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OPD : 30-Apr-2026 03:03PM Demographic Details Child's Name: Nitya Sharma Age: 8 Year 2 Month 10 Days Gender: Female DOB: 2018-02-20 Mother’s age (years): 33 years Mother’s occupation: Homemaker Father’s age (years): 35 years Father’s occupation: Govt teacher Type of family: Joint Number of family members: 7 Number of siblings: 2 Details of siblings (Age and sex): 1- 10 year female, 2-5 years male Address: Morena Contact: 8770818397 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Understanding not as per age Duration of symptoms: realized delayed milestones since 2 years age Interaction history: Eye contact: Sustained Interaction: Doesnt understand how to approach Behavioral history: Sensory Concerns: Auditory: Fear of loud sounds Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Hypothyroidism Others:: Levels were normal during pregnancy Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Leaking PV, Oligo Gestational Age: FT Birth Weight: 2.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: Yes Seizures: No Others: At 1 year admitted for AGE, 1 BT Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Others: H/o TB , hypothyroidism in mother Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 5 months Roll over: Achieved Age of attainment: 6 months Sitting without support: Achieved Age of attainment: 8 months Standing without support: Achieved Age of attainment: 1.5 years Walking without support: Achieved Age of attainment: 2 years Running: Achieved Age of attainment: Climbing upstairs: Achieved Age of attainment: Climbing downstairs: Achieved Age of attainment: Standing on one foot: Achieved Age of attainment: Skipping: 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 Scribbling: Achieved Age of attainment: Drinking from cup: Achieved Age of attainment: Buttoning / Unbuttoning: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: 7 months Pointing: Achieved Age of attainment: Delayed Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 2 years 2 word Phrases: Achieved Age of attainment: 5 years Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 2 years 2 word Phrases: Achieved Age of attainment: 5 years Details:: Uses 2 word phrases for basic needs Communication & Language Assessment Non-Verbal Communication Grading:- Pointing: Consistent meaningful pointing Understanding gestures: Emerging Following commands (gesture + verbal): 1-step Answering Questions:- What Echolalia: Present Patterned speech: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: Comes when called: Achieved Age of attainment: Copying parents in tasks: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 4. Needs minimal assistance Toilet training: 5. Independent Dressing: 4. Needs minimal assistance Undressing: 4. Needs minimal assistance Type of Play : 4. Parallel Outdoor play duration: 2 hours Details:: Doesnt understand basic rules Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Saraswati Shishu Mandir Grade: 1 Hours spent in school: 5 hours Board: MP Location: Morena Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 10 hours Afternoon nap: No Duration of Afternoon nap: 1-2 hours Sleep disturbances: No Daily Screen Time Duration: < 2 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 25 Kg Height: 130 cm Head circumference: 55 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD Others: Keeps mouth predoninatly open d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Normal Deep tendon reflexes: KJ-2+/2+, AJ- 2+/2+ Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ? ID . ASD features Advice Evaluation: IQ, ISAA, DSM5 ASD General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 30-Apr-2026 03:03PM Demographic Details

Child's Name: Nitya Sharma
Age: 8 Year 2 Month 10 Days
Gender: Female
DOB: 2018-02-20
Mother’s age (years): 33 years
Mother’s occupation: Homemaker
Father’s age (years): 35 years
Father’s occupation: Govt teacher
Type of family: Joint
Number of family members: 7
Number of siblings: 2
Details of siblings (Age and sex): 1- 10 year female, 2-5 years male
Address: Morena
Contact: 8770818397
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Understanding not as per age
Duration of symptoms: realized delayed milestones since 2 years age

Interaction history:

Eye contact: Sustained
Interaction: Doesnt understand how to approach

Behavioral history:

Sensory Concerns:

Auditory: Fear of loud sounds

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Hypothyroidism
Others:: Levels were normal during pregnancy

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Leaking PV, Oligo
Gestational Age: FT
Birth Weight: 2.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: Yes Seizures: No Others: At 1 year admitted for AGE, 1 BT

Past/Current therapies: Nil Past/Current medications: Nil Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No Others: H/o TB , hypothyroidism in mother

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 5 months
Roll over: Achieved

Age of attainment: 6 months
Sitting without support: Achieved

Age of attainment: 8 months
Standing without support: Achieved

Age of attainment: 1.5 years
Walking without support: Achieved

Age of attainment: 2 years
Running: Achieved

Age of attainment:
Climbing upstairs: Achieved

Age of attainment:
Climbing downstairs: Achieved

Age of attainment:
Standing on one foot: Achieved

Age of attainment:
Skipping: 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

Scribbling: Achieved

Age of attainment:

Drinking from cup: Achieved

Age of attainment:

Buttoning / Unbuttoning: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 7 months
Pointing: Achieved

Age of attainment: Delayed
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 2 years

2 word Phrases: Achieved

Age of attainment: 5 years

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 2 years

2 word Phrases: Achieved

Age of attainment: 5 years

Details:: Uses 2 word phrases for basic needs

Communication & Language Assessment

Non-Verbal Communication Grading:-

Pointing: Consistent meaningful pointing
Understanding gestures: Emerging
Following commands (gesture + verbal): 1-step

Answering Questions:-

What Echolalia: Present Patterned speech: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment:
Comes when called: Achieved

Age of attainment:
Copying parents in tasks: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 5. Independent
Bathing: 4. Needs minimal assistance
Toilet training: 5. Independent
Dressing: 4. Needs minimal assistance
Undressing: 4. Needs minimal assistance

Type of Play : 4. Parallel Outdoor play duration: 2 hours Details:: Doesnt understand basic rules Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Saraswati Shishu Mandir
Grade: 1
Hours spent in school: 5 hours
Board: MP
Location: Morena

Diet History:

Food preferences: Mixed
Food allergies: No
Junk food intake: Occasional

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: No
Duration of Afternoon nap: 1-2 hours
Sleep disturbances: No

Daily Screen Time

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

Examination

a. Vitals:

b. Anthropometry:

Weight: 25 Kg Height: 130 cm Head circumference: 55 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD Others: Keeps mouth predoninatly open

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

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

Oromotor Examination

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

CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: ? ID . ASD features

Advice

Evaluation: IQ, ISAA, DSM5 ASD
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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