OPD :
21-Jul-2026 02:21PM
Demographic Details
- :
Mohammad Taqi
- :
4 Year 5 Month 23 Days
- :
Male
- :
2022-01-28
- :
35 years
- :
Homemaker
- :
37 years
- :
Private job
- :
Joint
- :
11
- :
2
- :
10 yr male, 2.5 yr female
- :
Kila gate
- :
8305673582
- :
Doctor
- :
Mother
Presenting Concerns
- :
Speech delay
Interaction history:
- :
Fleeting
- :
limited
Behavioral history:
Repetitive behaviors (RRBs):
Hand flapping, spinning, jumpin, running to and fro
Patterned behavior or activities:
Hyperactivity
Inattention
Impulsivity
Object obsession
Temper tantrums
Stubbornness
Mouthing of objects
:
Irrelevant laughing
Sensory Concerns:
- :
Hypersensitive
- :
Seeks pressure
- :
Avoids swings
:
Doesnt cooperate for haircut
Birth & Perinatal History:
Antenatal History
- :
Yes
- :
3
- :
Natural
-
High-risk factors in pregnancy:
- PIH
- Ante partum haemorrhage
Natal and Postnatal History:
- :
Institutional
- :
LSCS
- :
Prev LSCS
- :
FT
- :
2.7 Kg
- :
Cried immediately after birth
- :
No
- :
No
Past history:
:
Yes
:
No
:
At 1.5 mon diagnosed with CHD. months back open heart surgery for CHD
:
Nil
:
Nil
Investigations done-
:
Not done
:
Not done
Family history:
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
4 months
-
:
Achieved
:
5 months
-
:
Achieved
:
6 months
-
:
Achieved
:
12 months
-
:
Achieved
:
13 months
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
Fine Motor
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
12 months
:
Not achieved
:
Achieved
:
Language
Receptive:-
-
:
Not achieved
-
:
Not achieved
-
:
Not achieved
- :
Not following
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Not achieved
:
Not achieved
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Not achieved
:
Not achieved
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Emerging
- :
Emerging
- :
Absent
- :
Absent
- :
Absent
- :
Nil
Answering Questions:-
:
Present
Social
-
:
Achieved
:
2 months
-
:
Achieved
:
8 months
-
:
Not achieved
-
:
Not achieved
-
:
Not achieved
Response to Name Call
Sitting tolerance- (in minutes)
- :
Doesnt sit
- :
1-2 minutes
:
Aligns toys in objects
ADL Skills (Age-appropriate)-
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
Type of Play : 3. Onlooker
Academic History:
- :
Yes
- :
Regular
- :
Anganbadi
- :
Going to anganbadi sin ce 10 days
Diet History:
- :
Mixed
- :
No
- :
Occasional
Sleep History
- :
8 hours
- :
Yes
- :
2-3 hours
-
:
Daily Screen Time
-
:
< 1 hour
- :
Mobile and TV
Examination
a. Vitals:
b. Anthropometry:
:
13 Kg
:
95 cm
:
47 cm
c. General Examination
:
Surgical scar mark over ant chest
:
Ab
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
- :
No
- :
Proper
- :
Proper
- :
Improper
- :
Improper
:
NAD
:
NAD
:
NAD
:
? ASD
Advice
- :
IDP 2/week + PMT 1/week
- :
ISAA, DSM5 ASD (Next month)
- :
Next month
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food