OPD :
15-Sep-2026 05:20PM
Demographic Details
- :
Rudra Aswal
- :
3 Year
- :
Male
- :
2023-09-05
- :
32 years
- :
Homemaker
- :
34 years
- :
Air force
- :
Joint
- :
15
- :
1
- :
9 year old female
- :
Morar
- :
7773013437
- :
Doctor
- :
Parents
Presenting Concerns
- :
Speech delay, delayed walking
Interaction history:
- :
Sustained
- :
age-appropriate
Behavioral history:
Temper tantrums
Stubbornness
Birth & Perinatal History:
Antenatal History
- :
No
- :
Natural
Natal and Postnatal History:
- :
Institutional
- :
LSCS
- :
Previous LSCS
- :
Late PT
- :
2.5 Kg
- :
Cried immediately after birth
- :
No
- :
No
Past history:
:
No
:
No
:
H/o Breath holding spells
:
Nil
:
Nil
Investigations done-
:
Not done
:
Not done
Family history:
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
6 months
-
:
Achieved
:
7 months
-
:
Achieved
:
12 months
-
:
Achieved
:
30 months
-
:
Achieved
:
34 months
-
:
Not achieved
-
:
Not achieved
-
:
Not achieved
Fine Motor
:
Achieved
:
6 months
:
Achieved
:
9 months
:
Achieved
:
12 months
:
Achieved
:
Language
Receptive:-
-
:
Achieved
:
9 months
-
:
Achieved
:
12 months
-
:
Achieved
:
- :
1-step
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
12 months. regressed
:
Not achieved
:
Not achieved
:
Not achieved
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
12 months. regressed
:
Not achieved
:
Not achieved
:
Not achieved
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Consistent
- :
Consistent
- :
Consistent
- :
Inconsistent meaningful pointing
- :
Emerging
- :
1-step
Answering Questions:-
Social
-
:
Achieved
:
3 months
-
:
Achieved
:
9 months
-
:
Achieved
:
-
:
Achieved
:
Response to Name Call
Sitting tolerance- (in minutes)
ADL Skills (Age-appropriate)-
- :
2. Started attempting
- :
2. Started attempting
- :
1. Dependent
- :
1. Dependent
- :
2. Started attempting
Type of Play : 4. Parallel
Academic History:
- :
No
Diet History:
- :
Mixed
- :
No
- :
Daily
Sleep History
- :
9-10 hours
- :
Yes
- :
2-3 hours
Daily Screen Time
Examination
a. Vitals:
b. Anthropometry:
:
12 Kg
:
47 cm
c. General Examination
:
Ab
:
Ab
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
:
Pallor+, Language delay, gait abnormality, wide based gait, difficulty in balance
:
Regression in talking, walking
Advice
- :
IDP +PT 2/week + LDP 1/week + PMT 1/15 days
- :
Speech and language evaluation
- :
CBC, Iron profile, Ca, Vitamin B12, Vitamin D, Thyroid profile. EEG. ECG.
- :
Syp Histafer 5 ml BD. Syp Multivitamin A to Z 5 ml BD.
- :
Next month
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food
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