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Demographic Details Child's Name: Akshaya Jain Age: 2 Year 10 Month 9 Days Gender: Female DOB: 2023-04-22 Mother’s age (years): 30 years Mother’s occupation: Homemaker Father’s age (years): 33 years Father’s occupation: Private job Type of family: Joint Number of family members: 6 Number of siblings: 0 Address: Chetakpuri Contact: 9004823322 Referred By: Doctor Presenting Concerns Chief concerns: Speech delay, poor understanding Interaction history: Eye contact: Sustained Behavioral history: 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): Low birth weight Gestational Age: FT Birth Weight: 2.24Kg Resuscitation required: No Past history: Hospitalization: No Seizures: No Others: At 9 month admitted for pneumonia Investigations done- Hearing assessment: Done Details: BERA- normal 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: 9 months Standing without support: Achieved Age of attainment: 11 months Walking without support: Achieved Age of attainment: 14 months 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: 12 months Pointing: Achieved Age of attainment: 14 months Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 2 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 2 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Pointing: Consistent meaningful pointing Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 20 months Waving bye bye: Achieved Age of attainment: 24 months Comes when called: Achieved Age of attainment: Asking for food and toilet: Not achieved Response to Name Call Sitting tolerance- (in minutes) For interaction: 2-4 minutes For tasks: 2-4 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: Yes Type of school: Regular Name of School: Little millenium Grade: Play group Hours spent in school: 1.5 hours Location: Chetakpuri Diet History: Food allergies: No Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Sleep disturbances: No Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 12.7 Kg Head circumference: 45 cm c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Consciousness: active, alert, playful Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Power: Tone normal Deep tandon reflexes: DTR- KJ-2+/2+, AJ-2+/2+ Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Others: Started sucking CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: M chat 4 (Medium risk) Advice Investigations: DQ (DST, VSMS), Speech and language evaluation General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Akshaya Jain
Age: 2 Year 10 Month 9 Days
Gender: Female
DOB: 2023-04-22
Mother’s age (years): 30 years
Mother’s occupation: Homemaker
Father’s age (years): 33 years
Father’s occupation: Private job
Type of family: Joint
Number of family members: 6
Number of siblings: 0
Address: Chetakpuri
Contact: 9004823322
Referred By: Doctor

Presenting Concerns

Chief concerns: Speech delay, poor understanding

Interaction history:

Eye contact: Sustained

Behavioral history:

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): Low birth weight
Gestational Age: FT
Birth Weight: 2.24Kg
Resuscitation required: No

Past history:

Hospitalization: No Seizures: No Others: At 9 month admitted for pneumonia

Investigations done-

Hearing assessment: Done Details: BERA- normal 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: 9 months
Standing without support: Achieved

Age of attainment: 11 months
Walking without support: Achieved

Age of attainment: 14 months

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: 12 months
Pointing: Achieved

Age of attainment: 14 months
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 2 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 2 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Pointing: Consistent meaningful pointing

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 20 months
Waving bye bye: Achieved

Age of attainment: 24 months
Comes when called: Achieved

Age of attainment:
Asking for food and toilet: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: 2-4 minutes
For tasks: 2-4 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: Yes
Type of school: Regular
Name of School: Little millenium
Grade: Play group
Hours spent in school: 1.5 hours
Location: Chetakpuri

Diet History:

Food allergies: No

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Sleep disturbances: No

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 12.7 Kg Head circumference: 45 cm

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Consciousness: active, alert, playful

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Power: Tone normal
Deep tandon reflexes: DTR- KJ-2+/2+, AJ-2+/2+

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Others: Started sucking

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

Impression: M chat 4 (Medium risk)

Advice

Investigations: DQ (DST, VSMS), Speech and language evaluation
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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