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OPD : 14-May-2026 11:05AM Demographic Details Child's Name: Radha Age: 2 Year 2 Month 29 Days Gender: Female DOB: 2024-02-15 Contact: 9826490526 Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Birth & Perinatal History: Antenatal History Others:: Perinatal history- not available Natal and Postnatal History: If yes- Duration & Indication: In orphanage- since May 2024 Past history: Hospitalization: No Seizures: No Investigations done- Hearing assessment: 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: 6 months Standing without support: Achieved Age of attainment: 12 months Walking without support: Achieved Age of attainment: 14 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 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: 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 Details:: Inconsistent use of kinship words Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Drag for needs: Consistent Joint attention: Consistent Pointing: Consistent meaningful pointing Understanding gestures: Consistent Following commands (gesture + verbal): 1-step Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 4 months Waving bye bye: Achieved Age of attainment: 9 months Response to Name Call Details: 10/10 Sitting tolerance- (in minutes) For interaction: Can sit for prolonged periods For tasks: Can sit for prolonged periods ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 2. Started attempting Undressing: 2. Started attempting Details:: Indicates with cues Type of Play : 5. Associative Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed diet Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours Daily Screen Time Duration: Zero Examination a. Vitals: HR: 94/min RR: 24/min Temperature: afebrile b. Anthropometry: Weight: 9 Kg Height: 81 cm Head circumference: 44 cm c. General Examination Dysmorphology: ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Consciousness: Awake, alert Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Normal Deep tendon reflexes: KJ 2+/2+, AJ- 2+/2+ Superficial reflexes: Present, Plantars- B/l extensors Meningeal signs: Absent Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ? Expressive language delay. M char R score- 2 Advice Intervention plan: Speech and language evaluation

OPD : 14-May-2026 11:05AM Demographic Details

Child's Name: Radha
Age: 2 Year 2 Month 29 Days
Gender: Female
DOB: 2024-02-15
Contact: 9826490526

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Birth & Perinatal History: Antenatal History

Others:: Perinatal history- not available

Natal and Postnatal History:

If yes- Duration & Indication: In orphanage- since May 2024

Past history:

Hospitalization: No Seizures: No

Investigations done-

Hearing assessment: 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: 6 months
Standing without support: Achieved

Age of attainment: 12 months
Walking without support: Achieved

Age of attainment: 14 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

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: 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

Details:: Inconsistent use of kinship words

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 4 months
Waving bye bye: Achieved

Age of attainment: 9 months

Response to Name Call

Details: 10/10

Sitting tolerance- (in minutes)

For interaction: Can sit for prolonged periods
For tasks: Can sit for prolonged periods

ADL Skills (Age-appropriate)-

Eating: 5. Independent
Bathing: 2. Started attempting
Toilet training: 2. Started attempting
Dressing: 2. Started attempting
Undressing: 2. Started attempting

Details:: Indicates with cues

Type of Play : 5. Associative Academic History:

Is child enrolled in school: No

Diet History:

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

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

HR: 94/min RR: 24/min Temperature: afebrile

b. Anthropometry:

Weight: 9 Kg Height: 81 cm Head circumference: 44 cm

c. General Examination

Dysmorphology: ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Consciousness: Awake, alert

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Normal
Deep tendon reflexes: KJ 2+/2+, AJ- 2+/2+
Superficial reflexes: Present, Plantars- B/l extensors

Meningeal signs: Absent

Oromotor Examination

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

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

Impression: ? Expressive language delay. M char R score- 2

Advice

Intervention plan: Speech and language evaluation

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