CASE REPORT

Seven Years Six Month Old Girl with

Cerebral Palsy Quadriplegic Spastic

GMFCS V, MACS III, CFCS III, EDACS II

Andriaz Kurniawan

NIM: 22041417310008

Moderator:

dr. I Made Widagda,Sp.KFR

PHYSICAL MEDICINE AND REHABILITATION PROGRAM

MEDICAL FACULTY OF DIPONEGORO UNIVERSITY
MEDICAL REHABILITATION DEPARTMENT
Dr.KARIADI GENERAL HOSPITAL SEMARANG
2021

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I. PATIENT IDENTITY
Name : An. UF
Birth date : 19 September 2013
Sex : Female
Age : 7 years 6 month old
Address : Wonosari, Ngaliyan, Semarang

II. PARENT IDENTITY

Father name: Mr. IR Mother name: Mrs. LH
Age: 41 years old Age: 39 years old
Occupation: Online Driver Occupation: Factory employee
Education: Senior High School Education: Senior Hgh School

III. ANAMNESIS (Alloanamnesis with her parents)

Chief complaint : patient can not standing and walking
History of Present Illness:
At this age patient still can not standing and walking independently or with assistance.
Patient can move in her home by creeping. Patient can sit from lay position and roll over
independently. Patient can sit without support for several minutes, usually she can sitting with
hand support. Patient has stiffness in both legs and in her arms. Patient need help for eating and
drinking, she can eat use spoon but it’s still a mesh, but mostly he was fed by her mother or her
caregiver. She can drink use bottle. Patient take a shower, toileting, dressing dependently.
Patient can understand simple instruction, can claps her hands, reach and graps object or
toys, can understand parts of her body, she is difficult to hold a pencil, must use an pencil
modification, she can not draw vertical line with pencil and can not writing a letter. Patient can
communicate with her family, she is able to say combination 2-3 word but it does not clear
articulation of speech and do not have many word. Her mother and caregiver understand the
words, but unfamiliar person mostly do not understand the words. Patient show her desire
verbally but unclear or by pulling or pointing to her mother or caregiver. Patient can count
number until 10 and but can not mention colours. Patient can eat family menu and drinking, no
choking or coughing when eating and drinking. Sometimes there is drooling. Her mother needs
approximately 30 minutes to feed her at each meal. She is not picky eater and eat according to

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the family menu with various consistencies. Patient still wearing diapers although she can tell
when she has urinate and defecate. Patient gets tired easly, can’t do activity in long time.
Patient attends 1st grade elementary school at SLB YPAC Semarang. She gets therapy one a
week for physical therapy (standing and stretching exercise) and occupational therapy program
in YPAC (hand function exercise). Since March 2020 (covid pandemi) patient did not attend
school and therapy, but her mother always give stimulation at home. She has AFO but not using
it regularly. She has wheelchair but it is not yet properly wheelchair.

Pre Natal History :

Patient is the second child born from G2P1A0 mother. Mother’s age was 31 y.o during
pregnancy. ANC in obstetric regularly. Maternal history of seizures, high blood pressure,
drinking herbal or drugs outside the vitamin is denied.
Natal History :
Patient was born spontaneously on 32 weeks gestational age because of KPD in hospital. Birth
weight 1900 grams, body length 43 cm, but her mother forget the head circumference. Crying
(+) but not adequat, blueish (-). Hospitalized for 2 weeks in NICU
Postnatal History:
History of TB (+) at 4 years old, jaundice (-), seizure (-), head trauma (-)

History of past illness

 Developmental delay was noted by his mother at 3 months old because he can not rolling
and lift his head but patient was able to smile.
 Diagnosed with TB at 4 years old and had 2 years therapy

History of family illness

There is no family member with history of developmental delay.

History of sosio economic

Her father is driver online dan her mother is a factory employee. Patient is live with her parent
and brother. They live in a one level house. The bathroom has a squatting toilet. There is no step
stairs in the house. The street towards the house is in level surface Patient taken care by her
parent and grandmother. Patient have enough attention and love from her family. The parent’s
income per month ± Rp 4.000.000.

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History of Basic Immunization : Complete

History of feeding
a. Breast feeding : 0-3 months old
b. Formula milk : 3 months old – now
c. Rice + milk : 18 month old – now, SGM 4-5x / day + 200 cc
- Quantity : 3x / day, enough portion
- Quality : chicken, fish, tempe, vegetables (variously)
Impression : feeding is enough in quality and quantity
History of growth and developmental
Growth
At birth: BB = 1900 gram, PB = 43 cm, LK = forgot
Now : Body weight = 19 kg; Body height = 116 cm; Head circumference = 48 cm, LILA = 18cm
BMI 14,1 kg/m2; WAZ: -1,89; HAZ: -1,41; BMI for age: -1,50
Impresson: adequate nutrition status

Developmental
Gross motor
 Head up : 5 bulan
 Roll over: 5 bulan
 Crawling : unable
 Sit without support: 5 tahun
 Stand without support: unable
 Walking : unable
Fine motor:
 Holding object : 1 years old
 Reaching object: 1,5 years old
 Build up cube : 5years old
 Unbutton shirt : unable
Language:
 Smile : 3 months old

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  Laugh : 4 months old
 Babble : 1,5 years old
 Mention one word : 3 years old
 Mention combination word: 5 years old
Personal social :
 Expressed desire : 3 years old
 Clapped hand : 2 years old

DDST II
Gross motor 7 month old
Fine motor 3 years 9 month
Language 4,5 years
Personal social 24 month
Impression: Global develoopmental delay

IV. PHYSICAL EXAMINATION

General : compos mentis, eye contact, active, comprehension fair.
condition
Communi : Receptive language (±), expressive language (+) unclear
cation
Posture : Sit  head control (+) and trunk control (+) sitting in W
position (+)
Gait : Not testable
Vital sign : HR = 94x/ minute, RR = 20 x/minute, T = afebris
Head : Normocephal (HC: 48 cm)
Eye : Conjuctiva anemis (-/-), sclera icteric (-/-), strabismus (-/+),
hipertelorisme (-/-),direct light reflex (+/+),upslanting eyes(-/-)
Nose : Saddle nose (-), discharge (-)
Mouth : lip seal (+) inadequate, tounge thrust (-), drooling (+), dental
caries (-), macroglossia (-), tonic bite reflex (-), oral hygiene :
good, tightness in chewing muscle (-)
Neck : symetrical, lymph node enlargement (-/-), head control (+),
forward head posture (+)
Trunk : trunk control (+), scoliosis (-) , kyphosis posture (+)

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Internal :
status
Thorax : Lung:

 Inspection: symmetric in static and dinamic), intercostal

retraction (-)
 Palpation: stem fremitus right = left
 Percussion: sonor
 Auscultation: vesiculer (+): wheezing (-), rales (-)
Heart:

 Inspection: ictus cordis unseen

 Palpation: ictus cordis palpated on ICS V left medial
midclavicula, not lifted
 Percussion = left border 2 cm left medial midclavicula
line ICS V upper border ICS III left parasternal line
 Auscultation: heart sound I-II reguler; murmur (-)
Abdomen :  Inspection: flat
 Palpation: supel,hepar/lien not palpable, tenderness (-)
 Percussion: timphany (+)
 Auscultation: bowel sound (+) normal
Postur
Anterior:
- Shoulder simetris
- Pelvic obliquity (-)
- Ankle varus bilateral
- Ankle inversion bilateral
- Ankle plantar flexion bilateral
Lateral:
- Forward head posture (+)
- Kyphotic (+)
- Hyperlordotic (-)
- Genu recurvatum (-)
Posterior:
- Shoulder simetris
- Scoliosis (-)
- Pelvic obliquity (-)
- Ankle varus bilateral
- Ankle inversion bilateral
- Ankle plantar flexion bilateral

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 Neuromusculer status
Superior Inferior
Dextra Sinistra Dextra Sinistra
Movement + + + +
MMT Impression >3 Impression >3 Impression < 3 Impression < 3
Tonus MAS 2 MAS 2 MAS 3 MAS 3
Trofi Eutrofi Eutrofi Eutrofi Eutrofi
Physiological +3 +3 +3 +3
reflex
Patological - - + (Babinski) + (Babinski)
reflex
Clonus - - + +

EXTREMITAS SUPERIOR
REGIO Normal Dextra (Passive) Sinistra(Passive)
Shoulder
S : (Ext – 0 – Flexi ) S : (45 – 0 – 180) Full ROM Full ROM
F : (Abd – 0 – Add) F : (180 – 0 – 45) Full ROM Full ROM

T (F90) : (Abduksi 90) T (F90) :(30 – 0 – 120) Full ROM Full ROM

R (F90) : (Abduksi 90) R(F90) :

Full ROM Full ROM
(Ext Rot – 0 – Int Rot) (90 – 0 – 70)

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 Elbow
S : (Ext – 0 – Flexi ) S : (10 – 0 – 150) Full ROM Full ROM
R : (Sup – 0 – Pro) R : (80 – 0 – 70) Full ROM Full ROM
Wrist
S : (Ext – 0 – Flexi ) S : (70 – 0 – 80) Full ROM Full ROM
F : (Abd – 0 – Add) F : (20 – 0 – 30 ) Full ROM Full ROM
Finger
S : (Ext – 0 – Flexi ) Full ROM Full ROM

HIP Normal Dextra Aktif Sinistra Aktif

S : (Ext – 0 – Flex) S : (15 – 0 – 125) 15-0-110 15-0-110

F : (Abd – 0 – Add) F : (45 – 0 – 15) 35-0-15 35-0-15

KNEE

S : (Ext – 0 – Flex) S : (0 – 0 – 135) 10-10-135 10-10-135

ANKLE

S : (Dorso – 0 – Plantar) S : (20 – 0 – 50) 10-0-50 10-0-50

R : (Eversi – 0 – Inversi) R : (20 – 0 – 40) 10-0-30 10-0-30

Finger

MTP-S :(Ext – 0 – Flex) Full ROM Full ROM

Leg length examination

 Clinical length : 60 cm/60 cm
 Apparent length : 65 cm/65 cm
Impression : leg length discrepancy (-)

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Primitive refleks:
 Palmar grasp reflex (-)
 Plantar grasp reflex (-)
 Sucking reflex (-)
 Rooting reflex (-)
Spinal Level
 Flexor withdrawal (-)
 Extensor thrust (-)
 Crossed extension (-)
Brain stem level
 ATNR (-)
 STNR (-)
 Tonic labyrinthine prone (-)
 Positive supporting reaction (-)
 Negative supporting reaction (-)
 Associated reactions (-)
Mid brain level
 Neck righting (+)
 Body righting acting on the body (-)
 Labyrinthine righting acting on the head (-)
 Optical righting acting on the head (-)
 Amphibian reaction (-)
Automatic reaction
 Moro reflex (-)
 Landau reflex (-)
 Parachute reaction (+)
Cortikal Level
Supine (-) Prone (-)
Sitting (-) Hopping 1-3 (-)
Kneel standing (-) Four foot kneeling (-)
Impression : brain maturity level  Mid brain

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Special test:
 Thomas test +/+
 Spastic adductor hip +/+
 Popliteal angle: 40°/40°
 Silverskiold test +/+
 Duncan-Ely test -/-
Eye hand coordination : left : good, right : good
Hand to hand coordination : poor
Hand to mouth coordination : poor
Hand Function

Reach : Functional/ Functional

Grasp : Functional/ Functional

Release : Functional/ Functional

3 jaw chuck : Not functional/ Not functional

Tip to tip : Not functional/ Not functional

Side to side : Not functional/ Not functional

Side to pad : Not functional/ Not functional

Hook : Not functional/ Not functional

Cylindrical : Not functional/ Not functional

Spherical : Not functional/ Not functional

Mobility
Balance
 Sit: able in W position with hand support
 Stand: unable
Ambulation
 Crawling : unable
 Walk: unable
Transfer
 Supine to sit: able
 Sit to stand: unable

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 Cognitive test : able to put up a puzzle, able to mention part of body, several name of animal
and count numbers until ten.
Impression : good
 GMFCS: level V (use wheelchair indoor and outdoor)
 MACS : level III (difficult to handle object, needs help to prepare or modify activities)
 CFCS : level III (effective sender and reciever with familiar partners)
 EDACS: level II (eats and drinks safely but some limitation to efficiency)

V. CLINICAL DIAGNOSIS
Cerebral Palsy Quadriplegi Spastik GMFCS V MACS III CFCS III, EDACS II
VI. ICF DIAGNOSIS
ICF CODE DESCRIPTION PATIENT’S CONDITION
Body Structures
s110 Structure of brain Cerebral Palsy
s7502 Structure of ankle and foot Ankle varus bilateral
Ankle inversi bilateral
Ankle equinus
s75012 Muscle of lower leg Tightness hamstring, hip flexore, hip
adductor, gastrocnemius
s760 Structure of trunk Kyphotic posture
Body Functions
b735 Muscle tone function Spasticity on upper extremity (MAS 2) and
lower extremity (hip & knee MAS 2, ankle
MAS 3)
b730 Muscle power function Muscle weakness in upper and lower
extremities (hip extensor, hip abductor, knee
extensor, ankle dorsoflexor)
b710 Mobility of joint functions ROM limitation in ankle
b799 Neuromusculoskeletal and Kyphotic posture
movement-related functions, Sitting in W position
other specified
b320 Articulation function Poor articulation
b4550 General physical endurance Patient gets tired easily, can’t do activity in long time

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b510 Ingestion function Drooling
Activities and Participation
d450 Walking Can not walking independently
d410 Changing basic body position Sit to standing position helped by her mother
or caregiver
d415 Maintaining a body position Patient can not maintain standing position
d530 Toileting Patient still wearing diapers and was not fully
trained to express urge to urinate and defecate
d5101 Washing whole body Patient needs help washing his body,
especially lower extremity and perianal area
d540 Dressing Patient needs help in upper and lower
dressing
d550 Eating Difficulty to use spoon and glas, mostly fed
by her mother or caregiver
d170 Writing Lack of prewriting skills and coordination
d815 School education Patient has attended 1st grade elementary
school, can not participate in class activity
d880 Engagement in play Difficulty when follow some play activities
Environmental Factors
e310 Immediate family Good family support
e580 Health service, system and Insurance covered by BPJS
policies
e155 Assistive products and Use wheelchair indoor and outdoor activity
technology for personal indoor
and outdoor mobility and
transportation

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 VII. REHABILITATION PROBLEM
1. Communication problem
2. Limitation in ADL
3. Spasticity upper and lower extremity
4. Weakness in upper and lower extremity muscle
5. ROM limitation
6. Ambulation problem
7. School education
8. Kypotic posture
9. Ankle varus, inversion and equinus bilateral

VIII. PROGNOSIS
 Quo ad Vitam : ad bonam
 Quo ad Sanationam : ad malam
 Quo ad Functionam :
Ambulation : Ambulation using wheelchair
Communication : Verbally and non verbally effective and understandable
ADL : Partial dependent (eating,dressing)
Education : Appropriate education based on IQ test
IX. GOAL
Short term:
 Improved lip closure for communication
 Decrease of spasticity (MAS 1-2)
 Maintain ROM
 Correction posture (while sitting, eating, sleeping)
Long term:
 Improved articulation
 Improved independency of ADL (eating,dressing)
 Improved prewriting skill
 Prevent contracture
 Appropriate education

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X. REHABILITATION PROGRAM

No Problems Goals Program

1 COMMUNICATION  Improved lip closure for  Articulation training

 Speaking unclear, communication  Oromotor exercise and massage
disarthria  Improve articulation  Learn more vocabulary verbal and non verbal language, expressive
 Inadequate lip closure language exercise

 Education: Singing, story telling, continue oromotor exercise at

home. Educate the parent learn non verbal communication

2 LIMITATION IN ADL  Improve independency  Fine motor and coordination of hands exercise
 Lack of pre writing of ADL (eating,
skills and coordination dressing)  Education: Learn to draw circle, square, cross, and triangle
 Limitation of ADL  Improved prewriting  Educate her mother and caregiver to let their child do feeding by
(requires assistance in skill himself with minimal assistance.
feeding, dependent in  Toilet training
bathing, toileting,
dressing)

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No Problems Goals Program

3. AMBULATION
• Tightness in hip flexor,
hip adductor, hamstring,
ankle plantarflexor
• Spasticity of lower and
upper extremity
 Decrease muscle
tightness and spasticity
 ROM and Gentle stretching exercise (flexor hip, adductor hip,
hamstring, gastrocnemius)
• F: 7x/week
• I: slight discomfort
• T: 3 set @ 10 repetion hold 20 s
• T: Stretching exc, ROM exc

• Education: Continue ROM and stretching exercise at home

• Muscle weakness
• Improved upper and • Strengthening exercise upper ext(shoulder and triceps) and
lower extremities lower extremity (gluteus medius, gluteus maximus, quadriceps
strength femoris, tibialis anterior)
• Back extensor exercise
• Ambulation aid: wheelchair
• Education:
Educate caregiver playing kicking the ball.
Prone lying while playing with puzzle or toy

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4. POSTURAL PROBLEM
 Forward head and
kyphotic postur
 Sitting in W position
 Hip, knee, ROM
limitation
 Ankle varus, inversion,
equinus bilateral
 
5 EDUCATION
School Education
• Posture correction
(while eating, sitting,
and sleeping)
• Maintain ROM and
prevent contracture
• Appropriate education • Plan: consult to pyschologist for IQ test
• Posture correction
• Proper sitting positioning
• Use cerebral palsy chair with trunk and pelvic strap, cushion
pad, calf strap
• Standing table
• Fitting, check out AFO
• Plan: hip surveillance
Education:
 Educate caregiver correct posture use CP chair when eating and
playing, avoid sitting in W-position. Sole of foot touch the floor.
(plantigrade position)
 Use AFO regularly
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