OPD :
07-Jul-2026 03:14PM
Demographic Details
- :
Vidhi Pal
- :
3 Year 8 Month 27 Days
- :
Female
- :
2022-10-10
- :
Joint
- :
8
- :
1
- :
3 years old female
- :
Jalon
- :
9651620732
- :
Doctor
- :
Parents
Presenting Concerns
- :
Delayed milestones
- :
Noticed since 2 years
Interaction history:
- :
Sustained
- :
age-appropriate
Behavioral history:
Birth & Perinatal History:
Antenatal History
- :
No
- :
Natural
- :
Conceived after 16 years of marriage. Surgically operated for Endometrial Cyst.
Natal and Postnatal History:
- :
Institutional
- :
NVD
- :
FT
- :
2.5 Kg
- :
Delayed cry
- :
Yes
- :
Yes
- :
NICU stay- for 6 days
Past history:
:
No
:
No
:
PT going on for 3 months
Investigations done-
:
Not done
:
Not done
Family history:
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
12 months
-
:
Achieved
:
18 months
-
:
Achieved
:
24 months
-
:
Not achieved
-
:
Not achieved
Fine Motor
:
Achieved
:
12 months
:
Achieved
:
15 months
:
Not achieved
Language
Receptive:-
-
:
Achieved
:
12 months
-
:
Achieved
:
24 months
- :
1-step
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Not achieved
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Not achieved
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Consistent
- :
Consistent
- :
Consistent
- :
Consistent meaningful pointing
- :
Consistent
- :
1-step
Answering Questions:-
Social
-
:
Achieved
:
2 months
-
:
Achieved
:
12 months
-
:
Achieved
:
30 months
-
:
Achieved
:
Response to Name Call
Sitting tolerance- (in minutes)
ADL Skills (Age-appropriate)-
- :
2. Started attempting
- :
2. Started attempting
- :
1. Dependent
- :
3. Needs significant assistance
- :
2. Started attempting
Type of Play : 4. Parallel
Academic History:
- :
No
Diet History:
- :
Mixed
- :
No
- :
Nil
Sleep History
- :
8 hours
- :
Yes
- :
2-3 years
Daily Screen Time
Examination
a. Vitals:
b. Anthropometry:
:
11 Kg
:
92 cm
:
46 cm
c. General Examination
:
ab
:
ab
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
- :
Gross motor and Fine motor
- :
Hypertonia
- :
KJ-2+/2+, AJ-2+/2+
Oromotor Examination
- :
No
- :
Proper
- :
Proper
- :
Improper
- :
Proper
:
Sits in w position, poor balance and coordination, scissoring reduced :
NAD
:
NAD
:
GDD
Advice
- :
Parents counselled
- :
Syp Cogniwella3 5 ml OD
- :
After 2 months
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food