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Welcome to Otika template!
Yesterday
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Patient Details
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OPD :
15-May-2026 11:17AM
Demographic Details
Child's Name
:
Rudhransh Nagar
Age
:
2 Year 7 Month 27 Days
Gender
:
Male
DOB
:
2023-09-18
Mother’s age (years)
:
34 years
Mother’s occupation
:
Homemaker
Father’s age (years)
:
36 years
Father’s occupation
:
MP Police
Type of family
:
Nuclear
Number of family members
:
4
Number of siblings
:
1
Details of siblings (Age and sex)
:
5 year old female
Address
:
Thatipur
Contact
:
7999144258
Referred By
:
Doctor
Informant
:
Parents
Presenting Concerns
Chief concerns
:
Speech delay
Interaction history:
Eye contact
:
Fleeting
Quality of Interaction
:
limited
Behavioral history:
Repetitive behaviors (RRBs):
spinning
Patterned behavior or activities:
Hyperactivity
Inattention
Impulsivity
Temper tantrums
Stubbornness
Sensory Concerns:
Auditory
:
Fear of loud sounds
Details:
:
Afraid of slides and bicycle. Doesnt cooperate for haircut
Birth & Perinatal History:
Antenatal History
Consanguinity
:
No
Type of conception
:
Natural
High-risk factors in pregnancy:
Hypothyroidism
Others:
:
1 spontaneous abortion at 8 weeks
Natal and Postnatal History:
Place of Birth
:
Institutional
Mode of Delivery
:
LSCS
Indication for LSCS (if applicable)
:
Previous LSCS
Gestational Age
:
Late PT
Birth Weight
:
2.5 Kg
Cry at birth
:
Cried immediately after birth
NICU stay
:
No
If yes- Duration & Indication
:
Neonatal screening of thyroid- normal
Past history:
Hospitalization
:
No
Seizures
:
No
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
:
3 months
Roll over
:
Achieved
Age of attainment
:
5 months
Sitting without support
:
Achieved
Age of attainment
:
8 months
Standing without support
:
Achieved
Age of attainment
:
13 months
Walking without support
:
Achieved
Age of attainment
:
15 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
:
Consistent
Drag for needs
:
Emerging
Answering Questions:-
Echolalia
:
Present
Social
Social smile
:
Achieved
Age of attainment
:
4 months
Stranger anxiety
:
Achieved
Age of attainment
:
Waving bye bye
:
Not achieved
Response to Name Call
Details
:
2/10
Sitting tolerance- (in minutes)
For interaction
:
Doesnt sit
For tasks
:
Doesnt sit
ADL Skills (Age-appropriate)-
Eating
:
2. Started attempting
Bathing
:
2. Started attempting
Toilet training
:
1. Dependent
Details:
:
Doesnt indicate for urine and stool
Type of Play : 3. Onlooker
Academic History:
Is child enrolled in school
:
No
Diet History:
Food preferences
:
Mixed
Food allergies
:
No
Junk food intake
:
Occasional
Sleep History
Total sleep duration (night)
:
9-10 hours
Afternoon nap
:
Yes
Duration of Afternoon nap
:
2-3 hours
Sleep disturbances
:
No
Daily Screen Time
Duration
:
> 2 hours
Type of screen
:
Mobile and TV
Examination
a. Vitals:
b. Anthropometry:
c. General Examination
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 cahr R score- 12 (High risk). ASD
Advice
Intervention plan
:
IDP 2/week + PMT 1/week
Medications
:
CST
Follow up plan
:
After 1 month
General recommendation-
Zero Screen Time
Physical interactive play
No Junk food
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