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OPD : 17-Sep-2026 11:20AM Demographic Details Child's Name: Shivam Mittal Age: 8 Month 6 Days Gender: Male DOB: 2025-06-13 Contact: 7828262942 Investigations done: EEG (1.5 y): Focal epileptiform activity (Left frontal spike and wave discharges) Interaction history: Eye contact: Suboptimal Behavioral history: Birth & Perinatal History: Antenatal History Natal and Postnatal History: Past history: Investigations done- Family history: Developmental History: Gross Motor Neck holding: Achieved Age of attainment: Partial Fine Motor Language Expressive:- Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social 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 : 1. Unoccupied Academic History: Diet History: Food preferences: Mixed Food allergies: No Sleep History Total sleep duration (night): 10 -11 hours Afternoon nap: Yes Duration of Afternoon nap: 30 minutes Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Height: 77 cm Head circumference: 43 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypertonia Deep tendon reflexes: KJ-3+/3+, AJ- 3+/3+ Superficial reflexes: Plantars- B/l Extensors Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Spasticity + (UL>LL), DTR- Brisk, Pull to sit- head lag+. Infrequent jerky movements noted in right lower limb, head Advice Intervention plan: IDP+ PT 5/week Medications: Syp Zenoxa (300mg/5ml) BD, Syp Calyumm P 5ml BD, Syp Baclof (5mg/5ml) 1.5 ml TDS General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 17-Sep-2026 11:20AM Demographic Details

Child's Name: Shivam Mittal
Age: 8 Month 6 Days
Gender: Male
DOB: 2025-06-13
Contact: 7828262942
Investigations done: EEG (1.5 y): Focal epileptiform activity (Left frontal spike and wave discharges)

Interaction history:

Eye contact: Suboptimal

Behavioral history:

Birth & Perinatal History: Antenatal History

Natal and Postnatal History:

Past history:

Investigations done-

Family history:

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: Partial

Fine Motor

Language

Expressive:-

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

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 : 1. Unoccupied Academic History:

Diet History:

Food preferences: Mixed
Food allergies: No

Sleep History

Total sleep duration (night): 10 -11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 30 minutes

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Height: 77 cm Head circumference: 43 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypertonia
Deep tendon reflexes: KJ-3+/3+, AJ- 3+/3+
Superficial reflexes: Plantars- B/l Extensors

Oromotor Examination

Drooling: Yes
Chewing: Improper
Swallowing: Improper
Sucking: Improper

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

Impression: Spasticity + (UL>LL), DTR- Brisk, Pull to sit- head lag+. Infrequent jerky movements noted in right lower limb, head

Advice

Intervention plan: IDP+ PT 5/week
Medications: Syp Zenoxa (300mg/5ml) BD, Syp Calyumm P 5ml BD, Syp Baclof (5mg/5ml) 1.5 ml TDS
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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