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OPD : 03-Jun-2026 03:48PM Demographic Details Child's Name: Aaradhya Dhakad Age: 8 Year Gender: Female DOB: 2018-05-26 Mother’s age (years): 42 years Mother’s occupation: Homemaker Father’s age (years): 44 years Father’s occupation: Farming Type of family: Nuclear Number of family members: 3 Number of siblings: 1 Details of siblings (Age and sex): 17 years Address: Kailaras Contact: 9993339385 Referred By: Doctor Informant: Father Presenting Concerns Chief concerns: Speech delay Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 2.5 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: Nicu stay- 5 days. Perinatal asphyxia Past history: Hospitalization: Yes Seizures: Yes Others: At 3 years age-GTCS, not asso with fever, f/b LOC. NO AEDs were given on discharge Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Done Details: OAE- pass/pass 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: 8 months Sitting without support: Achieved Age of attainment: 10 months Standing without support: Achieved Age of attainment: 3 years Walking without support: Achieved Age of attainment: 4 years Running: Achieved Age of attainment: Climbing upstairs: Achieved Age of attainment: Climbing downstairs: Achieved Age of attainment: Hopping: Achieved Age of attainment: Fine Motor Bidextrous grasp: Achieved Age of attainment: Unidextrous grasp: Achieved Age of attainment: Pincer grasp: Achieved Age of attainment: Scribbling: Not achieved Drinking from cup: Achieved Age of attainment: Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: Pointing: Achieved Age of attainment: 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 2 word Phrases: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved 2 word Phrases: Not achieved Details:: 3 words- Mumma, papa, aaja- since 2 years 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): 2-step Answering Questions:- Social Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 3. Needs significant assistance Bathing: 4. Needs minimal assistance Toilet training: 4. Needs minimal assistance Dressing: 3. Needs significant assistance Undressing: 3. Needs significant assistance Details:: Indicates for urine and stool by gestures Type of Play : 5. Associative Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Biscuit occasional Sleep History Total sleep duration (night): 9 hours Afternoon nap: No Daily Screen Time Duration: < 1 hour Examination a. Vitals: b. Anthropometry: Weight: 16 Kg Height: 118 cm Head circumference: 50 cm c. General Examination Dysmorphology: Mild clindodactyly d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Fine motor Tone: Hypotonia Deep tendon reflexes: KJ- 2+/2+ AJ- 2+/2+ Superficial reflexes: Plantars- flexor/flexor Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Examination summary: Poor hand grip, mild hypotonia CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ?ID withe expressive speech delay Advice Intervention plan: IDP 2/week + PMT 1/15 days Evaluation: DQ (VSMS, DST), Speech and language evaluation Medications: Syo Cos 3 5 ml OD Follow up plan: After reports General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 03-Jun-2026 03:48PM Demographic Details

Child's Name: Aaradhya Dhakad
Age: 8 Year
Gender: Female
DOB: 2018-05-26
Mother’s age (years): 42 years
Mother’s occupation: Homemaker
Father’s age (years): 44 years
Father’s occupation: Farming
Type of family: Nuclear
Number of family members: 3
Number of siblings: 1
Details of siblings (Age and sex): 17 years
Address: Kailaras
Contact: 9993339385
Referred By: Doctor
Informant: Father

Presenting Concerns

Chief concerns: Speech delay

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 2.5 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: Nicu stay- 5 days. Perinatal asphyxia

Past history:

Hospitalization: Yes Seizures: Yes Others: At 3 years age-GTCS, not asso with fever, f/b LOC. NO AEDs were given on discharge

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

Hearing assessment: Done Details: OAE- pass/pass 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: 8 months
Sitting without support: Achieved

Age of attainment: 10 months
Standing without support: Achieved

Age of attainment: 3 years
Walking without support: Achieved

Age of attainment: 4 years
Running: Achieved

Age of attainment:
Climbing upstairs: Achieved

Age of attainment:
Climbing downstairs: Achieved

Age of attainment:
Hopping: Achieved

Age of attainment:

Fine Motor

Bidextrous grasp: Achieved

Age of attainment:

Unidextrous grasp: Achieved

Age of attainment:

Pincer grasp: Achieved

Age of attainment:

Scribbling: Not achieved

Drinking from cup: Achieved

Age of attainment:

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment:
Pointing: Achieved

Age of attainment:
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

2 word Phrases: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

2 word Phrases: Not achieved

Details:: 3 words- Mumma, papa, aaja- since 2 years

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): 2-step

Answering Questions:-

Social

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 3. Needs significant assistance
Bathing: 4. Needs minimal assistance
Toilet training: 4. Needs minimal assistance
Dressing: 3. Needs significant assistance
Undressing: 3. Needs significant assistance

Details:: Indicates for urine and stool by gestures

Type of Play : 5. Associative Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed
Food allergies: No
Junk food intake: Biscuit occasional

Sleep History

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

Daily Screen Time

Duration: < 1 hour

Examination

a. Vitals:

b. Anthropometry:

Weight: 16 Kg Height: 118 cm Head circumference: 50 cm

c. General Examination

Dysmorphology: Mild clindodactyly

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Fine motor
Tone: Hypotonia
Deep tendon reflexes: KJ- 2+/2+ AJ- 2+/2+
Superficial reflexes: Plantars- flexor/flexor

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper

Examination summary: Poor hand grip, mild hypotonia CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: ?ID withe expressive speech delay

Advice

Intervention plan: IDP 2/week + PMT 1/15 days
Evaluation: DQ (VSMS, DST), Speech and language evaluation
Medications: Syo Cos 3 5 ml OD
Follow up plan: After reports
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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