CEREBRAL PALSY

MASTER: S AGE: 4 Years (D.O.B. 14/10/2009) SEX: Male ADD: Thiruvatriyur, Chennai INFORMANT: Mother (Reliability Good)

CHIEF COMPLAINTS:
Inability to use left upper limb and inability to walk, Delayed developmental milestones, Seizures since 2 years of age.

Antenatal
1st TRIMESTER Registered and immunized at a private hospital in Banglore. Conceived spontaneously after 5yrs of 1st child birth Folic acid supplements were taken. No H/o fever, rash , lymphadenopathy ,arthralgia, no exposure to drugs and radiations.
2nd TRIMESTER Quickening felt at 5 months; TT - 2 doses were given; Iron and Calcium supplements were taken. No h/o increase in blood sugars and blood pressure. Anomaly scan was done and was said to be normal. Had an emotional impact due to her husbands heart attack.

3rd TRIMESTER Fetal movements perceived; No h/o bleeding per vaginum. Poor weight gain during pregnancy

Natal: At 38 weeks, mother perceived decreased fetal movements for which she was taken to hospital and was advised emergency caesarian section (breech presentation),
Baby did not cry immediately after birth, required some tactile stimulation and oxygen, He had a Birth wt of 1.82 kg,was told to have had head circumference smaller for age,without any obvious congenital malformation, Passed urine and meconium within 48hours. Neonatal: Was in I.C.U. for 10 days, required oxygen support for 1 day Tube feeds -- direct breast feeds. No h/o Neonatal seizure, jaundice, fever and irritability. Discharged on day 15 of life with weight of 2 kg.

History Of Presenting Illness:

INABILITY TO USE LEFT UPPER LIMB AND BOTH LOWER LIMBS:
H/o fisting of upper limb; scissoring of lower limbs Had difficulty in changing Diapers; Mother gives a history of increased right hand usage since 5 months UL: RT: He is able to feed himself with spilling LT: he is not able to take objects from floor RT: able to lift his hand above shoulder; LT: not able to do so LOWER LIMB: Not Able to Stand/Walk but drags himself over his bottom. C/o abnormal posturing of lower limbs

SEIZURE: Duration: 2 years

Mother C/o multiple jerky movements of the body. around 10 to 15 episodes per day, each lasting for 2 to 3 sec, without any postictal drowsiness or incontinence. He is under anti-convulsant medication

DEVELOPMENTAL HISTORY
DOMAINS GROSS MOTOR FINE MOTOR EXPECTED
Hop or ride a tricycle, climb upstairs and downstairs with one leg Draws +, Copies or makes steps

ACHIEVED
Not able to stand or walk

LANGUAGE
SOCIAL HEARING AND VISION

Reaches for objects Feeds himself using spoon with spilling Tell a story Interacts with mother by cooing Plays co-operatively in a Prefers mother and group babbles Responds to mother and Listens and replies: Identifies basic colours turn towards sound
He gets excited looking at his mother

H/O CRANIAL NERVES: Able to follow light; H/o abnormal eye position No h/o deviation of angle of mouth; No h/o facial asymmetry; Responds to call; No h/o regurgitation of foods; Able to move his head from side to side, No h/o deviation of tongue on protrusion. H/O SENSORY SYSTEM: Cries when he gets hurt while dragging over his bottom.

H/O ANS: Bowel control attained . bladder control not attained OTHER: No H/O trauma.

H/O COMPILCATIONS:
NO -previous surgery , -dental caries,, -constipation; bed sores. Hardening of skin in the left foot

Past H/O:
Child was admitted at 1 year of age, was diagnosed to have pneumonia for which i.v. medications were given for 5 days. Subsequently the condition of the child improved.

Immunization H/O:
Appropriately immunized for age as per EPI. B.C.G. scar present. Typhoid vaccine given other optional vaccines not given . Last vaccination was given at 2 years of age.

Dietary H/O:
Exclusively breast fed up to 6 months of age, subsequently started on complementary feeds. C/o difficulty in feeding semi-solids Now He is not able to take solid foods.

24 - HR RECALL PROTEIN CALORIE

EXPECTED OBSERVED
20g 1300kcals 20g 1250kcals

GAP
50

Family H/O: 38 years 29 years

10 years

4 years

No h/o similar complaints in the family. No H/O contact with a known case of TB; anyone in the family receiving medicine from DOTS centre. Socioeconomic H/O: E+ O+ I= 14 Lower middle class III of Modified Kuppuswamy Scale.

Summary:
4 year old child 2nd born to non consanguineous parents with significant antepartum and peripartum problems, DELAYED DEVELOPMENTAL MILESTONES with right handedness since 5 months of age, with Lt Eye Squint, Seizure and on antiepileptic medication, I would like to think in terms of a Chronic Non Progressive Motor Disorder, probably CEREBRAL PALSY.

GENERAL EXAMINATION
Child is sitting comfortably in the mothers lap, is cheerful, has paucity of movements on the left upper and both lower limbs. Drooling of saliva present.

No Pallor No Icterus No Cyanosis No Clubbing No Generalised Lymphadenopathy No Edema.

PARAMETERS

OBSERVED

EXPECTED

IMPRESSION

LENGTH

99

100

99

Normal
As per McLarens classification

WEIGHT

13

16

81.5

Normal
As per IAP classification

HC

45

50

<3rd percentile Microcephaly

MAC

14.5

Normal

VITALS:
PULSE: Rate: 94/min, Rhythm: regular, Volume: normal, No specific character No radio-radial delay, radio-femoral dealy Peripheral pulses well felt. R.R.: 24/min, Thoracoabdominal B.P.: 100/60mm hg in Right Upper limb, Supine position C.F.T.: < 3 sec Temperature: 990F

Head To Toe Examination:

Head size appears to be smaller for age. No dysmorphic facies No conjunctival/corneal xerosis,bitot spot Squint of the left eye present No dental carries, swollen gums, cheilosis, angular stomatitis. No skin ulcers, injury marks or healing skin lesions No involuntary movements seen No spinal deformity Equinus deformity of foot noted more on left side than right Callosities present on the dorsum of foot more on left side than right No Neurocutaneous markers.

SYSTEMIC EXAMINATION - CNS

HIGHER MENTAL FUNCTION:
Higher mental function of the child could not be checked, but the child is comfortable with the mother, gets irritated when approached by outsiders. Child uses his right hand for all activities and not the left hand. Consciousness could not be checked Oriented to parents but not to time and place Memory Cant be checked Irritable when approached by strangers Speech - Babbles

CRANIAL NERVE EXAMINATION

1st Nerve : could not be checked

2nd Nerve: Visual acuity - could not be checked but able to recognize mother Light Reflex present
3rd, 4th & 6th Nerve: dolls eye movement present in both sides. 5th Nerve: Conjunctival reflex +, Pain sensation over the face ellicitable 7th Nerve: No forehead wrinkling while crying No deviation of angle of mouth

8th Nerve: He is able to respond to sound,and his name when called upon. Hearing distraction test present 9th, 10th Nerve: uvula is central, Gag reflex present. 11th Nerve: able to shrug his shoulder against gravity, move his head from side to side 12th Nerve: No fasciculations,wasting of tongue noted. No deviation of tongue noted on protrusion.

MOTOR SYSTEM EXAMINATION:

POSTURE: Both upper limb is in flexion at the elbow joint with hand open; Both lower limbs are in partial flexion at the hip and knee joint: Equinus deformity - both ankles. BULK Midarm Forearm Rt 15 cm 13 cm Lt 15 cm 13 cm

Thigh
Leg TONE:

24 cm
16 cm

24 cm
16 cm

Hypertonia in Lt upper limb and both lower limbs

Spastic type

POWER
Flexion Extension Abduction Adduction

Rt
Shoulder Joint 4/5 4/5 4/5 4/5 Elbow Joint 4/5 4/5 Wrist Joint 3/5 3/5

Lt
3/5 3/5 3/5 3/5

Flexion Extension

3/5 3/5

Flexion Extension

3/5 3/5

Flexion Extension Abduction Adduction

3/5 3/5 3/5 3/5

Hip Joint

3/5 3/5 3/5 3/5

Flexion Extension

3/5 3/5

Knee Joint

3/5 3/5

Dorsiflexion Plantarflexion Inversion & Eversion

Ankle Joint 3/5(restricted) 3/5(restricted) not able to check

not able to check not able to check not able to check

REFLEXES
Biceps Triceps Supinator Knee Ankle

Rt

Lt

Brisk Brisk Brisk EXAGGERATED ELICITED

Brisk Brisk Brisk EXAGGERATED ELICITED

Superficial reflexes: Conjunctival Abdominal Cremasteric Plantar Primitive reflex: Palmomental Reflex present

Rt Present Present Present Extension

Lt Present Present Present Extension

Sensory System Examination: Complete systemic examination could not be done but response to touch and pain sensation could be elicited.

Cerebellar Signs:
No hypotonia, pendular knee jerk, No Past pointing while reaching out for objects Meningeal Signs: No neck stiffness Spine: Spine appears normal

OTHER SYSTEMS R.S: B/L air entry present, normal bronchovesicular breath sound heard, no added sound. C.V.S.: S1/S2 heard, no murmur . P/A: Soft, no organomegaly bowel sounds present.

FINAL DIAGNOSIS:
Spastic Triplegia, secondary to antenatal and perinatal insult, Grade 4 functional Disability, Microcephaly, seizure disorder, Global developmental delay, Left eye squint/Malalignment, with Equinus deformity, without any evidence of protein energy malnutrition/ micronutrient deficiency.

CEREBRAL PALSY
Cerebral Palsy is a static encephalopathy. It is defined as a Non-progressive disorder of posture and movement. Often assosciated with epilepsy and abnormalities of speech, vision and intellect resulting from a defect or lesion of the developing brain. It consist of: a. motor handicap. b. non-motor handicap ( 1).

INVESTIGATIONS
CT MRI
(preferred modality)

Considering DDs: a. urine for metabolic screening. b. chromosomal analysis.

TREATMENT

COMPREHENSIVE ONGOING MULTIDISCIPLINARY NEUROREHABILITATION PROGRAMME

TEAM MANAGEMENT
Pediatric neurologist. Physiotherapist. Occupational therapist. Orthopedic/Neuro surgeon. Speech therapist Social workers. Nutritionist.

CEREBRAL PALSY

MEDICATIONS
Anti-convulsants: Valproate Carbemezapine, Phenytoin, Phenobarbitone Anti-spastic drugs: Baclofen, Dantrolene sodium, Benzodiazepines.

Anti-reflux drugs: Metaclopromide, Lansoprazole.

OVERVIEW

The incidence of cerebral palsy has remained virtually unchanged over the past 40 years at approximately 2.5 per 1000 live births

ETIOLOGY
Prenatal Brain malformations In utero stroke Congenital cytomegalovirus infection Perinatal Hypoxic ischemic encephalopathy Viral encephalitis Meningitis Postnatal Accidental head trauma Anoxic insult Child abuse

Prematurity

DIAGNOSIS
cerebral palsy remains a clinical diagnosis, and represents a continuing role for the art of medicine. The essential findings include: Delayed motor milestones Abnormal muscle tone Hyperreflexia Absence of regression or evidence of a more specific diagnosis. These clinical findings should be present to the degree that the child appears unlikely to outgrow these findings.

TYPES OF CP
Spastic Hemiplegia (unilateral involvement) Diplegia (disporprotionate lower extremity involvement) Quadriplegia (total body involvement) Dyskinetic Choreoathetoid Dystonic Hypotonic Mixed

PRESENTING HISTORY
Describe childs problems in terms of: Reasons for current admission motor and non-motor Developmental sequence complications

milestones in correct

Treatment received
Social issues

IMPORTANT POINTS IN HISTORY:

PREGNANCY:
Prematurity, Maternal diseases (uncontrolled diabetes, maternal hypertension, poor weight gain). Fever, rash, lymphadenopathy. Drugs or exposure to radiation Emergency C/S. Syntocinon usage Prolonged rupture of membrane. Prolonged 2nd stage of labour. Delayed weak cry, delayed poor sucking, Hyperbilirubinemia, neonatal seizures, RDS, Trauma, meningitis

DELIVERY:

AFTER BIRTH: Prematurity signs/ small size baby

RISK FACTORS FOR CP:

Family history of CP,

Malpresentation(breech)
Low socioeconomic status,

Choroiamniotis,
Persistent LOW APGAR SCORE at 20 minutes

Prolonged second stage of labour.

EXAMINATION
Head circumference. Eyes for squint and nystagmus. Anthropometry. Tone active and passive methods. 180 degrees. Demonstrate hyperreflexia Look for persistance of primitive reflexes Look for dysmorphic features/neuro-cutaneous markers for other causes

GROSS MOTOR FUNCTIONAL

CLASSIFICATION SYSTEM
LEVEL
I
II

FUNCTION
Ambulatory in all settings
Walks without aides but has limitations in community settings Walks with aides Mobility requires wheelchair Dependent for mobility

III IV V

HOW TO PRESENT
For instance;
A patient whose all 4 limbs are affected and found to be spastic with squint, microcehaly on examination and history revealed difficult labor and treatment for respiratory distress.

Would Be Classifed As:

Spastic quadriplegic CP due to birth asphyxia and possible microcephaly, Mental Retardation, squint and aspiration pneumonia.

THE END