CEREBRAL

PALSY
Case presentation
NAME : Master ABC
AGE : 1 year
SEX : Male
INFORMANT : Mother
RELIABILITY : Good
CHIEF COMPLAINTS
Child not able to sit and stand till date and always being bed ridden.

HISTORY OF PRESENTING ILLNESS

Child was brought to the hospital after the mother noticed that the child did not develop age
appropriate milestones such as sitting or standing .
The child has H/O two episodes of convulsions during 2 nd and 3rd months for which he is on
medication.
H/O exaggerated movements when there is noise
H/O scissoring of legs
H/O difficulty in putting diapers
H/O difficulty in getting up from bed
H/O social smile at 9th month
H/O not attaing neck control
H/O not turning over while lying
H/o not able to crawl , sit or stand
H/o not uttering monosyllables
H/o being able to see objects
No h/o defective ocular movements
No h/o squint
No h/o facial asymmetry
No h/o drooling of saliva
No h/o deviation of angle of mouth while eating
No h/o constant irritable crying
No h/o abnormal involuntary movements
No h/o contractures in legs
No h/o recurrent respiratory tract infections
No h/o jaundice
No h/o difficulty in sound production
No h/o abnormal sleep pattern
ANTENATAL HISTORY

Conceived at 24 years of age

Weight gained in pregnancy- 12 kg
Obstetric score P1L1A0

Registered at the local PHC

Pregnancy was confirmed bt UPT after missed periods

FIRST TRIMESTER

No h/o radiation exposure/drug intake

No h/o hyperemesis gravidarum
No h/o fever with rash/lymphadenopathy
No h/o recent blood transfusion
No h/o polyuria , polydypsia
Dating scan done at 10 weeks
Folic acid tablets taken
SECOND TRIMESTER
Quickening felt at 20 weeks
No h/o PIH /GDM
Iron folic acid tablets taken
Anomaly scan at 20 weeks
Two doses of Td taken at 4th and 5th month
THIRD TRIMESTER
H/o UTI with fever and got treated
H/o foul smelling discharge
No h/o lower abdominal pain
No h/o PIH , GDM
No h/o bleeding/draining PV
No h/o PROM
No h/o any chronic debilitating illness in the mother
Growth scan taken at 33 weeks
NATAL HISTORY
No delay in delivery after rupture of membranes.
Full term vaginal delivery
Birth weight 2.9 kg
Baby not cried immediately after birth
Admitted in NICU in ICH

POSTNATAL HISTORY
H/o neonatal seizures after admission in NICU for which the child was started on AEDs
No h/o neonatal jaundice or cyanosis
Treated and discharged after 21 days from NICU
DEVELOPMENTAL HISTORY

GROSS MOTOR
Neck holding — Not attained

LANGUAGE
COOS —Attained
Monosyllable — Not attained

SOCIAL AND ADAPTIVE.

Social smile — Attained at 9 months

VISION AND HEARING.

Vision — Normal
Hearing — Normal
IMMUNIZATION HISTORY
Fully immunised upto 9 months

PAST HISTORY
h/o two episodes of convulsions during 2nd and 3rd month

TREATMENT HISTORY
On treatment for convulsions

FAMILY HISTORY
Non consanguineous marriage
No h/o Similar illness in any other members
No h/o convulsions in other family members
Summary
One year old male child born of non consanguineous marriage ,term , normal weight has a
history of global developmental delay and stiffening of all 4 limbs with abnormal /eventful
perinatal period with neonatal seizures and NICU admission for 21 days
GENERAL EXAMINATION
Child is alert and active
Child was in supine position, with legs crossed,

POSTURE

Upper limb
Adducted at shoulder joint
Flexed at elbow and wrist joint and fingers
Cortical thumb seen

Lower limb
Extended and adducted at hip
Extended at knee
Plantar flexion seen
Scissoring is positive
Pallor seen
No icterus
No cyanosis
No clubbing
No generalised lymphadenopathy
No pedal edema

VITALS
Pulse rate - 100/min Normal in rate rhythm volume character
Respiratory rate - 35/min, predominantly abdominothoracic
Blood pressure - 90/60 mmhg in left upper arm in supine position
Temperature - Afebrile
HEAD TO TOE EXAMINATION
Head – Microcephaly ( - 2 SD)
No abnormal head movements , anterior fontanelle not closed
Face: No dysmorphic facies
Eyes: No telangiectasis , no ptosis, no enophthalmos , corneal opacity.
Neck: normal
Ears: normal, startle response to sound is observed
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,no neurocutaneous markers
ANTHROPOMETRY
Observed Expected
Length 74cm 75cm
Weight 8kg 9kg
Head circumference 41cm 46cm

CNS EXAMINATION
Alert , active
Not looking at the examiner
No response to verbal commands
CRANIAL NERVE EXAMINATION

CRANIAL NERVES FINDINGS

1 could not be elicited
2 Pupillary reflex present, Menace reflex absent , Able to see objects
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 the loud sound

9,10 No pooling of secretions, no nasal regurgitation , Gag reflex not tested

11 Could not be elicited

12 No deviation on protruding the tongue

MOTOR SYSTEM

BULK RIGHT LEFT

UPPER LIMBS WASTING OF MUSCLES SEEN WASTING OF MUSCLES SEEN

LOWER LIMBS WASTING OF MUSCLES SEEN WASTING OF MUSCLES SEEN

TONE UPPER LIMBS LOWER LIMBS

INSPECTION STIFF STIFF

PALPATION RIGID RIGID

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

RANGE OF MOVEMENTS
UPPER LIMB DECREASED DECREASED
LOWER LIMB DECREASED DECREASED

IMPRESSION- Spastic extremities ( clasp knife )

POWER ( Best observed ) RIGHT LEFT

UPPER LIMB 3/5 3/5

LOWER LIMB 3/5 3/5

NECK Could not be done

ABDOMEN ABLE TO MOVE IN BED POWER NORMAL

REFLEXES

Superficial reflexes
Conjuctival reflex- ＋
Abdominal reflex- ＋
Plantar reflex- Babinski sign

Deep tendon reflex

Biceps reflex- ＋＋＋
Triceps reflex- ＋＋＋
Knee jerk- ＋＋＋
Ankle jerk- ＋＋＋

IMPRESSION: DTR Brisk. , babinski sign present

DEVELOPMENTAL ASSESSMENT
Pull to sit — Tightening of muscles seen
Vertical suspension — scissoring of legs seen

Persistent neonatal reflexes

Moro present
ATNR present
Rooting reflex present

CEREBELLAR SYSTEM EXAMINATION

Not done

AUTONOMIC NERVOUS SYSTEM EXAMINATION

not done
No meningeal signs ;
Cranium —Microcephaly
Spine — No Deformities / Tenderness

SENSORY SYSTEM
Pain responded by cry
Other sensations could not be elicited

CVS
S1 S2 heard ,no added sounds

RS
Normal vesicular breath sounds
No retractions seen
DIAGNOSIS
One year old boy with global delayed milestone and
microcephaly with convulsions with non progressive static
motor deficit most probably a spastic quadriplegic cerebral
palsy due to perinatal injury to the fetal brain
INVESTIGATIONS
MRI
ENT & Ophthalmology Evaluation
EEG
Cbc
Hb

TREATMENT
Multidisciplinary approach
Occupational therapy
Physiotherapy
Speech therapy
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