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Welcome to Otika template!
Yesterday
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Patient Details
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OPD :
23-Jun-2026 10:15AM
Demographic Details
Child's Name
:
Lakshay
Age
:
3 Year 3 Month 30 Days
Gender
:
Male
DOB
:
2023-02-24
Mother’s age (years)
:
28 years
Mother’s occupation
:
Homemaker
Father’s age (years)
:
35 years
Father’s occupation
:
Private job
Type of family
:
Joint
Contact
:
7879020372
Referred By
:
Doctor
Informant
:
Parents
Presenting Concerns
Chief concerns
:
Delayed speech, Hyperactivity
Interaction history:
Eye contact
:
Poor
Quality of Interaction
:
limited
Behavioral history:
Repetitive behaviors (RRBs):
Handflapping, stimming
Patterned behavior or activities:
Hyperactivity
Inattention
Impulsivity
Object obsession
Temper tantrums
Stubbornness
Aggression
Mouthing of objects
Others Emotional History Details
:
Irrelevant laughing
Sensory Concerns:
Tactile
:
Hyposensitive
Visual
:
Seeks visuals
Proprioception
:
Seeks pressure
Vestibular
:
Seeks movement
Details:
:
Doesnt cooperate for haircut in salon
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
:
2.5 Kg
Cry at birth
:
Cried immediately after birth
Resuscitation required
:
No
NICU stay
:
No
Past history:
Hospitalization
:
No
Seizures
:
No
Others
:
At 1 year- admitted for AGE
Investigations done-
Hearing assessment
:
Done
Details
:
OAE- B/l pass
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
:
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
:
Not achieved
Understanding gestures
:
Not achieved
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:-
Need-based communication
:
Emerging
Drag for needs
:
Inconsistent
Joint attention
:
Inconsistent
Pointing
:
Absent
Understanding gestures
:
Absent
Following commands (gesture + verbal)
:
Nil
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
Comes when called
:
Not achieved
Copying parents in tasks
:
Not achieved
Asking for food and toilet
:
Not achieved
Response to Name Call
Details
:
3/10
Sitting tolerance- (in minutes)
For interaction
:
Doesnt sit
For tasks
:
1-2 minutes
ADL Skills (Age-appropriate)-
Eating
:
2. Started attempting
Bathing
:
1. Dependent
Toilet training
:
1. Dependent
Dressing
:
1. Dependent
Undressing
:
1. Dependent
Type of Play : 2. Isolated
Academic History:
Is child enrolled in school
:
No
Diet History:
Food preferences
:
Picky eater
Food allergies
:
No
Junk food intake
:
Occasional
Sleep History
Total sleep duration (night)
:
8-9 hours
Afternoon nap
:
Yes
Duration of Afternoon nap
:
1-2 hours
Sleep disturbances
:
Yes
Daily Screen Time
Duration
:
<30 minutes
Examination
a. Vitals:
b. Anthropometry:
c. General Examination
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
Drooling
:
No
Chewing
:
Proper
Swallowing
:
Proper
Blowing
:
Improper
Sucking
:
Improper
CVS examination
:
NAD
Respiratory System examination
:
NAD
Per abdomen examination
:
NAD
Impression
:
? ASD
Advice
Intervention plan
:
IDP 2/week + PMT 1/week
Evaluation
:
DSM5 ASD, ISAA (Later)
Follow up plan
:
After 1 month
General recommendation-
Zero Screen Time
Physical interactive play
No Junk food
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