OPD :
16-Feb-2026 10:39AM
Demographic Details
- :
Rashi Pal
- :
7 Year 8 Month 28 Days
- :
Female
- :
2018-05-19
- :
23
- :
Homemaker
- :
24
- :
Works in Nagpur
- :
Joint
- :
2
- :
1- 5 year old female, 2- 2 year old male
- :
Lalitpur
- :
9076966705
- :
Doctor
- :
Grandparents
- :
On Valproate (200mg/5ml) 22mg/kg/day, Phenobarbitobe (20mg/5ml) 1.5 mg/kg
- :
EEG (6 years)- Generlaised epiletiform discharges, MRI Brain (6 years)- WNL
Presenting Concerns
- :
Poor understanding, speech delay
Interaction history:
Behavioral history:
Mouthing of objects
Birth & Perinatal History:
Antenatal History
- :
No
- :
16
- :
Natural
Natal and Postnatal History:
- :
Institutional
- :
NVD
- :
FT
- :
Not known
- :
Cried immediately after birth
- :
No
- :
Delivered at the gate of labor room, H/o fall at the time of delivery.
Past history:
:
No
:
1st episode of abnormal body movements at 2 years age in all 4 limbs lasting for 1-2 minutes, f/b LOC for 1-2 minutes. Multiple episodes since then. Always withdrawal seizures. Last episode of similar semiology 4 days back. On antiepileptics
Investigations done-
:
Done
:
Reports not there
:
Done
:
Reports not there
Family history:
:
No
Developmental History:
Gross Motor
-
:
Achieved
:
4 months
-
:
Achieved
:
1 year age
-
:
Achieved
:
2 years
Fine Motor
:
Achieved
:
4 months
:
Achieved
:
6 months
:
Achieved
:
1 year
:
Not achieved
Language
Expressive:-
:
Achieved
:
2 months
:
Achieved
:
6 months
:
Not achieved
Expressive:-
:
Achieved
:
2 months
:
Achieved
:
6 months
:
Not achieved
Communication & Language Assessment
Non-Verbal Communication Grading:-
- :
Absent
Answering Questions:-
Social
-
:
Not achieved
-
:
Not achieved
-
:
Not achieved
-
:
Not achieved
Response to Name Call
Sitting tolerance- (in minutes)
ADL Skills (Age-appropriate)-
- :
2. Started attempting
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
- :
1. Dependent
Academic History:
- :
Yes
- :
Regular
- :
Junior high school
- :
1
- :
30 minutes to 1 hour
- :
Gadiyana, Lalitpur
- :
Doesnt sit in school. Caregivers accompany child in class
Diet History:
- :
Picky eating
- :
Daily
Sleep History
- :
10-11 hours , improper sleeping and waking time
- :
Yes
-
:
Yes
Daily Screen Time
Examination
a. Vitals:
b. Anthropometry:
:
18 Kg
:
46 cm
c. General Examination
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
- :
Tone- normal
- :
DTR- KJ 3+/3+, AJ- 2+/2+
Oromotor Examination
- :
Yes
- :
Proper
- :
Proper
:
NAD
:
NAd
:
NAD
:
Intellectual Disability. Epilepsy.
Advice
- :
Parents counselled.
- :
IQ testing, Language and speech evaluation.
- :
Continue antiepileptics .
-
General recommendation-
-
Zero Screen Time
-
Physical interactive play
-
No Junk food
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