Homeocysteine
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