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OPD : 05-May-2026 04:39PM Demographic Details Child's Name: Shiva Tomar Age: 4 Year 9 Month 18 Days Gender: Male DOB: 2021-07-17 Mother’s age (years): 32 years Mother’s occupation: Homemaker Father’s age (years): 32 years Father’s occupation: Indian Navy Type of family: Joint Number of family members: 9 Number of siblings: 0 Address: Shatabdipuram Contact: 7489177440 Referred By: Doctor Informant: Mother, cousin Presenting Concerns Chief concerns: Speech delay Duration of symptoms: Realized regression of speech after 1.5 yr Interaction history: Eye contact: Suboptimal Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Arratoys in linenges Inattention Object obsession Temper tantrums Stubbornness Others Emotional History Details: irrelevant laughing 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: 2 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: 3 year- started therapies (8 months) stopped in Feb Investigations done- Hearing assessment: Done Details: BERA- normal 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: 6 months Standing without support: Achieved Age of attainment: 9 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: Hopping: 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: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 12 months (Crude) Following commands: 1-step 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: Consistent Joint attention: Inconsistent Pointing: Attempts Understanding gestures: Absent Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 9 months Waving bye bye: Not achieved Copying parents in tasks: Not achieved Response to Name Call Details: 3/10 Sitting tolerance- (in minutes) For interaction: 3-5 minutes For tasks: More for taks ADL Skills (Age-appropriate)- Eating: 4. Needs minimal assistance Bathing: 3. Needs significant assistance Toilet training: 3. Needs significant assistance Dressing: 2. Started attempting Undressing: 3. Needs significant assistance Details:: Needs assistance for cleaning Type of Play : 2. Isolated Outdoor play duration: 1-2 hours Details:: Slide, swings Academic History: Is child enrolled in school: No Additional information: Discontinued. Was inconsistent Diet History: Food preferences: Mixed Food allergies: No Junk food intake: 1-2 times/week Sleep History Total sleep duration (night): 7-8 hours Afternoon nap: Yes Duration of Afternoon nap: 3 hours Sleep disturbances: Yes Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 15 Kg Height: 103 cm Head circumference: 49 cm c. General Examination Dysmorphology: Present Neurocutaneous markers: Hyperpigmented patch over back of left knee d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypotonia Deep tendon reflexes: DTR- KJ-2+/2+, AJ 2+/2+ Superficial reflexes: B/l plantar flexors Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper Examination summary: Predominantly open mouth, maxillary prominence, prominent ears, inverted V lip CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 3/week + PMT 1/week Evaluation: DQ (VSMS+DST), ISAA, DSM5 ASD, Speech and language evaluation Investigations: MRI Brain (later), Fragile X TPPCR Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 05-May-2026 04:39PM Demographic Details

Child's Name: Shiva Tomar
Age: 4 Year 9 Month 18 Days
Gender: Male
DOB: 2021-07-17
Mother’s age (years): 32 years
Mother’s occupation: Homemaker
Father’s age (years): 32 years
Father’s occupation: Indian Navy
Type of family: Joint
Number of family members: 9
Number of siblings: 0
Address: Shatabdipuram
Contact: 7489177440
Referred By: Doctor
Informant: Mother, cousin

Presenting Concerns

Chief concerns: Speech delay
Duration of symptoms: Realized regression of speech after 1.5 yr

Interaction history:

Eye contact: Suboptimal
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Arratoys in linenges Inattention Object obsession Temper tantrums Stubbornness Others Emotional History Details: irrelevant laughing

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: 2 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: 3 year- started therapies (8 months) stopped in Feb Investigations done-

Hearing assessment: Done Details: BERA- normal 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: 6 months
Standing without support: Achieved

Age of attainment: 9 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:
Hopping: 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: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 12 months (Crude)
Following commands: 1-step

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: Consistent
Joint attention: Inconsistent
Pointing: Attempts
Understanding gestures: Absent
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 9 months
Waving bye bye: Not achieved
Copying parents in tasks: Not achieved

Response to Name Call

Details: 3/10

Sitting tolerance- (in minutes)

For interaction: 3-5 minutes
For tasks: More for taks

ADL Skills (Age-appropriate)-

Eating: 4. Needs minimal assistance
Bathing: 3. Needs significant assistance
Toilet training: 3. Needs significant assistance
Dressing: 2. Started attempting
Undressing: 3. Needs significant assistance

Details:: Needs assistance for cleaning

Type of Play : 2. Isolated Outdoor play duration: 1-2 hours Details:: Slide, swings Academic History:

Is child enrolled in school: No
Additional information: Discontinued. Was inconsistent

Diet History:

Food preferences: Mixed
Food allergies: No
Junk food intake: 1-2 times/week

Sleep History

Total sleep duration (night): 7-8 hours
Afternoon nap: Yes
Duration of Afternoon nap: 3 hours
Sleep disturbances: Yes

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 15 Kg Height: 103 cm Head circumference: 49 cm

c. General Examination

Dysmorphology: Present Neurocutaneous markers: Hyperpigmented patch over back of left knee

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypotonia
Deep tendon reflexes: DTR- KJ-2+/2+, AJ 2+/2+
Superficial reflexes: B/l plantar flexors

Oromotor Examination

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

Examination summary: Predominantly open mouth, maxillary prominence, prominent ears, inverted V lip CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Advice

Intervention plan: IDP 3/week + PMT 1/week
Evaluation: DQ (VSMS+DST), ISAA, DSM5 ASD, Speech and language evaluation
Investigations: MRI Brain (later), Fragile X TPPCR
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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