**Reason for referral**:
Concern regarding delayed speech development.
**Persons present during appointment**:
Patient, mother, and father.
**History of Symptoms**:
Patient has demonstrated limited verbal communication skills. First words were spoken at 18 months, but vocabulary has not expanded significantly. No history of regression. Hearing tests were performed and were normal. No previous interventions trialled.
**Discussion with Family/Patient**:
Parents expressed concerns about the child's ability to communicate with peers. Reassured parents that early intervention can be beneficial and that further assessment is needed.
**Past Medical history including Birth History**:
Born at 39 weeks gestation via spontaneous vaginal delivery. Birth weight 7lbs 8oz. No complications during delivery. No significant past medical history. No previous surgeries.
**Medication History**:
No current medications or herbal supplements.
**Developmental History**:
Sat up at 6 months, walked at 12 months. Currently able to follow simple instructions. Limited vocabulary, uses gestures to communicate needs.
**Family and Social History**:
No family history of speech or language disorders. Lives at home with both parents and a younger sibling. Attends nursery three days a week.
**Summary of Previous Investigations**:
Hearing test performed at 18 months, results were normal.
**Examination**:
Weight: 12kg, Height: 85cm, HR: 100 bpm, RR: 22, Temp: 37.0C. Alert and interactive. Speech assessment revealed a limited vocabulary of approximately 10 words. Able to follow simple instructions. No other abnormalities noted.
**Impression**:
Delayed speech development. Possible speech delay.
**Plan**:
Referral to speech and language therapy. Schedule follow-up appointment in 3 months. Provide parents with resources on speech development.
**Reason for referral**:
[reason for referral] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Persons present during appointment**:
[persons present during appointment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**History of Symptoms**:
[details of symptoms, interventions trialled and important negatives] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Discussion with Family/Patient**:
[details of concerns and reassurances provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Past Medical history including Birth History**:
[details of birth history including gestational age, mode of delivery, birth weight, any complications, describe past medical history, previous surgeries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Medication History**:
[medications and herbal supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Developmental History**:
[details of developmental milestones, any concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Family and Social History**:
[details of family history and relevant social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Summary of Previous Investigations**:
[details of investigations performed, including results if available] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Examination**:
[details of physical examination findings, vital signs, any abnormalities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Impression**:
[summary of clinical impression/assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Plan**:
[management plan, next steps, referrals, or follow-up required] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)