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OPD : 30-Mar-2026 12:31PM Demographic Details Child's Name: AKSHAT TIWARI Age: 3 Year 9 Month 10 Days Gender: Male DOB: 2022-06-20 Mother’s age (years): 34 years Mother’s occupation: Homemaker Father’s age (years): 38 years Father’s occupation: In IAF (Srinagar) Type of family: Nuclear Number of family members: 4 Number of siblings: 1 Details of siblings (Age and sex): 1- 7 years male Address: Srinagar Contact: 8168354045 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay, behavioral issues Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Puts things in line Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Sensory Concerns: Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Previous LSCS Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Cried immediately after birth NICU stay: No Past history: Hospitalization: No Seizures: No Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: Yes Others: Speech delay in elder sibling 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: 7 months Standing without support: Achieved Age of attainment: 11 months Walking without support: Achieved Age of attainment: 13 months 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 Drinking from cup: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: Inconsistent Pointing: Achieved Age of attainment: Inconsistent 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:- Drag for needs: Consistent Joint attention: Inconsistent Pointing: Attempts Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Not achieved Response to Name Call Details: 7/10 Sitting tolerance- (in minutes) For interaction: Less than a minute For tasks: Better for tasks Details:: Scribbles over wall ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Drags parents to toilet at home but not outside Type of Play : 2. Isolated Outdoor play duration: Infrequent Academic History: Is child enrolled in school: No Diet History: Food allergies: No Junk food intake: Biscuits Sleep History Total sleep duration (night): 8 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours. (Infrequent) Sleep disturbances: No Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 17.95 Kg Head circumference: 54 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: 1 cafe au lait macule over back (Left side)- 2.5*1.5 cm 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: Improper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ?ASD Advice Intervention plan: Home Based Program 1/week Evaluation: Language evaluation (Later), ISAA, DSM 5 ASD Investigations: MRI Brain (in view of Cafe au lait macule), CBC, Ca, S Vitamin D2, Vitamin B12, S. Homocysteine, S Lead General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 30-Mar-2026 12:31PM Demographic Details

Child's Name: AKSHAT TIWARI
Age: 3 Year 9 Month 10 Days
Gender: Male
DOB: 2022-06-20
Mother’s age (years): 34 years
Mother’s occupation: Homemaker
Father’s age (years): 38 years
Father’s occupation: In IAF (Srinagar)
Type of family: Nuclear
Number of family members: 4
Number of siblings: 1
Details of siblings (Age and sex): 1- 7 years male
Address: Srinagar
Contact: 8168354045
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay, behavioral issues

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Puts things in line Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums
Sensory Concerns:

Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Previous LSCS
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Cried immediately after birth
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: Yes Others: Speech delay in elder sibling

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: 7 months
Standing without support: Achieved

Age of attainment: 11 months
Walking without support: Achieved

Age of attainment: 13 months

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

Drinking from cup: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: Inconsistent
Pointing: Achieved

Age of attainment: Inconsistent
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:-

Drag for needs: Consistent
Joint attention: Inconsistent
Pointing: Attempts

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Not achieved

Response to Name Call

Details: 7/10

Sitting tolerance- (in minutes)

For interaction: Less than a minute
For tasks: Better for tasks

Details:: Scribbles over wall

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Details:: Drags parents to toilet at home but not outside

Type of Play : 2. Isolated Outdoor play duration: Infrequent Academic History:

Is child enrolled in school: No

Diet History:

Food allergies: No
Junk food intake: Biscuits

Sleep History

Total sleep duration (night): 8 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 hours. (Infrequent)
Sleep disturbances: No

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 17.95 Kg Head circumference: 54 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: 1 cafe au lait macule over back (Left side)- 2.5*1.5 cm

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: Improper
Sucking: Proper

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

Impression: ?ASD

Advice

Intervention plan: Home Based Program 1/week
Evaluation: Language evaluation (Later), ISAA, DSM 5 ASD
Investigations: MRI Brain (in view of Cafe au lait macule), CBC, Ca, S Vitamin D2, Vitamin B12, S. Homocysteine, S Lead
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

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