HGD AND PEDIA CONDITIONS OUTLINE

I. History and Examination

a. Prenatal
b. Perinatal
c. Postnatal
II. Growth
III. Development

I. History and Examination

Natal- “birth”

Prenatal- “pre” –

PRENATAL HX --- Accdg to Molnar: 70-80% of CP cases are prenatal in origin

1. Hereditary: Family History (Parents)

2. Radiatio: X – Ray, 1st trimeste
3. Maternal Infection: STORCH (MC Infection during prenatal)

S – Syphilis

T O – Toxoplasmosis- cat’s feces “taesplasmosis”

R – Rubella “german measles”

C – Cytomegalo Virus

H – Herpes Simplex *** HSV 1- cold sores, HSV2- sexually transmitted “genital herpes”

4. Prematurity: “most common antecedent to of Cerebral Palsy” (Molnar)

(N)- Gestational age: 38 – 42 weeks

Premature- 37 weeks

 Mc CP caused by prematurity: CP spastic diplegia

5. Hemorrhage: Bleeding
 MC type: Periventricular/ intraventricular hemorrhage
 Least Common type: Subdural hemorrhage
6. Anoxia:
- No O2 inside the womb
-Resulting to ischemic brain injury

6. Kernicterus: Hyperbilirubinemia on the basal ganglia

Triad of Kernicterus

a. H – Hearing Loss
b. A – Athetosis (slow, writhing, and worm-like movements)

c. P – Parinaud’s syndrome (Loss of upward gaze)

PERINATAL FACTORS –“IMMEDIETALY BEFORE OR AFTER BIRTH”

Primaparous- first time giving birth - <18 hours

Multiparous <12 hours

#Gravidity- # of pregnancies

#Parity- # of livebirths

Documentation:

3 pregnancies

3 live births

= G3P3

Woman pregnant for the first time and had twins

G1P1

3 pregnancy miscarriage 1

G3P2

APGAR SCORING

0 1 2
A Blue (both limbs and Acrocyanosis (pink body, Pink (both limbs and
trunk) blue limbs) trunk)
P (-) pulse <100 bpm <100 bpm
G NR Weak cry or Grimaces Cries, pulls away when
when stimulated stimulated
A (-) movement Slight flexion activity of Spontaneous movt,
extremities resists limb extension
R (-) respiration Irregular, weak, gasping Strong cry

***Best indicator for respiration  CRIES

APGAR Grading:

7-10 – good prognosis

5-6- impending respiratory arrest

0-4- needs ventilator support

Taken after 1, 5,10 mins

Max score- 10

Postnatal Factors – post= after birth

1, Infection-mc postnal factor

Mc postnatal infection: Menigitis

2nd- Encephalitis

2. Trauma

3. Toxicity mc: Poisoning

Growth – increase in physical size and dimensions relative to maturity

Newborn: - head is large

- Prominent abdomen
- Short limbs

COG: xiphoid process

Late childhood- anterior to S2

A. Head Circumference

Newborn N @ 35cm

After 4 mos (+6) = 41 cm

After 12 mos (+6) = 47 cm

Adult (+) 10 = 57 cm

Increased HC- Macrocephaly

Decreased HC- Microcephaly (mc Spastic Hemi) – growth retardation

Increased CSF brain- hydrocephalus

Increased SC- hydromyelia

B. Weight

Newborn @ 3.4 kg or 3400 g

After 5 mos = doubles

After12 mos = triples

Annually =2kg
 LBW- 1,500-2,500 g

VLBW- < 1,500 g (CP Spastic Diplegia)

C. Height = N @ 50 cm
Adult Ht = 2 y/o Ht x2
Peak Growth
Girl – during menarche
Boy- after puberty

D. Other Musculoskeletal Findings

Genu Varum ( bowlegged) – 0-2 yrs

Genu Valgum (knocked knee) 2-8 y/o

Pes Planus (Flatfoot) 0-18 mos

DEVELOPMENTAL SCALES- Denver –Deviation to normal dev’t

Bayley- Mental & Motor Scales (Beyley loves M & M’s)

Gessel- indicator of current developmental level (OLDEST)

Reflexes- automatic response for protection- SEARCH IF ALL ARE CORRECT!!!!!!!!!!

1. Primitive aka Infantile/ Spinal Reflexes

- Lowest form of reflexes
2. Tonic/ Brainstem Reflex
3. Cortical/Midbrain – highest form of reflex

PRIMITIVE/ SPINAL (FCT MSSGER)

Reflex Stimulus Rxn Age of

Suppression
Flexor Withdrawal Pinprick/ noxious Mass Flexion of 0-2 mos
“Flexole stimulus in SOLE of ipsilateral LE
Withdrawal” foot
Crossed Extension Pinprick/ noxious Mass Extension of 0-2 mos
stimulus on BALL C/L LE
offoot
Traction (pull to sit) Pull B UE Mass Flexion of B 4-6 mos
UE
Moro Sudden neck ABD, EXT of limbs 4-6 mos
Extension then ADD, FLEXION
Startle Loud noice 4-6 mos
 Galant “Galandi” Stroke Paraspinal Lateral Trunk 0-2 mos
Mms Flexion towards
stimulus
Grasp Palmar- p on palm Mass Flexion of Palmar-5-6 mos
Plantar-p on ball of Toes/Hand Plantar – 12-14
foot mos
“MAINTAINED”
PRESSURE
Rooting Stroke side of the Head rotation 4 mos
check towards the
stimulus

**

MORO-last to do!!!

Galant-first to be integrated

Plantar Grasp- neeed to be integrated to do standing

Tonic/ Brainstem

(PASTA a la TONIC)

STIMULUS RXN AGE OF

SUPRESSION
Positive Supporting Wt. bearing on ball Mass EXT of B LE 3-5 mos
of foot
ATNR Head rotation Jaw- UE ext 6-7 mos
Occiput- UE flex
STNR Head flex/ext Head flexed- UE 6-7 mos
flexed, LE ext
Head Ext- UE ext, LE
ext
TLR Supine/prone Supine- extensor 4-6 mos
tone
Prone- flexor tone
ASSOCIATED Voluntary resisted Involuntaet movt
REACTIONS movt of 1 side of the other side

ATNR – aka bow and arrow

- Fencing position

Positive Support- need to be integrated to be able walk/ stairclimb

ATNR – Rolling, hand to mouth

STNR-quadruped, crawling

Cortical/Midbrain – highest form of reflex

Stimulus Response

Body Righting Acting on Prone/supine Head will orient vertically

Head (BOH)

Body Righting Acting on Passively rotate Other segment will follow

Body (BOB) Reflex upper/lower trunk
segment

Optic Righting Tilt pt Head will orient vertically

Labyrinthine Head (Occlude vision) Tilt pt Head will orient vertically

Righting

Protective Extension or Displace COG outside Arms/ legs extend/ abduct

Parachute Reactions BOS to support body against
falling (ipsilateral)

Equilibrium/ Tilting Displace COG outside Adjustment of tone and

Reactions BOS posture of trunk to
maintain balance (C/L)

Neck Righting acting on Passive Neck rotation Body rotates as a whole

the body (NOB) Reflex (logroll) to align the body
on the head

Righting- c vision

Labyrinthine Neck Righting- s vision

Piaget Stages

Age Purpose

1. Sensorimotor 0-2 yrs - Masters reflexes

- Capable of insight

2. Preoperational 2-7 yrs - Language formed

- Symbolic Play

3. Concrete Operational 7-11 yrs - Basic logical thinking

- Similarities and Differences

- Classification
 4. Formal Operational > 11 yrs -Abstract thinking

- Highest form of thinking

IQ SCORING

INTELLECTUAL SCALES

1. Standford- Binet – ax for mental age and IQ

2. Wechsler- verbal performance
3. Peabody- overview of achievement
4. Kaufman- mental processes independent of acquired knowledge

WRAT (Wide Range Achievement Test)- reading, arithmetic and spelling

5. WeeFim- FIM pedia

6. COAT (Children Orientation Amnesia Test) - Amnesia Test

Pyschosocial DEVELOPMENT- Erik Erikson

Psychosexual – Sigmund Freud

Important Events Age

Trust vs Mistrust Feeding/ comfort 0-1 y/o
Autonomy vs. Shame and Doubt Toilet Training/ Dressing 1-3 y/o
Initiative vs. Guilt Exploration/ Play 3-5 y/o
Industry vs. Inferiority School Activities 6-11 y/o
Identity vs Role Confusion Social Relationships/ Identity 12-18 y/o
Intimacy vs Isolation Intimate Relationships 18-40 y/o
Generativity vs Stagnation Work and Parenthood 40-65 y/o
Ego Integrity vs. Despair Reflection on Life 65>

Subtypes of Trust vs Mistrust

1. Lap Baby- 4 mos

2. Stranger Separation- 7 mos
3. Love affair with the word- 10 mos

Prognostication for Ambulation

A. Bleck’s
B. Molnar
 BLECK”S

Age done: 1-2 yrs

Grading:

0- good chance for ambulation

-Absent primitive reflexes
1- May have a chance/ guarded
2- Poor prognostication

Normal (+)/(-) Total

Moro (-)
ATNR (-)
STNR (-)
Parachute (+)
Extensor (-)
Thrust
Neck (+)
Righting
(Neck on
Body)
Foot (-)
Placement
Total

FMT:

0 – No ability

1 – Beginning ability, partially achieved, unreliable, insecure, momentary

2 – Reliable c abnormal pattern

3 – Reliable achieved, efficient, reliable c good pattern

Balance:

1 – Cannot assume or maintain

2 – Can assume but cannot maintain or vice-versa

3 – Can assume and maintain

4 – Can assume, maintain, weight shift & be challenged

Tolerance:
 Poor – 0-15 mins

Fair – 16-30 mins

Good – 31-45 mins

Normal – 45-60 mins

RGR:
Poor – (-) RGR or (+) Reach, (-) Grasp & Release
Fair – (+) Reach & Grasp c difficulty Releasing or (+) Reach c difficulty Grasping & releasing
Good – Complete RGR or (+) RGR

Molnar’s Prognostication for Ambulation

Good
- Able to sit independently at 2
- Able to stand independently at 4
- Absent primitive reflexes at 18-24 mos
Fair
- Able to sit independently at 3
- Able to stand independently at 5
Poor
- Able to sit independently at 4
-Able to stand independently at 6

Eye Tracking

Can see midline- 1 month

Extreme gaze- 3 mos

Gait Pattern (MEN 377)

Mature
Established
Normal

Hand Dominance (E,U,E)

Emerging- 18 mos

Usual- 2 yrs

Expected- 5 yrs

Types of Play
 1. Midline Hand play- 4 mos
2. Parallel Play- playing side by side s interaction?? 3 yrs
3. Cooperative Play – group play s interaction -4 yrs
4. Creative/ Competitive Team Play -5yrs

Types of Throw

1. Overhand throw – 3 yrs

2. Underhand Throw- 4 yrs
3. Diagonal Throw – 5 yrs

IQ SCORING

Steps

1. Write 2-13 (s 4, 6, 10)

2. Put 0 except 3 (put 5)
>130 Very Superior

120-129 Superior

110-119 Above Average

90-109 Average

80-89 Below Average

70-79 Borderline

50-69 Mild MR (Dull)

35-49 Moderate MR (Moron)

20-34 Severe MR (Imbecile)

<20 Profound (Idiot)

Gross motor Development (Molnar)

6 mos- sit c support

8 mos – sit s support

5 mos – pull to sit

10 mos-pull to stand

Newborn- flexor tone predominates, (+) ANW

4 mos- Roll P S “pour”

 7 mos Roll SP “seven”/, cervical lordosis “SErVENcal”

10 mos STANDS MOMENTARILITY, CREEP, CRUISES, Lumbar

Lordosis
14 mos SALBAHE
Walk alone
Arms in high guard
Wide base
Excessive hip and knee flexion
Foot contact on entire soele
Slight valgus of knees and veet
18 mos MALANDE
Arms at low guard
Mature supporting base
(+) HS
Walks backward
2 yrs Starts 2 run
Walks up and downstars c step to pattern
Jumps on B feet in place

3 yrs Runs Well

Pedals TRI-cycle
Broad Jumps
Walks upstairs alternating feet
4 yrs Walks up and down alternating feet
“H-O-P-S”

5 yrs “S-K-I-P-S”
Tiptoes
6 yrs Rides Bicycle “bisixlates” roller sixlates”
Roller skates
7 Continuing refinement of skills

Fine Motor

Newborn- Hands fisted

4 mos- Crude palmar grasp (grasp on ulnar side of palm)

Midline hand play (4-action)
7 mos Intermediate grasp – grasp without thumb
Transfers cube from one hand to another
10 mos Pincer grasp – thumb and index

14 mos SALBAHE
Holds crayon at full length
scribbles
Casts objects
 18 mos MALANDE
Holds crayon at butt end
Emerging hand dominance
Dumps raisin in the bottle
2 yrs Hand dominance usual
Draws Line
3 yrs Draws Circle

4 yrs Draws Cross, Frog like person, Cuts c scissors

5 yrs Hand dominance expected

Draws Triangle
Man c head,
6 yrs Prints alphabet
Mature catch and throw of ball
Big Diamond
7yrs Small Diamond

8 yrs 2D cross

9 yrs Cylinder

10 yrs Prism

Personal Social

5 mos- differitatation between mother and seld

Newborn- Habituation – decreased sensitivity to environmental

stimuli (light, noise etc)
4 mos- Recognized bottle
Lap Baby
7 mos (+) Stranger Anxiety
Looks for dropped objects
Talks to Mirror Image
10 mos Plays peek-a-boo
Finger feeds
Chews with rotatory movement
14 mos SALBAHE
Uses spoon c overpronation
Removes garment
18 mos Drinks from cup neatly,
Hug dulls
Imitate housework

2 yrs Pulls garment

Uses spoon well
Starts 2 toilet train
 3 yrs Gender identification
Toilet trained
Parallel play
Pours from pitcher
Unbuttions,
Washes and dries hand and face
Can be reasoned with
4 yrs Cooperative Play
Dresses c supervision distinguishing front and back
Does simple errands outside home
5 yrs Creative/ Competitive Team play
Uses fork for stabbing
Brushes teeth
Dresses s supervision except shoelaces

6 yrs Teacher – important authority

Uses fork appropriately
Knife for spreading
Table games
Mastery of grammar
Proper articulation
7 Eats c fork and knife (DRAW)
Combs hair (DRAW)
Responsible for grooming

Speech

Newborn- Cry, head turning to rattle/ voice

4 mos- Laughs, Squeals

Blows bubbles, rasbperries

7 mos Utter 1 syllable (Ma, Da, Pa)

10 mos Utter 2 syllables ( Mama, Dada, Papa)

Waves bye bye
Uses mama dada c meaning
Inhibits behavior to NO
14 mos SALBAHE
1 word- “gago”
Understand simple commands
18 mos Point to names body part
Says NO
Jargons
 2 yrs 2 words
Verbs
Refers to self by name
Uses mine, me
Follow simple directions
3 yrs 3 words
Stutters (Stutt3rs)
Recognizes 3 colors
Gender identification
Future tense
Asks what, who, where
Gives full name

4 yrs Questions why, when, how

Past tense, adjectives, adverbs
Repeat 4 digits
5 yrs Fluent speech
Gives name, age, address
Number concept to 10
6 yrs Mastery of grammar
Proper articulation

PEDIATRIC CONDITION

CP-disorder of movement and posture that results from a nonprogressive lesion to an immature brain –
nonprogressive unlike degenerative disorders like Parkinsons dse

- Leading cause of childhood disability

- Occurs less than 7 yrs old ( 7 yrs- maturation of brain)
- Incrased risk- FIRST TRIMESTER --- CNS FORMATION

Risk Factors

I. Prenatal- mc 70-80%
1. Prematurity
- Mc antecedent to CP
- 70-80%
- LBW (>2500 g)
- <37 weeks AOG (N@ 28-42 wks)
2. Intrauterine Infections (STORCH)
3. Multiple Births
4. Socioeconomic Status

Triad of Kernicterus
H- Hearing loss (Sensorineural)
 A- Athethosis
P- Parinaud’s ( upward gaze palsy)

Perinatal-

1. Abnormal Presentation (Breech)

2. Cord coil- umbilical cord coiled around the neck = Hypoxia (dec O2 perfusion in the brain)—SEARCH!
3. Placenta Previa- low placenta
4. Abruptio Placenta- premature separation of placenta from uterus
5. Hyperbilirubinemia

Postnatal

1. Trauma
2. Infections

Pathophysiology

1. Parasagittal Injury =

-Bilateral cortical and subcortical white matter necrosis

-Most frequent long term consequence- spastic quadriplegia

2. Periventricular Leukomalacia Highest and greats prediction of CP

Lesions extend up to the ventricles

- Common outcome of IVH

MC: Spastic Diplegia—d/t to

More severe- Spastic Quadriplegia

Compromise- cerebral blood flow

Watershed zone – near the lateral venticles
Intraventricular Hemorrhage

Grading
Grade 1- Isolated Germinal matrix
Grade 2- IVH c normal ventricular size
Grade 3 IVH c ventricular dilatation
Grade 4 IVH c parenchymal hemorrhage
(-) Deficit
S dilatation of ventricles (-) deficit
C dilatation (+) deficit
(+) deficit – greatest prediction of having CP

2. Focal/ Multifocal Ischemic Brain Necrosis

- MC sequelae: Spastic Hemiplegia
- Mc artery affected: MCA
 3. Status Marmoratus
-rarest
- located in the basal nuclei
Long term sequelae- choreoathethosis

4. Selective Neuronal Necrosis

- Decreased O2 in the brain
- Long term sequale- MR and seizures

CLASSIFICATION

1. According to Topography (location of affectation)

Monoplegia- 1 extremtiy affected
Diplegia- LE > UE
Triplegia – 3 limbs (mc B LE and 1 UE)
Quadriplegia- UE=LE
Hemiplegia- One side affected
Double Hemiplegia- UE>LE
2. According to tone
a. Spastic – mc (75%)
b. Dyskinetic
c. Mixed
d. Ataxic

A. Spastic
- Pyramidal tract lesion (Corticospinal Tract) (BA 4, 6, 3,1,2)
- S/SX: UMNL
- Hyperreflexia
- Clonus
- (+) Babunski
- Persistent Primitive Reflexes

Spastic Diplegia

- Aka Little’s Disease

- Usually N intelligence
- (+) Strabismus
- LE > UE
- (+) Synergy
- Flexor Synergy- “Froglike Positioning/ Pithed Frog Deformity (Bunnyhopping)
- Extensor Synergy- Scissoring posture (Combat crawl)
- MC type of hip deformity- Coxa Vara
- Mc spinal deformity-kyphoscoliosis

Spastic Quadriplegia
Poor prognosis

Worst prognostic type of CP

All extremities involved

(+) MR

(+) Straphanger sign/ Birdwing Deformity

(+) Opistothonus Posture

(+) Windswept Deformity- FADIR (dislocatable)

Spastic Hemiplegia

One side affected UE>LE

(+) Typical Arm posture (combination of flexor and extensor synergy)

Ambulatory

Homonymous Hemianopsia/ Strabismus

Dyskinetic- extrapyramidal lesion

Dys- abnormal

Kinetic- movement

1. Atheosis – slow, writhing , dital extremities

Athetoid CP

- Fluctuation of tone
- Asymmetric posturing (to provide stability)
- Hand spooning
- Athetoid dance (FABER during WB)
- Explosive Speech (fluctuating respiratory mms and they produce sound during inspiration

2. Chorea- abrupt, jerky

3. Choreoathetoid- combination of athethosis and chorea, large amplitude moeents
4. Dystonia- abnormal posturing found mc in trunk
5. Ataxic- hypotonia and incoordination  cerelbellum
Mixed – combination of spastic and dyskinetic

Etiology:

1. Bilirubin Encephalopathy aka Kernicterus

- Mc etiology of CP Ahtetoid
- Can be d/t ABO and RH Incompatibility
- Or G6pd- destruction of RBC

Bilirubin- formed by the breakdown of RBC (heme)

Inc bilirubin in the blood = hyperbilirubinema  brain -- > Kernicterus

ABO Incompatibility

Happens only if Mother – Type O—(IgG)-can cross the placenta

Neonate- Type A and B – (IgM) cannot cross the placenta

Pregnancy  Mother’s (Type O) immune system will detect a foreign substance (Type A and B)—Form Antibody
(IgG) will cross the placenta and go into baby’s cicrculation -- >Destruction of RBCs -- >Increase Bilirubin

RH Incompatibility

- Hemolytic dse of the newborn

- Eryhtoblastosis Fetalis
- Happens when mother is RH (-) and baby is RH (+)

Pregnancy  RH (+) Mother’s immune system will treat baby as foreign body (RH-) Formation of Antibodies -- >
Go to baby’s circulation  Destruction of RBCs  Increase Bilirubin

4 Types of CP Athetoid
1. Pure Athetoid
- Fluctuating Mm tone Low- Mid Tone
- Proximal >Distal
2. Spastic Athetoid- mc mixed type
- Fluctuating mm tone (normal to high)
3. Choreoathetoid- mc dyskinetic type
- Fluctauating mm tone (low to high normal(
4. Athetoid c Dystonia
Tone (Very low to very high)
 Ataxic
-cerebellum
S/SX
D- Dysmetria, Dyssnergia, Dysdiadochokinesia
R-ebound Phenomenon
T-remor
A-taxia
Nystagmus

Chant

Antero Paleo Spino Sterio Tone

Poste Neo Coor Cerebro Neo Coor

Flocculo Archi Vesti Equili

Poste Neo Coor Cerebro Neo Coor

Spinal Dysraphism

- Malformation in the neural tube

Neural Tube Formation

- 28 days after fertilization

Spina Bifida

- 2nd mc disability in childhood

- Divided spine/ incomplete fusion of the vertebral arches
- Lac of Folic Acid (B9)

Dx

Increased AlphaFetoProtein

Fetal Ultrasound

1. Spini Bifida Occulta

- Occulta (hidden)
- Mildest fprm
- -common in lumbosacaral segment
- (+) intact skin
- (-) herniation of meninges and neural elements
- (+) dimple
- (+) dermal sinus
- (+) nevus
2. Spina Bifida Aperta/ Cystica “Appear”
 - C exposure of neural elements

2 types

Meningocelce- meningeal herniation between the vertebrae

- (-) neural damge

Myelomeningocele- most severe

- Meningeal and neural element herniation

Diastematomyelia

-splitting of s.c

Hydromyelia

- Increased CSF in the central canal that can compress SC

Syringomyelia
-

Tethered Cord Syndrome

-traction of the COnus Medullaries

Arnold Chiari Malformation/ Chiari Malformation type 2

- Protrusion of cerebellum and brainstem to the foramen magnum

- Associated c spina bifida cystica

Type 1- Chari Malformation

- Cerebellum only

Congenital Anomalies

1. Trisomy 21 (Down Syndrome)

- Flat nasal bridge
- (+) Simian Crease (single crease in the palm)
- Lax AA ligament (C/I contact sports)

2. Trisomy 13 (Patau’s) “Patay”

- Lifespan- < 6 mos
- (+) cleft lip/ palate
- polydactly
- Abnormalities eyes, ears, heart  cause of death
3. Trisomy 18 (Edward’s)
- clenched hands c overlapping fingers
- Prominent occiput
 4. Cri Du Chat “crying of cat”
- Defect in Chromosome 5
- Poor sucking and swallowing

KIinefelter (Ch 47)- XXY

Turner(Ch 45) – X0

Prader Willi Syndrome

- Impaired satiety center

DEATH- Obesity

IV. Muscular Dystrophy

Sex-linked: (BED) – x-linked recessive

Pseudohypertophy

Absent ang dystrophin

Inheritance trait XLR

Onset before 4

Hyperlordotic ang posture

CHECK BRADDOM

1. DMD
- Xlr
- Dystrophin (-)
- (+) Gower’s Sign
- Pseudohyperthropy ng calf

Weak: quads andgmax

- Macroglossia

15 y/o –w/c bound

30 y/o – death -2 to respiratory complication

2. Becker
- Milder frm of DMD (few Dystrophin)
- 30 y/o - ambulatory
 3. Emery Dreiffus

Triad

-Early onset of contracture

Cardiac conduction defect

Prog mm weakness

(-) Emerin

apg

4. FascioScapulohumeral Dystrophy
- AD
Spared: Deltoid
Primary Disability- wscapular wingng (open door)

5. Limb Girdle Dystophy

- Shoulder, pelvic girdle
- Major feature- winging o scapula
6. Myotonic dystrophu
- Delay mm to relax
- Face, neck, hands, feet

Myotonic Phenomenon

- Tap Abductor Pollicis Brevis (Thenar)

- Flex instead of ABD

V. Congenital Myopathes
a. MyotoniaCongenita
Aka Infantile Herculinism aka Thomsen’s Disease –delay mm relaxation

b. Paramyotonia Congenita
Aka Eulenberg-s Disease

c. Nemaline Myopathy (Nema1)

-poor swallowing and sucking
- CH 1

d. Central Core Myopathy

- Decrease ATP
- - floppy baby
- CH 19

Complications of Spinal Dystraphism

T6-12 Kyphoscoliosis

L1,L2,L3 Severe severe, severe hip d/L

L4-L5- mld hip d/l

L5- calcaneovalgus

S1-calcaneovarus

S2- clawing of toes

S3-S4- sphincter control

Boom Duchene

Pseudohyperthopy

Absent ang dystrophin

Inheritance trait xlr

Onset before 4

Proximal mm weakness

Hyperlordotic ang posture

This is Duchene

Boom clap 13 y/o stop na ang aamulation

Boom clap

Ang tonge enlarge ang tongue enlarge