OPD :
02-Jul-2026 01:23PM
Demographic Details
- :
Harshita Khanna
- :
3 Year 5 Month 24 Days
- :
Female
- :
2023-01-08
- :
25 years
- :
Homemaker
- :
26 years
- :
Private job
- :
Joint
- :
7
- :
0
- :
D D Nagar
- :
9713619751
- :
Doctor
- :
Mother
Presenting Concerns
- :
Speech delay
- :
since 6 months
Interaction history:
- :
Sustained
- :
age-appropriate
Behavioral history:
Repetitive behaviors (RRBs):
spinning
Hyperactivity
Temper tantrums
Stubbornness
Sensory Concerns:
- :
Hypersensitive
- :
Hypersensitive
:
Wipes mouth immediately after eating
Birth & Perinatal History:
Antenatal History
- :
No
- :
Natural
Natal and Postnatal History:
- :
Institutional
- :
NVD
- :
FT
- :
2.5 Kg
- :
Cried immediately after birth
- :
No
- :
No
- :
MSL- kept under observation for few hours
Past history:
:
No
:
No
Investigations done-
:
Not done
:
Not done
Family history:
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
3 months
-
:
Achieved
:
5 months
-
:
Achieved
:
6 months
-
:
Achieved
:
8 months
-
:
Achieved
:
9 months
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
Fine Motor
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
12 months
:
Achieved
:
:
Achieved
:
Language
Receptive:-
-
:
Achieved
:
2.5 years
-
:
Achieved
:
3 years
-
:
Not achieved
- :
Not following
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
12 months
:
Not achieved
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
12 months
:
Not achieved
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Consistent
- :
Consistent
- :
Inconsistent
- :
Inconsistent meaningful pointing
- :
Absent
- :
Nil
Answering Questions:-
:
Present
Social
-
:
Achieved
:
2 months
-
:
Achieved
:
9 months
-
:
Achieved
:
3 years
-
:
Achieved
:
-
:
Achieved
:
3 years
Response to Name Call
Sitting tolerance- (in minutes)
- :
doesnt sit
- :
1-2 minutes
ADL Skills (Age-appropriate)-
- :
2. Started attempting
- :
2. Started attempting
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
Type of Play : 4. Parallel
Academic History:
- :
No
Diet History:
- :
Mixed
- :
No
- :
Occasional
Sleep History
- :
10 hours
- :
Yes
- :
3-4 hours
Daily Screen Time
-
:
< 2 hours
- :
Mobile and TV
Examination
a. Vitals:
b. Anthropometry:
:
12 Kg
:
92 cm
:
47 cm
c. General Examination
:
Ab
:
ab
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
- :
No
- :
Proper
- :
Proper
- :
Proper
- :
Proper
:
NAD
:
NAD
:
NAD
Advice
- :
IDP 2/week + PMT 1/week
- :
DQ, DSM5 ASD, ISAA (Later)
- :
BERA
- :
Syp IQ norm DHA 2.5 ml BD
- :
After 1 month
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food