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OPD : 23-Sep-2026 10:19AM Demographic Details Child's Name: Kirtika rajawat Age: 2 Year 1 Month 20 Days Gender: Female DOB: 2024-08-03 Number of siblings: 0 Address: Bhind Contact: 9329260546 Referred By: Doctor Informant: Mother, grandmother Investigations done: Hb- 11 g/dL, S ca- 9.18, vitamin d- sufficient Presenting Concerns Chief concerns: Delayed milestones Interaction history: Eye contact: Suboptimal Quality of Interaction: limited Behavioral history: Temper tantrums Stubbornness Aggression Mouthing of objects Sensory Concerns: 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: NVD Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Others: Frequent cough cold Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Done Details: BERA- normal Vision assessment: Done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 5 months Roll over: Achieved Age of attainment: 7 months Sitting without support: Achieved Age of attainment: 8 months Standing without support: Not achieved Walking without support: Not achieved Running: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 8 months Unidextrous grasp: Achieved Age of attainment: 9 months Pincer grasp: Not achieved Scribbling: Not achieved Drinking from cup: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Drag for needs: Absent Joint attention: Absent Pointing: Absent Understanding gestures: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Not achieved Waving bye bye: Not achieved Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 3. Onlooker Academic History: Is child enrolled in school: No Diet History: Food preferences: Picky eater Food allergies: No Junk food intake: Daily biscuits Sleep History Total sleep duration (night): 10-11 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Sleep disturbances: No Daily Screen Time Duration: > 2 hours Type of screen: Mobile Examination a. Vitals: b. Anthropometry: Weight: 12 Kg Head circumference: 45 cm c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypotonia Deep tendon reflexes: KJ-1+/1+, AJ- -/- Superficial reflexes: Plantars- B/l flexors Meningeal signs: Absent Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. ?Genetic Advice Intervention plan: Home strategies adviced Investigations: CK, TSH, free T3, free T4, lactate, ammonia. WES (later) Medications: As adviced by pediatrician Follow up plan: after investigations General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 23-Sep-2026 10:19AM Demographic Details

Child's Name: Kirtika rajawat
Age: 2 Year 1 Month 20 Days
Gender: Female
DOB: 2024-08-03
Number of siblings: 0
Address: Bhind
Contact: 9329260546
Referred By: Doctor
Informant: Mother, grandmother
Investigations done: Hb- 11 g/dL, S ca- 9.18, vitamin d- sufficient

Presenting Concerns

Chief concerns: Delayed milestones

Interaction history:

Eye contact: Suboptimal
Quality of Interaction: limited

Behavioral history:

Temper tantrums Stubbornness Aggression Mouthing of objects
Sensory Concerns:

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: NVD
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No Others: Frequent cough cold

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

Hearing assessment: Done Details: BERA- normal Vision assessment: Done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 5 months
Roll over: Achieved

Age of attainment: 7 months
Sitting without support: Achieved

Age of attainment: 8 months
Standing without support: Not achieved
Walking without support: Not achieved
Running: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 8 months

Unidextrous grasp: Achieved

Age of attainment: 9 months

Pincer grasp: Not achieved

Scribbling: Not achieved

Drinking from cup: Not achieved

Language

Receptive:-

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

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent
Drag for needs: Absent
Joint attention: Absent
Pointing: Absent
Understanding gestures: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Not achieved
Waving bye bye: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Type of Play : 3. Onlooker Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Picky eater
Food allergies: No
Junk food intake: Daily biscuits

Sleep History

Total sleep duration (night): 10-11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours
Sleep disturbances: No

Daily Screen Time

Duration: > 2 hours
Type of screen: Mobile

Examination

a. Vitals:

b. Anthropometry:

Weight: 12 Kg Head circumference: 45 cm

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypotonia
Deep tendon reflexes: KJ-1+/1+, AJ- -/-
Superficial reflexes: Plantars- B/l flexors

Meningeal signs: Absent

Oromotor Examination

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

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

Impression: GDD. ?Genetic

Advice

Intervention plan: Home strategies adviced
Investigations: CK, TSH, free T3, free T4, lactate, ammonia. WES (later)
Medications: As adviced by pediatrician
Follow up plan: after investigations
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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