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OPD : 15-May-2026 05:31PM Demographic Details Child's Name: Kartikey Rawat Age: 2 Year 3 Month 21 Days Gender: Male DOB: 2024-01-24 Mother’s age (years): 27 years Mother’s occupation: Homemaker Father’s age (years): 35 years Father’s occupation: Pharmacy Type of family: Joint Number of family members: 3 Address: Aamkho Contact: 8516803913 Referred By: Doctor Informant: Parents Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Temper tantrums Stubbornness Mouthing of objects Sensory Concerns: Auditory: Fear of loud sounds Visual: Seeks visuals Details:: Doesnt cooperate for haircut 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): Fetal distress Gestational Age: ?34 wks Birth Weight: 2.3 Kg Cry at birth: Cried immediately after birth NICU stay: Yes If yes- Duration & Indication: Admitted for 8 hours for NNHB for DSPT Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Not done 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: 6 months Sitting without support: Achieved Age of attainment: 12 months Standing without support: Not achieved Walking without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 8 months Unidextrous grasp: Achieved Age of attainment: 12 months Pincer grasp: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: 18 months Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 18 months Babbling: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- 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: 10/10 Sitting tolerance- (in 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 : 3. Onlooker Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed. Bottlefeeding+ Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 9-10 Afternoon nap: Yes Duration of Afternoon nap: 3-4 hours Daily Screen Time Duration: > 5 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 9.5 Kg Height: 75 cm Head circumference: 43.5 cm c. General Examination Dysmorphology: Downs phenotype, umbilical hernia Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Drooling: Yes Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Downs syndrome Advice Intervention plan: IDP (+PT) 2/week + PMT 1/week Evaluation: Speech and language evaluation Investigations: CBC, Thyroid profile, Calcium, S. Vitamin D2, S. Vitamin B12, Complete ophthalmological exam, BERA, USG abdomen General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 15-May-2026 05:31PM Demographic Details

Child's Name: Kartikey Rawat
Age: 2 Year 3 Month 21 Days
Gender: Male
DOB: 2024-01-24
Mother’s age (years): 27 years
Mother’s occupation: Homemaker
Father’s age (years): 35 years
Father’s occupation: Pharmacy
Type of family: Joint
Number of family members: 3
Address: Aamkho
Contact: 8516803913
Referred By: Doctor
Informant: Parents

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Temper tantrums Stubbornness Mouthing of objects
Sensory Concerns:

Auditory: Fear of loud sounds
Visual: Seeks visuals

Details:: Doesnt cooperate for haircut

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): Fetal distress
Gestational Age: ?34 wks
Birth Weight: 2.3 Kg
Cry at birth: Cried immediately after birth
NICU stay: Yes
If yes- Duration & Indication: Admitted for 8 hours for NNHB for DSPT

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Nil Investigations done-

Hearing assessment: Not done 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: 6 months
Sitting without support: Achieved

Age of attainment: 12 months
Standing without support: Not achieved
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 8 months

Unidextrous grasp: Achieved

Age of attainment: 12 months

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 18 months

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 18 months

Babbling: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

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: 10/10

Sitting tolerance- (in 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 : 3. Onlooker Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed. Bottlefeeding+
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 9-10
Afternoon nap: Yes
Duration of Afternoon nap: 3-4 hours

Daily Screen Time

Duration: > 5 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 9.5 Kg Height: 75 cm Head circumference: 43.5 cm

c. General Examination

Dysmorphology: Downs phenotype, umbilical hernia Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Drooling: Yes
Chewing: Proper
Swallowing: Proper
Blowing: Proper
Sucking: Improper

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

Impression: Downs syndrome

Advice

Intervention plan: IDP (+PT) 2/week + PMT 1/week
Evaluation: Speech and language evaluation
Investigations: CBC, Thyroid profile, Calcium, S. Vitamin D2, S. Vitamin B12, Complete ophthalmological exam, BERA, USG abdomen
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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