OPD :
31-Jul-2026 12:59PM
Demographic Details
- :
Akay Singh
- :
2 Year 5 Month 4 Days
- :
Male
- :
2024-02-27
- :
Nuclear
- :
4
- :
1
- :
8 year old female
- :
Gwalior
- :
9304340285
- :
Camp
- :
Parents
Presenting Concerns
- :
Infantile spasms
Behavioral history:
Repetitive behaviors (RRBs):
Jumping, running to and fro, toe walking
Patterned behavior or activities:
Hyperactivity
Inattention
Impulsivity
Temper tantrums
Stubbornness
Mouthing of objects
Encopresis
Sensory Concerns:
- :
Seeks pressure
- :
Seeks movement
Birth & Perinatal History:
Antenatal History
- :
No
- :
Natural
-
High-risk factors in pregnancy:
- PIH
- Hypothyroidism
- :
1 Spontaneous abortion at 10 weeks. Child's neonatal screening for hypothyroidism- normal
Natal and Postnatal History:
- :
Institutional
- :
NVD
- :
Induced labor
- :
41 week
- :
2.7 Kg
- :
Cried immediately after birth
- :
No
- :
No
Past history:
:
Yes
:
Yes
:
Infantile spasms since 1 year age.
:
Nil
:
ACTH, Prednisolone, vigabatrin, topiramate
Investigations done-
:
Done
:
Normal
:
Done
:
Normal.
Family history:
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
4 months
-
:
Achieved
:
6 months
-
:
Achieved
:
9 months
-
:
Achieved
:
13 months
-
:
Achieved
:
16 months
-
:
Achieved
:
-
:
Achieved
:
-
:
Achieved
:
Fine Motor
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
12 months
:
Achieved
:
Language
Receptive:-
-
:
Achieved
:
9 months
-
:
Achieved
:
12 months
-
:
Not achieved
- :
Not following
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
12 months
Expressive:-
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
12 months
:
Regression of non verbal communication and speech, currently no meaningful words.
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Absent
- :
Absent
- :
Absent
- :
Absent
- :
Absent
- :
Nil
Answering Questions:-
:
Present
Social
-
:
Achieved
:
2 months
-
:
Achieved
:
8 months
Response to Name Call
Sitting tolerance- (in minutes)
- :
Doesnt sit at one place
- :
Doesnt sit at one place
ADL Skills (Age-appropriate)-
- :
2. Started attempting
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
Type of Play : 2. Isolated
Academic History:
- :
No
Diet History:
- :
Mixed
- :
No
- :
Occasional
Daily Screen Time
-
:
< 1 hour
- :
Mobile and TV
Examination
a. Vitals:
b. Anthropometry:
:
11 Kg
:
94 cm
:
45 cm
c. General Examination
:
Ab
:
Ab
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
- :
No
- :
Proper
- :
Proper
- :
Improper
- :
Improper
:
NAD
:
NAD
:
NAD
:
IESS
Advice
- :
EEG repeat. CBC, Ca, Vitamin D, LFT, RFT, vitamin B12 (Later)
- :
Continue same medications
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