OPD :
24-Jul-2026 12:30PM
Demographic Details
- :
Shivansh sahu
- :
2 Year 8 Month 2 Days
- :
Male
- :
2023-11-22
- :
30 years
- :
Homemaker
- :
31 years
- :
Business
- :
Joint
- :
6
- :
0
- :
Bhander
- :
8819080812
- :
Doctor
- :
Parents
Interaction history:
- :
Fleeting
- :
limited
Behavioral history:
Repetitive behaviors (RRBs):
spinning, running to and fro
Patterned behavior or activities:
Hyperactivity
Inattention
Impulsivity
Object obsession
Temper tantrums
Stubbornness
Aggression
Mouthing of objects
Sensory Concerns:
- :
Seeks pressure
:
Doesnt cooperate for haircut
Birth & Perinatal History:
Antenatal History
- :
No
- :
Natural
-
High-risk factors in pregnancy:
- Pre-eclampsia
- Ante partum haemorrhage
Natal and Postnatal History:
- :
Institutional
- :
LSCS
- :
FT
- :
2.7 Kg
- :
Cried immediately after birth
- :
No
- :
No
Past history:
:
No
:
No
Investigations done-
:
Not done
:
Not done
Family history:
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
4 months
-
:
Achieved
:
5 months
-
:
Achieved
:
6 months
-
:
Achieved
:
15 months
-
:
Achieved
:
18 months
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
Fine Motor
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
12 months
:
Achieved
:
Language
Receptive:-
-
:
Not achieved
-
:
Achieved
:
2 years
-
:
Achieved
:
Delayed. inconsistent.
- :
Not following
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Not achieved
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Not achieved
:
speaks few kinship words inconsistently
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Inconsistent
- :
Inconsistent
- :
Inconsistent
- :
Attempts
- :
Absent
- :
Nil
Answering Questions:-
:
Present
Social
-
:
Achieved
:
12 months
-
:
Achieved
:
12 months
Response to Name Call
Sitting tolerance- (in minutes)
- :
doesnt sit
- :
5 minutes
ADL Skills (Age-appropriate)-
- :
2. Started attempting
- :
2. Started attempting
- :
1. Dependent
- :
1. Dependent
- :
2. Started attempting
Type of Play : 2. Isolated
Academic History:
- :
No
Diet History:
- :
Picky eater. Bottlefeeding. Sweet craving.
- :
No
- :
1-2 times/week
Sleep History
- :
10 hours
- :
Yes
- :
1-4 hours
Daily Screen Time
-
:
> 2 hours
- :
Mobile and TV
Examination
a. Vitals:
b. Anthropometry:
c. General Examination
:
first web-space syndactyly
:
Ab
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
- :
No
- :
Improper
- :
Proper
- :
Improper
- :
Improper
:
NAD
:
NAD
:
NAD
:
? ASD. Mchat 11
Advice
- :
IDP 1/week + PMT 1/week
- :
DQ, ISAA, DSM5 ASD (Later)
- :
CBC, Calcium, s vitamin D, S. Vitamin B12, thyroid profile. BERA. MRI Brain (Later)
- :
Every month
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food
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