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Patient Details


Demographic Details Child's Name: Jiyanshi Sahu Age: 3 Year 4 Month 18 Days Gender: Female DOB: 2022-10-31 Mother’s age (years): 33 years Mother’s occupation: Homemaker Father’s age (years): 36 years Father’s occupation: Business Type of family: Joint Number of family members: 10 Number of siblings: 2 Details of siblings (Age and sex): 1-10 yr, 2- 5 months; females Address: Mahova Contact: 6386490072 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Behavioral concerns Interaction history: Eye contact: Sustained Behavioral history: Stubbornness Aggression Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: Around 2.5 kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: Yes Seizures: Yes Others: 1st episode- In June 2025: Abnormal body movements in the form of tonic seizure, with up rolling of eyeball, f/b LOC, not associated with Fever. 2nd episode in December of similar semiology. AEds were started Past/Current medications: Syp Levilex was started after 2nd episode. No seizures after December Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 months Roll over: Achieved Age of attainment: 5 months Sitting without support: Achieved Age of attainment: 6 months Standing without support: Achieved Age of attainment: 10 months Walking without support: Achieved Age of attainment: 12 months Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Achieved Age of attainment: 6 months Pincer grasp: Achieved Age of attainment: 12 months Language Receptive:- Joint attention: Achieved Age of attainment: 8 months Pointing: Achieved Age of attainment: 12 months Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 24 months Complete sentences: Achieved Age of attainment: 30 months Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 24 months Complete sentences: Achieved Age of attainment: 30 months Communication & Language Assessment Non-Verbal Communication Grading:- Following commands (gesture + verbal): 1-step Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 7 months Waving bye bye: Achieved Age of attainment: 9 months Comes when called: Achieved Age of attainment: 12 months Copying parents in tasks: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 4. Needs minimal assistance Bathing: 2. Started attempting Toilet training: 4. Needs minimal assistance Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : 5. Associative Academic History: Is child enrolled in school: No Diet History: Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 10-11 hours Afternoon nap: No Sleep disturbances: Yes Daily Screen Time Duration: <30 minutes Examination a. Vitals: b. Anthropometry: Weight: 12.2 Kg Head circumference: 49 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Consciousness: Conscious Orientation: Oriented to place and person Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Deep tandon reflexes: Normal Other: Tone normal Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Epilepsy Hopes from the consultation: Improvement in behavioral concerns (stubborness, temper tantrums) Advice Intervention plan: Parents counselled Follow up plan: Review after 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

Demographic Details

Child's Name: Jiyanshi Sahu
Age: 3 Year 4 Month 18 Days
Gender: Female
DOB: 2022-10-31
Mother’s age (years): 33 years
Mother’s occupation: Homemaker
Father’s age (years): 36 years
Father’s occupation: Business
Type of family: Joint
Number of family members: 10
Number of siblings: 2
Details of siblings (Age and sex): 1-10 yr, 2- 5 months; females
Address: Mahova
Contact: 6386490072
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Behavioral concerns

Interaction history:

Eye contact: Sustained

Behavioral history:

Stubbornness Aggression

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: Around 2.5 kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: Yes Seizures: Yes Others: 1st episode- In June 2025: Abnormal body movements in the form of tonic seizure, with up rolling of eyeball, f/b LOC, not associated with Fever. 2nd episode in December of similar semiology. AEds were started

Past/Current medications: Syp Levilex was started after 2nd episode. No seizures after December Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 months
Roll over: Achieved

Age of attainment: 5 months
Sitting without support: Achieved

Age of attainment: 6 months
Standing without support: Achieved

Age of attainment: 10 months
Walking without support: Achieved

Age of attainment: 12 months

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp: Achieved

Age of attainment: 6 months

Pincer grasp: Achieved

Age of attainment: 12 months

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 8 months
Pointing: Achieved

Age of attainment: 12 months
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 24 months

Complete sentences: Achieved

Age of attainment: 30 months

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 24 months

Complete sentences: Achieved

Age of attainment: 30 months

Communication & Language Assessment

Non-Verbal Communication Grading:-

Following commands (gesture + verbal): 1-step

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 7 months
Waving bye bye: Achieved

Age of attainment: 9 months
Comes when called: Achieved

Age of attainment: 12 months
Copying parents in tasks: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 4. Needs minimal assistance
Bathing: 2. Started attempting
Toilet training: 4. Needs minimal assistance
Dressing: 2. Started attempting
Undressing: 2. Started attempting

Type of Play : 5. Associative Academic History:

Is child enrolled in school: No

Diet History:

Food allergies: No
Junk food intake: Occasional

Sleep History

Total sleep duration (night): 10-11 hours
Afternoon nap: No
Sleep disturbances: Yes

Daily Screen Time

Duration: <30 minutes

Examination

a. Vitals:

b. Anthropometry:

Weight: 12.2 Kg Head circumference: 49 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Consciousness: Conscious
Orientation: Oriented to place and person

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Deep tandon reflexes: Normal
Other: Tone normal

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Proper
Sucking: Proper

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

Impression: Epilepsy

Hopes from the consultation: Improvement in behavioral concerns (stubborness, temper tantrums)
Advice

Intervention plan: Parents counselled
Follow up plan: Review after 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

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