CEREBRAL PALSY

MENTOR:Prof.Y.K.Ambedkar,
Medical Director,
Wadia hospital ,
Mumbai

MADHUMITHA
FINAL YEAR,GVMC
Name: abc
Age: 5years
Address: Iruvelpet
Informant: Mother
Reliability: Good
CHIEF COMPLAINTS

not attained age appropriate milestones since 1 year

BIRTH HISTORY
First order child
Non consanguineous mariage

ANTENATAL HISTORY
Conceived at the age of 22 spontaneous conception
Weight gained in pregnancy- 12 kg
Periconceptional folic acid not taken
Registered case , no of antenatal visits: 6

FIRST TRIMESTER
Pregnancy confirmed by UPT at 2 weeks after missed periods
First dose of Td taken
No h/o radiation exposure
H/o fever for 10 days not associated with rashes, paracetamol was taken
other than that no medication
No h/o maternal hypothyroidism
Dating scan done at 10 weeks
Folic acid tablets taken
SECOND TRIMESTER
Quickening felt at 20 weeks
Iron folic acid tablets taken
Anamoly scan at 20 weeks- normal
OGCT done -normal
Second dose of Td taken
No h/o headache ,blurring of vision ,pedal Edema
No h/o polyuria, polydipsia
No h/o fever with rash, lymphadenopathy
Not h/o bleeding PV
THIRD TRIMESTER
appreciate fetal movements well
No H/o lower abdominal pain
No h/o UTI
No h/o pre eclampsia, headache ,blurring of vision, pedal Edema
No h/o bleeding/draining PV
No h/o polyuria, polydipsia
No h/o maternal infections
No h/o PROM
Growth scan taken at 33 weeks - normal
LABOUR
Date and time: 29.7.2015 time :6.30 pm
POG: 39 weeksVertex presentation, conducted by doctor at hospital,
Full term normal vaginal delivery, no instrumentation.
No delay in delivery after rupture of membranes.
Liquor clear
No fever before or after delivery
NEONATAL HISTORY
Birth weight: 2.9 kg
Baby did not cry immediately after birth
Resuscitation done, details not known to mother.
Admitted to NICU
duration: 3 days
For birth asphyxia
No h/o convulsions at that time
mother is not aware of the apgar score
Time of voiding urine and passage of meconium not known
No meconium stained liquor
Breast feeding was started after 3 hours
 DEVELOPMENTAL HISTORY
GROSS MOTOR AGE OF ATTAINMENT EXPECTED AGE DEVELOPMENTAL
NECK HOLDING 1 YEAR 3 MONTHS QUOTIENT
ROLL OVER 6 MONTHS 5 MONTHS
SITS WITH SUPPORT 8 MONTHS 6 MONTHS
SITS WITHOUT SUPPORT 2 YEARS 8 MONTHS
STANDS WITH SUPPORT
STANDS WITHOUT SUPPORT
3 YEARS
NOT ATTAINED
9 MONTHS
12 MONTHS
15%
 FINE MOTOR AGE OF ATTAINMENT EXPECTED AGE DEVELOPMENT
UNIDEXTROUS REACH 7 MONTHS 4 MONTHS QUOTIENT
BIDEXTROUS REACH 1.5 YEARS 6 MONTHS
IMMATURE PINCER GRASP 3 YEARS 9 MONTHS
MATURE PINCER GRASP NOT ATTAINED 12 MONTHS 15%

LANGUAGE AGE OF ATTAINMENT EXPECTED AGE DEVELOPMENTAL

COOING 3 MONTHS 3 MONTHS QUOTIENT
RAZZING 7 MONTHS 7MONTHS
MONOSYLLABLES
BISYLLABLES
2.5 YEARS
4 YEARS
6 MONTHS
9 MONTHS
20%
1-2 WORDS WITH 4 YEARS 12 MONTHS
MEANING
8 TO 10 WORDS NOT ATTAINED 18 MONTHS
SOCIAL AND ADAPTIVE AGE OF ATTAINMENT EXPECTED AGE DEVELOPMENTAL
SOCIAL SMILE 4 MONTHS 2 MONTHS QUOTIENT
RECOGNIZES MOTHER 3 MONTHS 3 MONTHS
SMILES AT MIRROR IMAGE
WAVES BYE BYE
8 MONTHS
3 YEARS
6MONTHS
9 MONTHS
40%
SIMPLE BALL GAME 3 YEARS 12 MONTHS
ASKS FOR FOOD 4 YEARS 2 YEARS
HISTORY OF PRESENTING ILLNESS
The child was apparently normal before 1 year, After which mother
noticed that child has not attained the age appropriate mile stones.
Child didn't attain neck holding even after 1 year , mother compared
the child growth with the neighbour child of same age and found her
baby has not attained the mile stones ,only after 1.5 years child attained
neck holding, so she went to nearby hospital where the the child was
diagnosed as a case of Global developmental delay and was referred to
higher centres.
Mother didn't bring the previous records with her in this visit, She said
the child was given physiotherapy and speech therapy but they
continued the treatment up to 3 years of age
Child able to recognize mother which was attained at 3 months.
H/o difficulty in holding baby
H/o inconsolable cry occasionally
H/o stiffness in all 4 limbs
H/o difficulty in geting up from bed
H/o difficulty in taking objects from height
H/o difficulty in mixing foods
H/o spillage of water and food while taking it to mouth
H/o diffculty in changing diapers
Mother noticed that crawling was abnormal
Child was able to crawl at 2.5 years of age
Able to perceive touch
Able to appreciate the pain, responds by crying
Able to appreciate hot and cold temperature
H/o difficulty in breast feeding the child
H/o contractures in legs
H/o recurrent respiratory tract infections
No h/o regression of attained milestone
No h/o convulsions
No h/o fever
No h/o emotional disturbances
No h/o aggressive behaviour
No h/o sleep disturbances
No h/o early hand preference
No h/o drooling of saliva
No h/o squint
No h/o collection of foods in the cheeks
No h/o deviation of angle of mouth while eating
No h/o nasal reurgitation
No h/o change of voice
No h/o abnormal involuntary movements
No h/o fasciculations
No h/o titubation
No h/o nystagmus
No h/o speech abnormalities
No h/o intention tremors
Bowel and bladder movements regular
Child is dry by day by 4 years
No h/o spinal deformites
No h/o decrease /increase in size of head
No h/o trauma to head
No h/o frequent falls
IMMUNIZATION HISTORY

Immunized appropriate for age

At birth. BCG ,OPV, Hep B1

6 wk- Pentavalent-1, PCV1
10 wk -Pentavalent -2
14 wk- Pentavalent-3, PCV2
9 months- MMR-1,JE-1,PCV-B
20 months- MMR2 , JE 2,DPT-B1
PAST HISTORY
The child is a known case of Global developmental delay diagnosed at
the age of 2 years

TREATMENT HISTORY
Child was undergoing treatment , physiotherapy& speech therapy
DIET HISTORY
Child was exclusively breast fed for 6 months,complementary feeding started at 6 months
Breast feeding was continued till 1 years

TIME ITEM QUANTITY PROTEIN CALORIE

7 am Coffee 100 ml 1g 100 Kcal

11 am Idly, sambhar 3, 3 tabespoon 13 g 280Kcal

2 pm dal rice 1 bowl 7g 235Kcal

6 pm milk, biscuts 200ml, 4 8g 200 Kcal
8 pm dosa sambhar 2,3 tablespoon 13g 380Kcal

DIETRY INTAKE OBSERVED EXPECTED COMMENT

CALORIE 1195KCAL 1450 K CAL 17.5% DEFECIT

PROTEIN 42 g 27g ADEQUATE

FAMILY HISTORY
No h/o Similar illness in anyother members
No h/o convusions
No h/o Inborn errors of metabolism.
SOCIOECONOMIC HISTORY
Urban area,pucca house
No overcrowding,well ventilated house.
belongs to lower middle ( according to Kuppusamy scale)
separate kitchen,separate toilet and bathroom
Fuel :LPG
Water is obtained from muncipality stored in overhead tanks and not boiled before
drinking.
waste disposed in streetbins,h/o mosquitoes breeding site near house
h/o rodents present .no h/o livestocks near the house
no h/o pet animals.
CONTACT HISTORY
No h/o contact with a k/c/o TB
SUMMARY
A 5yr old healthy male child.First order ,born out of non
consanguineous marriage belonging to lower middle class, with chief
complaints of Not attaining age appropriate milestones since 1 year with
h/o birth asphyxia and NICU admission for 3 days ,with stiffness of all
four limbs k/c/o global developmental delay with developmental age of
14 months
GENERAL EXAMINATION

Baby is conscious , hydration fair

Child was in supine position, with legs crossed, responded to verbal
commands by his mother
Pull to sit:Tightening of muscles seen
Pallor present- Moderate
No icterus
No cyanosis
No clubbing
No genralized lymphadenopathy
No pedal edema
VITALS
Pulse rate- 100/min Normal in rate rhytm volume character, no
radioradial, no radiofemoral delay
All peripheral pulses felt
Respiratory rate- 30/min, predominantly abdominothoracic
Blood pressure- 90/60 mmhg in left upper arm in supine position
Temperature- Afebrile
Airway- No pooling of secretions
ANTHROPOMETRY
PARAMETERS OBSERVED EXPECTED INFERENCE BASED ON

WEIGHT 16 Kg 18Kg <-2SD WHO CHART

LENGTH 100CM 107CM -1SD WHO CHART

HEAD 50 cm 50 cm 50th centile WHO CHART

CIRCUMFERENCE
CHEST 47.5 cm 41 cm 50th centile WHO CHART
CIRCUMFERENCE
MIDUPPERRARM 14cm 16.5cm -2 SD WHO CHART
CIRCUMFERENCE

* Normal head circumference rules out cp - in most cases

HEAD TO TOE EXAMINATION
Head: Normal in size, anterior &posterior frontannele closed
no abnormal head movements
Face: No dysmorphic facies
Eyes: No telegectasia, epicanthus absent, no ptosis,enopthalmus,corneal opacity.
Neck: normal
Ears: normal
Oral cavity: No cleft palate, no dental caries
Chest: normal
Extremities: No polydactyly,syndactyly,palm normal
Genitalia: normal
Back : normal, no tuft of hair , no bed sores seen
Contractures present in both feet( dorsiflexed)
CNS EXAMINATION
Conscious, active
CRANIAL NERVE EXAMINATION
CRANIAL NERVES FINDINGS

1 could not be elicited

2 Pupillary reflex present, menace reflex present ,Recognizes mother

3,4,6 Able to follow objects in all directions Light reflex ( both direct and indirect light
reflex ) present
5 mastication normal,corneal reflex present

7 Face normal, no deviation of angle of mouth, nasolabial folds present on both

sides,
No drooling of saliva.
8 Turns to the side of loud sound produced, Alerts to sound of ringtone
9,10 No pooling of secretions, no nasal reurgitation, Gag reflex not tested
11 Could not be elicited
12 No deviation of protuded tongue

IMPRESSION: Cranial nerves - normal

MOTOR SYSTEM

BULK RIGHT LEFT

UPPERLIMBS WASTNG OF MUSCLES SEEN WASTING OF MUSCLES SEEN

LOWERLIMBS WASTNG OF MUSCLES SEEN WASTNG OF MUSCLES SEEN

BULK RIGHT LEFT
UL-ARM 15.5cm 15.5cm
FOREARM 16.5cm 16.5cm
LL -THIGH 24cm 24cm
LEG 17.5 cm 17.5cm

TONE UPPERLIMBS LOWERLIMBS

INSPECTION STIFF STIFF

PALPATION RIGID RIGID

RESISTANCE TO PASSIVE RIGHT LEFT
MOVEMENTS
UPPER LIMB ↑ ↑
LOWER LIMB ↑ ↑

RANGE OF MOVEMENTS
UPPERLIMB DECREASED DECREASED
LOWER LIMB DECREASED DECREASED

IMPRESSION-Spastic extremities
POWER( best obsvered) RIGHT LEFT

UPPERLIMB 3/5 3/5

LOWERLIMB 3/5 3/5

NECK ABLE TO LIFT HEAD POWER NORMAL

ABDOMEN ABLE TO MOVE IN BED POWER NORMAL

REFLEXES

Superficial reflex:
Conjuctival reflex- ＋
Abdominal reflex- ＋
Plantar reflex- Babinski sign
Deep tendon reflex
Biceps reflex- ＋＋＋
Triceps reflex- ＋＋＋
Supinator reflex- ＋＋＋
Knee jerk- ＋＋＋
Ankle jerk- ＋＋＋

IMPRESSION: DTR exageratted, babinski sign present

No persistent neonatal reflexes.

CERBELLAR SYSTEM EXAMINATION
not done
AUTONOMIC NERVOUS SYSTEM EXAMINATION
not done
SENSORY SYSTEM
Pain
Able to perceive touch
other sensations could not be tested

SPINE&CRANIUM
Head size and shape normal
Spine - normal

CVS:
Inspection:
Jvp- not elevated
Palpation:
Apex beat
Parasternal heave absent
Auscultation:
S1 S2 normal
No added sound
No murmur

GIT:
Inspection:
Shape of the abdomen- normal
Umbilicus- central
No Sinus /scar/dilated veins
No Visible peristalsis
All regions move equally with respiration
no Visible lump

Palpation:
Shape of the abdomen: normal
Symmetry: symmetrical
No Palpable lump
No Organomegaly
RS:
Inspection
Shape: normal
Movement: symmetrical on both sides
Flaring of nose -Absent
Chest wall retraction absent
Palpation- Normal
Auscultation- NVBS, no added breath sound
SUMMARY
A 5 yr old male child with chief complaints of not attaining age
appropriate mile stones, with h/o stiffness of extremites, with h/o birth
asphyxia& NICU admission , ak/c/o GDD, On examination, moderate
pallor present,Head to toe examination was normal ,Cranial nerves
examination was normal, increased tone in all four limbs, DTR was
exagerrated,Other system examination was normal.
DIAGNOSIS

A case of CEREBRAL PALSY OF SPASTIC QUADRIPLEGIC TYPE

WITH GLOBAL DEVELOPMENTAL DELAY due to multifactorial
etiology &GMFCS-5 with immunization up to age
INVESTIGATIONS
CBC
MRI
Opthal&ENT evaluation

TREATMENT
Multdisciplinary approach
Occupational therapy
Physiotherapy
Positioning and parent education
Baclofen (0.01-0.3 mg/kg/day, divided bid or qid),
Benzodiazepines(0.2-2 mg/kg/day, divided bid or tid)
THANK YOU