MCQ Points

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Table of Contents
Table of Contents...........................................................................................................1 Brain Trauma Foundation Guidelines............................................................................3 Surgical Management of Acute Epidural Hematomas...............................................3 ndications for Surger!...........................................................................................3 Timing....................................................................................................................3 Met"ods..................................................................................................................3 Surgical Management of Acute Subdural Hematomas..............................................3 ndications for Surger!...........................................................................................3 Timing....................................................................................................................3 Met"ods..................................................................................................................3 Surgical Management of Traumatic #arenc"!mal $esions........................................% ndications..............................................................................................................% Timing and Met"ods..............................................................................................% Surgical Management of #osterior Fossa Mass $esions............................................% ndications..............................................................................................................% Timing....................................................................................................................% Met"ods..................................................................................................................& Surgical Management of 'epress Cranial Fractures..................................................& ndications..............................................................................................................& Timing....................................................................................................................& Met"ods..................................................................................................................& #ost(Traumatic Mass )olume Measurement in Traumatic Brain n*ur! #atients.....+ E,aluation of -ele,ant Computed Tomograp"ic Scan Findings................................ Basal Cisterns at t"e Midbrain $e,el...................................................................... Midline S"ift at t"e Foramen of Monro.................................................................. Traumatic Subarac"noid Hemorr"age..................................................................... 'iffuse A/onal n*ur! ...................................................................................................0 Adam1s 2europat"ological Grading 3 Classification of 'A .....................................0 'iffuse A/onal n*ur! 4 -adiological Grading..........................................................0 Traumatic $oss of Consciousness..............................................................................0 Grading S!stems............................................................................................................5 Cantu and Colorado Head n*ur! Grading S!stems...................................................5 Cantu6s Guidelines for -eturn to #la! after Concussion............................................5 7"en to -eturn to #la!8Colorado Medical Societ! Guidelines..............................5 C9MA..........................................................................................................................1: Breat"ing #atterns....................................................................................................1: #upils........................................................................................................................11 C#................................................................................................................................1; Compliance and Elastance........................................................................................1; T!pes of Edema........................................................................................................13 )icious C!cle of C#................................................................................................1% C# 7a,es................................................................................................................1& Abnormal 7a,es......................................................................................................1+ H................................................................................................................................1. T"e modified 'and! criteria suggested b! 7all .....................................................1. <e! 9nline -esources for Medicos..............................................................................10 Multiple ring(en"ancing lesions of t"e brain...............................................................;: @targetpg * www.facebook.com/targetpg * www.targetpg.in * 984211172

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Causes of multiple ring(en"ancing lesions of t"e brain...........................................;: 'ifferential diagnosis of multiple en"ancing lesions of t"e brain according to t"e si=e of t"e lesions.....................................................................................................;: Modified diagnostic criteria for neuroc!sticercosis.................................................;1 Met"ods used for establis"ing t"e diagnosis in patients >it" multiple en"ancing lesions of t"e brain...................................................................................................;1 Algorit"m for t"e differential diagnosis in an immunocompetent patient >it" multiple en"ancing lesions of t"e brain....................................................................;3 Algorit"m for t"e differential diagnosis in a "uman deficienc! ,irus infected patient >it" multiple en"ancing lesions of t"e brain............................................................;% Brain Abscess ( Stages.............................................................................................;% ......................................................................................................................................;% Endoscop!....................................................................................................................;& Entr! #oints and Tumour $ocation..........................................................................;& -adiation......................................................................................................................;+ T"e Four -s of -adiobiolog!...................................................................................;+ Cerebral Blood Flo> T"res"olds.............................................................................;. Code Stro?e Algorit"m ...........................................................................................;0 mmediate 'iagnostic Studies@ E,aluation of a #atient >it" Suspected Acute sc"emic Stro?e........................................................................................................;5 C"aracteristics of #atients >it" sc"emic Stro?e 7"o Could Be Treated >it" Tissue #lasminogen Acti,ator..................................................................................3: 'e,elopmental Milestones...........................................................................................31 Gross Motor Milestones...........................................................................................31 Fine Motor Milestones.............................................................................................31 Communication and $anguage.................................................................................31 Cogniti,e Milestones................................................................................................3;

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Brain Trauma Foundation Guidelines

Surgical Management of Acute Epidural Hematomas
Indications for Surgery
An epidural "ematoma AE'HB greater t"an 3: cm3 s"ould be surgicall! e,acuated regardless of t"e patient1s Glasgo> Coma Scale AGCSB score. An E'H less t"an 3: cm3 and >it" less t"an a 1&(mm t"ic?ness and >it" less t"an a &(mm midline s"ift AM$SB in patients >it" a GCS score greater t"an 0 >it"out focal deficit can be managed nonoperati,el! >it" serial computed tomograp"ic ACTB scanning and close neurological obser,ation in a neurosurgical center.

Timing
t is strongl! recommended t"at patients >it" an acute E'H in coma AGCS score C 5B >it" anisocoria undergo surgical e,acuation as soon as possible.

Methods
T"ere are insufficient data to support one surgical treatment met"od. Ho>e,erD craniotom! pro,ides a more complete e,acuation of t"e "ematoma.

Surgical Management of Acute Subdural Hematomas

Indications for Surgery
An acute subdural "ematoma AS'HB >it" a t"ic?ness greater t"an 1: mm or a midline s"ift greater t"an & mm on computed tomograp"ic ACTB scan s"ould be surgicall! e,acuatedD regardless of t"e patient1s Glasgo> Coma Scale AGCSB score. All patients >it" acute S'H in coma AGCS score less t"an 5B s"ould undergo intracranial pressure A C#B monitoring. A comatose patient AGCS score less t"an 5B >it" an S'H less t"an 1:(mm t"ic? and a midline s"ift less t"an &mms"ould undergo surgical e,acuation of t"e lesion if t"e GCS score decreased bet>een t"e time of in*ur! and "ospital admission b! ; or more points on t"e GCS and3or t"e patient presents >it" as!mmetric or fi/ed and dilated pupils and3or t"e C# e/ceeds ;: mm Hg.

Timing
n patients >it" acute S'H and indications for surger!D surgical e,acuation s"ould be performed as soon as possible.

Methods
f surgical e,acuation of an acute S'H in a comatose patient AGCS C 5B is indicatedD it s"ould be performed using a craniotom! >it" or >it"out bone flap remo,al and duraplast!.

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Surgical Management of Traumatic Parenchymal Lesions

Indications
#atients >it" parenc"!mal mass lesions and signs of progressi,e neurological deterioration referable to t"e lesionD medicall! refractor! intracranial "!pertensionD or signs of mass effect on computed tomograp"ic ACTB scan s"ould be treated operati,el!. #atients >it" Glasgo> Coma Scale AGCSB scores of + to 0 >it" frontal or temporal contusions greater t"an ;: cm3 in ,olume >it" midline s"ift of at least & mm and3or cisternal compression on CT scanD and patients >it" an! lesion greater t"an &: cm3 in ,olume s"ould be treated operati,el!. #atients >it" parenc"!mal mass lesions >"o do not s"o> e,idence for neurological compromiseD "a,e controlled intracranial pressure A C#BD and no significant signs of mass effect on CT scan ma! be managed nonoperati,el! >it" intensi,e monitoring and serial imaging.

Timing and Methods

Craniotom! >it" e,acuation of mass lesion is recommended for t"ose patients >it" focal lesions and t"e surgical indications listed abo,eD under ndications. Bifrontal decompressi,e craniectom! >it"in %0 "ours of in*ur! is a treatment option for patients >it" diffuseD medicall! refractor! posttraumatic cerebral edema and resultant intracranial "!pertension. 'ecompressi,e proceduresD including subtemporal decompressionD temporal lobectom!D and "emisp"eric decompressi,e craniectom!D are treatment options for patients >it" refractor! intracranial "!pertension and diffuse parenc"!mal in*ur! >it" clinical and radiograp"ic e,idence for impending transtentorial "erniation.

Surgical Management of Posterior Fossa Mass Lesions

Indications
#atients >it" mass effect on computed tomograp"ic ACTB scan or >it" neurological d!sfunction or deterioration referable to t"e lesion s"ould undergo operati,e inter,ention. Mass effect on CT scan is defined as distortionD dislocationD or obliteration of t"e fourt" ,entricleE compression or loss of ,isuali=ation of t"e basal cisternsD or t"e presence of obstructi,e "!drocep"alus. #atients >it" lesions and no significant mass effect on CT scan and >it"out signs of neurological d!sfunction ma! be managed b! close obser,ation and serial imaging.

Timing
n patients >it" indications for surgical inter,entionD e,acuation s"ould be performed as soon as possible because t"ese patients can deteriorate rapidl!D t"usD >orsening t"eir prognosis.

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Methods

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Suboccipital craniectom! is t"e predominant met"od reported for e,acuation of posterior fossa mass lesionsD and is t"erefore recommended.

Surgical Management of Depress Cranial Fractures

Indications
#atients >it" open AcompoundB cranial fractures depressed greater t"an t"e t"ic?ness of t"e cranium s"ould undergo operati,e inter,ention to pre,ent infection. #atients >it" open AcompoundB depressed cranial fractures ma! be treated nonoperati,el! if t"ere is no clinical or radiograp"ic e,idence of dural penetrationD significant intracranial "ematomaD depression greater t"an 1 cmD frontal sinus in,ol,ementD gross cosmetic deformit!D >ound infectionD pneumocep"alusD or gross >ound contamination. 2onoperati,e management of closed AsimpleB depressed cranial fractures is a treatment option.

Timing
Earl! operation is recommended to reduce t"e incidence of infection.

Methods
Ele,ation and debridement is recommended as t"e surgical met"od of c"oice. #rimar! bone fragment replacement is a surgical option in t"e absence of >ound infection at t"e time of surger!. All management strategies for open AcompoundB depressed fractures s"ould include antibiotics.

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Post Traumatic Mass !olume Measurement in Traumatic "rain #n$ury Patients

1. 'irect ,olumetric measurement >it" imaging soft>are using a modern computer tomograp"ic CT scanner is t"e gold standard. T"is "as been applied onl! on rare occasions. ;. T"e Fellipsoid met"odF >as de,eloped to calculate t"e ,olume of arterio,enous malformations. t is based on t"e concept t"at t"e ,olume of an ellipsoid is appro/imatel! one("alf of t"e ,olume of t"e parallelepiped Aa si/( faced pol!"edronD all of >"ose faces are parallelograms l!ing in pairs of parallel planesB into >"ic" it is placed. B! measuring t"ree diameters of a gi,en lesion in t"e arterial p"ase of an angiogramD a parallelepiped is constructedD and its ,olumeD di,ided in "alfD is close to t"e actual ,olume of t"e malformation. B! e/tending t"is concept from angiograp"! to CT scanningD calculation of space(occup!ing lesions becomes possible. T"e FABCF met"od "as been described b! <ot"ari et al. for t"e measurement of intracerebral "emorr"agesD and is also based on t"e concept of measuring t"e ,olume of an ellipsoid. T"e formula for an ellipsoid is@ )e G %33 H AA3;B AB3;B AC3;B >"ere AD BD and C are t"e t"ree diameters. For H G 3D t"e formula becomes )e G ABC3; T"e ,olume of an intracerebral "emorr"age can be appro/imated b! follo>ing t"e steps listed belo>@ dentif! t"e CT slice >it" t"e largest area of "emorr"age ASlice 1B A@ measure t"e largest diameterD A. B@ measure t"e largest diameter 5:I to A on t"e same sliceD B. C@ count t"e number of 1:(mm slices. Compare eac" slice >it" slice 1. f t"e "emorr"age is greater t"an .&J compared >it" slice 1D count t"e slice as 1. f t"e "emorr"age is ;& to .&JD count t"e slice as :.&. f t"e "emorr"age less t"an ;&JD do not count t"e slice. Add up t"e total C. 3. More recentl!D t"e FCa,alieri direct estimatorF met"od "as been introduced. t brea?s do>n t"e lesion on t"e CT scan into a corresponding number of points. T"e ,olume of a lesion is t"e product of t"e sum of t"e points t"at fall into t"e lesionD t"e area associated >it" eac" pointD and t"e distance bet>een t"e scan slices. A grid t"at is used to determine t"e number of points can be obtained b! p"otocop!ing a template pro,ided in t"e original article or b! preparing a uniforml! spaced point grid b! computer.

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E%aluation of Findings &ele%ant Computed

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Tomographic

Scan

Computed tomograp"ic ACTB scanning is t"e imaging modalit! of c"oice for traumatic brain in*ur! because of its >idespread a,ailabilit!D t"e rapid imaging timeD t"e lo> associated costsD and its safet!. CT scanning measures t"e densit! of tissues using /( ra!s. To standardi=e t"e imaging procedureD &(mm slices s"ould be obtained from t"e foramen magnum to t"e sella and 1:(mm slices s"ould be obtained abo,e t"e sellaD parallel to t"e orbitomeatal line. T"e follo>ing earl! CT scan findings correlate >it" outcome@ Status of t"e basal cisterns. Midline s"ift. Subarac"noid "emorr"age in t"e basal cisterns.

Basal Cisterns at the Midbrain Level

Compressed or absent basal cisterns indicate a t"reefold ris? of raised intracranial pressure and t"e status of t"e basal cisterns is related to outcome. T"e degree of mass effect is e,aluated at t"e le,el of t"e midbrain. Cerebrospinal fluid cisterns around t"e midbrain are di,ided into t"ree limbsD one posterior and t>o laterall! AFig. 1B. Eac" limb can be assessed separatel! as to >"et"er or not it is open or compressed. Basal cisterns can be@ 9pen Aall limbs openB. #artiall! closed Aone or t>o limbs obliteratedB. Completel! closed Aall limbs obliteratedB.

Midline Shift at the Foramen of Monro

T"e presence of midline s"ift is in,ersel! related to prognosis. Ho>e,erD interaction e/ists >it" t"e presence of intracranial lesions and ot"er CT parameters1. Midline s"ift at t"e le,el of t"e foramen of Monro s"ould be determined b! first measuring t"e >idt" of t"e intracranial space to determine t"e midline AFAFB. 2e/tD t"e distance from t"e bone to t"e septum pellucidum is measured AFBFB AFig. ;B. T"e midline s"ift can be determined b! calculating@ Midline s"ift G AA3;B ( B

Traumatic Subarachnoid Hemorrhage

Traumatic subarac"noid "emorr"age occurs in bet>een ;+ and &3J of all patients >it" se,ere traumatic brain in*ur!. Mortalit! is increased t>ofold in t"e presence of traumatic subarac"noid "emorr"age. T"e presence of subarac"noid "emorr"age in t"e basal cisterns carries a positi,e predicti,e ,alue of unfa,orable outcome of appro/imatel! .:J.

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Diffuse !onal In"ury

Adam's (europathological )rading * Classification of DA#
Grade @ A/onal n*ur! of #arasagittal >"ite matter of cerebral "emisp"ere Grade @ Grade K Focal $esion in Corpus Callosum Grade @ Grade K Focal $esion in Cerebral #eduncle

Diffuse A+onal #n$ury , &adiological )rading

CT Finding Grade Grade Grade AS>ellingB 2o Mes Mes Grade )

'iagnostic Criteria

Hematoma L ;& ml An! Abnormalities

2o 2o

2o Mes 2o

2o Mes Mes

Compression of Brain 2o Stem Cisterns Midline S"ift L & mm 2o ncidence A9,erall &+ JB Mortalit! -ate A9,erall ;% JB .J 1: J

2o ;% J 1% J

2o ;1 J 3% J

Mes %J &+ J

Traumatic Loss of Consciousness

N N N N C + "ours @ Concussion + to ;% "ours @ Mild DAI Coma L ;% "ours >it"out decerebration @ Moderate DAI Coma L ;% "ours >it" decerebration or flaccidit! @ Severe DAI 4 &: J Mortalit!

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Grading Systems
Cantu and Colorado Head #n$ury )rading Systems Grade Grade 8mild Grade ;8moderate Grade 38se,ere Cantu 2o $9C #TA C 3: min $9C C & min #TA L 3: min $9C L & min #TA L ;% "rs Colorado 2o $9C Confusion >3o amnesia 2o $9C Confusion >it" amnesia $9C

Cantu-s )uidelines for &eturn to Play after Concussion

Grade First Concussion Second Concussion Ma! return to pla! in ; >ee?s if as!mptomatic for 1 >ee? Third Concussion Terminate seasonD alt"oug" patient ma! return to pla! ne/t season if as!mptomatic

Grade 8 Ma! return to pla! if mild as!mptomatic for 1 >ee?

Grade ;8 Ma! return to pla! after Minimum of 1 mont" out of Same as abo,e moderate as!mptomatic for 1 competitionD ma! return to pla! t"en if >ee? as!mptomatic for 1 >ee? and consider termination of season dependent on s!mptoms Grade 38 Minimum of 1 mont"D se,ere ma! return to pla! if as!mptomatic for 1 >ee? Terminate seasonD alt"oug" ma! return to pla! ne/t season if as!mptomatic

.hen to &eturn to Play/Colorado Medical Society )uidelines

Grade of Concussion: Grade 1 concussion Multiple Grade 1 concussions Grade 2 concussion Multiple Grade 2 concussions Grade 3brief loss of consciousness (seconds) Grade 3prolonged loss of consciousness (minutes) Multiple Grade 3 concussions Return to play only after being asymptomatic with normal neurologic assessment at rest with exercise: 15 minutes or less 1 week 1 week 2 weeks 1 week 2 weeks 1 month or longer, based on decision of evaluating physician

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C#M
"reathing Patterns
'ifferent abnormal respirator! patterns are associated >it" pat"ologic lesions As"aded areasB at ,arious le,els of t"e brain. Tracings b! c"est(abdomen pneumograp"!D inspiration reads up. AAB C"e!ne(Sto?es respiration is seen >it" metabolic encep"alopat"ies and >it" lesions t"at impair forebrain or diencep"alic function. ABB Central neurogenic "!per,entilation is most commonl! seen in metabolic encep"alopat"iesD but ma! rarel! be seen in cases of "ig" brainstem tumors. ACB ApneusisD consisting of inspirator! pausesD ma! be seen in patients >it" bilateral pontine lesions. A'B Cluster breat"ing and ata/ic breat"ing are seen >it" lesions at t"e pontomedullar! *unction. AEB Apnea occurs >"en lesions encroac" on t"e ,entral respirator! group in t"e ,entrolateral medulla bilaterall!.

(From Saper, C. Brain stem modulation of sensation, movement, and consciousness. Chapter 45 in: Kandel, ER, Schwart , !", !essel, #$. %rinciples of &eural Science. 4th ed. $c'raw("ill, &ew )or*, +,,,, pp. -./01,1. B2 permission of $c'raw("ill.)

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Pupils

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3From Saper, C. Brain stemmodulation of sensation,movement, and consciousness. Chapter 45 in: Kandel, ER, Schwart , !", !essel, #$. %rinciples of &eural Science. 4th ed. $c'raw("ill, &ew )or*, +,,,, pp. -./01,1. B2 permission of $c'raw("ill.4

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IC$
Compliance and Elastance

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Types of Edema

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!icious Cycle of #CP

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#CP .a%es

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Abnormal .a%es

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IIH
The modified Dandy criteria suggested by .all
1. Signs and s!mptoms of increased intracranial pressure ;. Absence of locali=ing neurological findings A2ote@ abducens paresis is nonlocali=ing andD t"usD allo>edB 3. Absence of deformit!D displacementD and obstruction of t"e ,entricular s!stem and ot"er>ise normal results on neurodiagnostic studiesD >it" t"e e/ception of an increase in cerebrospinal fluid pressure Agreater t"an ;& cm H;9E pressures bet>een ;: and ;& cm H;9 pro,ide less certaint!B. %. 7a?efulness and alertness &. 2o ot"er cause of increased intracranial pressure present

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%ey #nline &esources for Medicos

!"st point #o"r Mobi$e / %ab$et on t&is Q' Co(e an( #o" can reac& t&e on$ine reso"rce. )*o nee( to remember $engt&# a((resses+. ,f Q' 'ea(er is not inb"i$t in #o"r &an(&e$( (e-ice. #o" can (own$oa( an app for free
Group Site and URL PG Target PG Preparation www.targetpg.com www.targetpg.in QR Code

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Book Re iews and Latest Boosk www!"edicalbooks!in

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$or %octors

#$ter MBBS www.aftermbbs.com

#$ter MBBS at Facebook www!$acebook!co"%a$ter"bbs

&e'ical an' (egal

%octors an' (aw Court &udg"ents regarding Medical #d"issions www!doctorsandlaw!co"

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Multi'le ring(enhancing lesions of the brain

Causes of multiple ring enhancing lesions of the brain

Differential diagnosis of multiple enhancing lesions of the brain according to the si0e of the lesions

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Modified diagnostic criteria for neurocysticercosis

Methods used for establishing the diagnosis in patients 1ith multiple enhancing lesions of the brain

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Algorithm for the differential diagnosis in an immunocompetent patient 1ith multiple enhancing lesions of the brain

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Algorithm for the differential diagnosis in a human deficiency %irus infected patient 1ith multiple enhancing lesions of the brain

"rain Abscess Stages

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)ndosco'y
Entry Points and Tumour Location
$ES 92 $9CAT 92 SO TAB $ TM F9E2'9SC9# C B 9#SM Anterior t"ird ,entricle 1 cm posterior to t"e KKK coronal suture ;(3 cm lateral to t"e midline Floor of t"e t"ird ,entricle 1 cm anterior to t"e KKK coronal suture ;(3 cm lateral to t"e midline #osterior t"ird ,entricle . cm posterior to t"e KKK nasion ; cm lateral to t"e midline Anterior lateral ,entricle 0 cm posterior to t"e KKK nasion %(+ cm lateral to t"e midline Atrium of t"e lateral 0 cm posterior to t"e KK ,entricle midline 1 cm lateral to t"e midline ,s. t"e superior parietal lobule Temporal "orn Superior parietal lobule K 9ccipital "orn 0 cm posterior to t"e K midline 1 cm lateral to t"e midline Fourt" ,entricle 1: cm posterior to t"e K3: nasion ; cm lateral to t"e midline ,s. suboccipital OSOA$ E2T-M #9 2T

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&adiation
The Four &s of &adiobiology
C92CE#T -AT 92A$E -eo/!genation H!po/ic cells or "!po/emic areas >it"in tumors are relati,el! more resistant to a gi,en dose of radiation. '!namic biologic c"anges >it"in t"e tumor suggest t"at cells t"at are "!po/ic during one fraction ma! be less so during subsePuent fractionsD and fractionation >ill t"us increase t"e c"ances of desired effect on t"e largest number of cells. -eassortment A gi,en dose of p"otons is most li?el! to irre,ersibl! damage '2A if t"e cell is in mitosis and t"e '2A is condensed as c"romosomes. Cells t"at are not in mitosis during one fraction ma! be so during subsePuent fractionsD so fractionation >ill increase t"e c"ances of desired effect on t"e largest number of cells. -epair T"e time bet>een fractions allo>s for repair of sublet"all! damaged cells before t"e ne/t dose. T"is is an ad,antage for fractionation onl! if normal tissue in t"e treatment ,olume is more efficient at t"is process t"an tumor cellsD >"ic" is usuall! t"e case. -epopulation T"e time bet>een fractions allo>s for replacement of lost cells before t"e ne/t dose. T"is is an ad,antage for fractionation onl! if normal tissue in t"e treatment ,olume is more efficient at t"is process t"an tumor cellsD >"ic" ma! or ma! not be t"e case for a gi,en tumor t!pe.

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Stro*e
Cerebral "lood Flo1 Thresholds

Cerebral blood $low t'res'olds $or critical $unctions! (#dapted $ro" #strup &) S*"on L) Branston +M) et al! Cortical e oked potential and e,tracellular -. and /. at critical le els o$ brain isc'e"ia! Stroke! 012234560762!8

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Code Stro2e Algorithm

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#mmediate Diagnostic Studies3 E%aluation of a Patient 1ith Suspected Acute #schemic Stro2e

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Characteristics of Patients 1ith #schemic Stro2e .ho Could "e Treated 1ith Tissue Plasminogen Acti%ator

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Develo'mental Milestones
)ross Motor Milestones
Milestones Head stead! in sitting #ull to sitD no "ead lag Hands toget"er in midline As!mmetric tonic nec? refle/ gone Sits >it"out support -olls bac? to stomac" 7al?s alone -uns ;.: 3.: 3.: %.: +.: +.& Developmental Implications Allo>s more ,isual interaction Muscle tone Self4disco,er! C"ild can inspect "ands in midline ncreasing e/ploration Truncal fle/ionD ris? of falls

1;.: E/plorationD control of pro/imit! to parents 1+.: Super,ision more difficult

Fine Motor Milestones

Milestones Grasps rattle -eac"es for ob*ects #almar grasp gone Transfers ob*ect "and to "and T"umb4finger grasp Turns pages of boo? Scribbles Builds to>er of t>o cubes Builds to>er of si/ cubes 3.& %.: %.: &.& 0.: 1;.: Developmental Implications 9b*ect use )isuomotor coordination )oluntar! release Comparison of ob*ects Able to e/plore small ob*ects

ncreasing autonom! during boo? time 13.: )isuomotor coordination 1&.: Oses ob*ects in combination ;;.: -ePuires ,isualD grossD and fine motor coordination

Communication and Language

Milestones Developmental Implications

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MCQ Points
Smiles in response to faceD ,oice 1.& Monos!llabic babble n"ibits to FnoF Follo>s one4step command >it" gesture Follo>s one4step command >it"out gesture Ae.g.D FGi,e it to meFB Spea?s first real >ord Spea?s %(+ >ords Spea?s 1:41& >ords Spea?s t>o4>ord sentences Ae.g.DFMomm! s"oeFB +.: ..: ..:

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C"ild more acti,e social participant E/perimentation >it" soundD tactile sense -esponse to tone Anon,erbalB 2on,erbal communication

1:.: )erbal recepti,e language 1;.: Beginning of labeling 1&.: AcPuisition of ob*ect and personal names 10.: AcPuisition of ob*ect and personal names 15.: Beginning grammatici=ationD corresponds >it" &:K >ord ,ocabular!

Cogniti%e Milestones
Milestones Developmental Implications

Stares momentaril! at spot >"ere ;.: $ac? of ob*ect permanence Aout of ob*ect disappeared Ae.g.D !arn ball sig"tD out of mindB droppedB Stares at o>n "and Bangs t>o cubes Onco,ers to! Aafter seeing it "iddenB Egocentric pretend pla! Ae.g.D pretends to drin? from cupB Oses stic? to reac" to! %.: Self4disco,er!D cause and effect 0.: Acti,e comparison of ob*ects 0.: 9b*ect permanence 1;.: Beginning s!mbolic t"oug"t 1..: Able to lin? actions to sol,e problems

#retend pla! >it" doll Agi,es doll 1..: S!mbolic t"oug"t bottleB

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