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OPD : 16-May-2026 01:46PM Demographic Details Child's Name: Vedant Sharma Age: 2 Year 3 Month 24 Days Gender: Male DOB: 2024-01-22 Mother’s age (years): 33 years Mother’s occupation: homemaker Father’s age (years): 33 years Father’s occupation: Govt job Type of family: Joint Number of family members: 8 Number of siblings: 1 Details of siblings (Age and sex): 7 years female Address: Shivpuri Contact: 9340615702 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay Interaction history: Eye contact: Suboptimal Quality of Interaction: age-appropriate Behavioral history: Temper tantrums Stubbornness Mouthing of objects Birth & Perinatal History: Antenatal History Consanguinity: No High-risk factors in pregnancy: Hypothyroidism Others:: Neonatal screening for hypothyroidism- normal Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Previous LSCS, MSL Gestational Age: FT Birth Weight: 3.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Others: At 1 mon- admitted for Febrile illness for 2 days 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: 5 months Sitting without support: Achieved Age of attainment: 8 months Standing without support: Achieved Age of attainment: 14 months Walking without support: Achieved Age of attainment: 15 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 Scribbling: Achieved Age of attainment: Drinking from cup: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 12 months Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Achieved Age of attainment: Details:: Uses Kinship words. Identifies family members. Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Drag for needs: Consistent Joint attention: Consistent Pointing: Consistent meaningful pointing Understanding gestures: Emerging Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 6 months Waving bye bye: Achieved Age of attainment: Inconsistent Response to Name Call Details: 8/10 Sitting tolerance- (in minutes) For interaction: 2-3 minutes For tasks: can sit for prolonged periods ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 1. Dependent Undressing: 2. Started attempting Type of Play : 4. Parallel Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Daily Screen Time Duration: < 1 hour Type of screen: TV Examination a. Vitals: b. Anthropometry: Weight: 10 Kg Height: 83 cm Head circumference: 47.8 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Normal Deep tendon reflexes: NAD Superficial reflexes: NAD Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: M chat R score- 3 Advice Intervention plan: Parents counselled Follow up plan: after 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 16-May-2026 01:46PM Demographic Details

Child's Name: Vedant Sharma
Age: 2 Year 3 Month 24 Days
Gender: Male
DOB: 2024-01-22
Mother’s age (years): 33 years
Mother’s occupation: homemaker
Father’s age (years): 33 years
Father’s occupation: Govt job
Type of family: Joint
Number of family members: 8
Number of siblings: 1
Details of siblings (Age and sex): 7 years female
Address: Shivpuri
Contact: 9340615702
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay

Interaction history:

Eye contact: Suboptimal
Quality of Interaction: age-appropriate

Behavioral history:

Temper tantrums Stubbornness Mouthing of objects

Birth & Perinatal History: Antenatal History

Consanguinity: No
High-risk factors in pregnancy:
1. Hypothyroidism
Others:: Neonatal screening for hypothyroidism- normal

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Previous LSCS, MSL
Gestational Age: FT
Birth Weight: 3.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No Others: At 1 mon- admitted for Febrile illness for 2 days

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: 5 months
Sitting without support: Achieved

Age of attainment: 8 months
Standing without support: Achieved

Age of attainment: 14 months
Walking without support: Achieved

Age of attainment: 15 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

Scribbling: Achieved

Age of attainment:

Drinking from cup: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 12 months
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Achieved

Age of attainment:

Details:: Uses Kinship words. Identifies family members.

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Drag for needs: Consistent
Joint attention: Consistent
Pointing: Consistent meaningful pointing
Understanding gestures: Emerging
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 6 months
Waving bye bye: Achieved

Age of attainment: Inconsistent

Response to Name Call

Details: 8/10

Sitting tolerance- (in minutes)

For interaction: 2-3 minutes
For tasks: can sit for prolonged periods

ADL Skills (Age-appropriate)-

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

Type of Play : 4. Parallel Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours

Daily Screen Time

Duration: < 1 hour
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 10 Kg Height: 83 cm Head circumference: 47.8 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Normal
Deep tendon reflexes: NAD
Superficial reflexes: NAD

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Proper
Sucking: Proper

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

Impression: M chat R score- 3

Advice

Intervention plan: Parents counselled
Follow up plan: after 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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