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OPD : 16-Sep-2026 03:01PM Demographic Details Child's Name: Satvik yadav Age: 2 Year 7 Month 4 Days Gender: Male DOB: 2024-02-12 Mother’s age (years): 28 years Mother’s occupation: Homemaker Father’s age (years): 33 years Father’s occupation: Business Type of family: Joint Number of family members: 5 Number of siblings: 0 Address: Hurawali Contact: 8717818911 Referred By: Doctor Informant: Father, grandmother Presenting Concerns Chief concerns: Speech delay Interaction history: Eye contact: Fleeting Interaction: Better with parents Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): spinning, toe walking, running to and fro Patterned behavior or activities: Hyperactivity Inattention Object obsession Temper tantrums Stubbornness Mouthing of objects Others Emotional History Details: Irrelevant laughing+ Sensory Concerns: Auditory: Hypersensitive Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Seeks movement 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): Cord around neck Gestational Age: FT Birth Weight: 2.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 3 months Roll over: Achieved Age of attainment: 5 months Sitting without support: Achieved Age of attainment: 7 months Standing without support: Achieved Age of attainment: 9 months Walking without support: Achieved Age of attainment: 15 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 Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Details:: Started speaking kinship words Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Drag for needs: Emerging Joint attention: Emerging Pointing: Attempts Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Social Response to Name Call Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: Better for tasks ADL Skills (Age-appropriate)- Eating: 1. Dependent 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: No Diet History: Food preferences: Picky eating Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 8 hours Afternoon nap: Yes Duration of Afternoon nap: 2 to 3 hours Daily Screen Time Duration: < 1 hour Examination a. Vitals: b. Anthropometry: Height: 87 cm Head circumference: 47 cm c. General Examination Neurocutaneous markers: 1 cafe au lait macule over right calf d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper Examination summary: Mild hypotonia, Dysmorphic features CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: M chat- 13 (High risk) Advice Intervention plan: IDP 2/week + PMT 1/week Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 16-Sep-2026 03:01PM Demographic Details

Child's Name: Satvik yadav
Age: 2 Year 7 Month 4 Days
Gender: Male
DOB: 2024-02-12
Mother’s age (years): 28 years
Mother’s occupation: Homemaker
Father’s age (years): 33 years
Father’s occupation: Business
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Address: Hurawali
Contact: 8717818911
Referred By: Doctor
Informant: Father, grandmother

Presenting Concerns

Chief concerns: Speech delay

Interaction history:

Eye contact: Fleeting
Interaction: Better with parents
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): spinning, toe walking, running to and fro Patterned behavior or activities: Hyperactivity Inattention Object obsession Temper tantrums Stubbornness Mouthing of objects Others Emotional History Details: Irrelevant laughing+
Sensory Concerns:

Auditory: Hypersensitive
Visual: Seeks visuals
Proprioception: Seeks pressure
Vestibular: Seeks movement

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): Cord around neck
Gestational Age: FT
Birth Weight: 2.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

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

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 3 months
Roll over: Achieved

Age of attainment: 5 months
Sitting without support: Achieved

Age of attainment: 7 months
Standing without support: Achieved

Age of attainment: 9 months
Walking without support: Achieved

Age of attainment: 15 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

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Details:: Started speaking kinship words

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Emerging
Drag for needs: Emerging
Joint attention: Emerging
Pointing: Attempts
Understanding gestures: Absent
Following commands (gesture + verbal): Nil

Answering Questions:-

Social

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: Better for tasks

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
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: No

Diet History:

Food preferences: Picky eating
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 8 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 to 3 hours

Daily Screen Time

Duration: < 1 hour

Examination

a. Vitals:

b. Anthropometry:

Height: 87 cm Head circumference: 47 cm

c. General Examination

Neurocutaneous markers: 1 cafe au lait macule over right calf

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Improper
Sucking: Improper

Examination summary: Mild hypotonia, Dysmorphic features CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: M chat- 13 (High risk)

Advice

Intervention plan: IDP 2/week + PMT 1/week
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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