CEREBRAL PALSY CASE

Name :Vikranth

Age : 4yrs

Sex: Male

Informant :Mother

ADDRESS :Sunctity

CHIEFCOMPLAINTS : Not attained walking

HISTORY OF PRESENT ILLNESS :

As child not attained walking , I want to start with antenatal

history

ANTENATAL HISTORY :

1ST TRIMESTER :

Pregnancy confirmed by upt

3 Antenatal checkups done
Iron &folic acid tablets taken
No H/o exposure to radiation, pets / toxic drugs
No H/o fever with rash
2ND TRIMESTER

Quickening felt at 5 months

Iron & calcium taken
2 TT doses taken at 5 and 7 months
USG done at 5 and 7 months
no abnormality detected

3RD TRIMESTER

H/o blurring of vision and headache and diagnosed as

pregnancy induced HTN
No H/o Diabetes , SLE& Excess Wt gain

NATALHISTORY :

Baby Deliverd at 8 months emergency delivery because

of uncontrolled HTN (which was pregnancy induced ) and
oligohydromnios
C- section done -institutional delivery
Baby did not cry immediately after birth (delayed cry)
H/o seizures on 3rd day of life for which baby was shifted
to NICU - seizures subsided at the time of discharge from
NICU

baby was on anticonvulsant medication for 3 months in

divided doses
Birth wt 2kg
Breasting feeding started at 2nd day
POSTNATAL HISTORY :
No H/o neonatal jaundice /cyanosis/pallor/respiratory
distress
H/o seizures present on 3rd day of life

DEVELOPMENT HISTORY:

GROSS MOTOR:

OBSERVED EXPECTED DIFFERANCE

NECK 9M 3M 6M
HOLDING
SITTING 12M 6M 6M
WITH
SUPPORT
SITTING 15M 8M 7M
WITHOUT
SUPPORT
STANDING 2YRS 12M 12M
WITH
SUPPORT
WALKING 3YRS 15M 21M
FINE MOTOR :
OBSERVED EXPECTEFD DIFFERANCE
PALMAR 15M 6M 9M
GRASP
PINCER 18M 9M 9M
GRASP
SCRIBLLING 2YRS 18M 6M
DRAWING 4YRS 3YRS 12M
CIRCLE

LAGUANGE:

OBSERVE EXPECTE DIFFERENC

D D E
COOING 8M 2M 6M
MONOSYLLABLE 14M 6M 8M
S
DISYLLABLES 18M 9M 9M
WORDS 3YRS 1YR 24M
PSYCHOSOCIAL :

OBSERVE EXPECTE DIFFERANC

D D E
SOCIAL SMILE 10M 2M 8M
RECOGNISIN 10M 3M 7M
G MOTHER
STRANGER 15M 6M 9M
ANXIETY

The child who is supposed to have attained

walking by 1 yr of age has not attained it (even after 4 yrs)
weakness is present in the limbs which is more in the
lower limbs - static and persisting (non progressive)

ASSOCIATED COMPLAINTS :
H/o difficulty changing diapers
No H/o fever ,chills and rigors

HIGHER FUNCTIONS :
Child recognizes mother and father ,
No loss ofconsciousness, not oriented to time and place
H/o change in behaviour ,
Not interested in surroundings, not playing and eating well
H/o no fluency in speech, difficulty in comprehension
and obeying of commands (cognitive function affected)
sleep pattern normal
H/oblurring of vision & squint, drooling of saliva
collection of fluid in cheeks,
No H/O of Deviation of angle of mouth, tinnitus& vertigo
Nasal regurgitation ,change in voice (no cranial nerve
involvement)

No H/o wasting of muscles , H/o of stiffness

H/o weakness of both upper and lower limbs but more
profound in lower limbs unable to walk (motor system
affected)

Gait - not attained ,cannot walk without support seissuring

gait
No H/o involuntary movements
No H/o fasciculations
Child is able to appreciate touch ,pain ,pressure and
temperature (sensory system not affected)

No H/o flatness titubation (holding movements of head)

and nystagmus (no cerebellar signs)
No H/o bowel and bladder disturbance , No H/o flushing of
skin ,sweating ,pallor,coldness or edema (autonomic
system not affected)

No H/o spinal deformities

No H/o bedsores / contractors (no complications)
No H/oheadache ,vomitings ,visual disturbance or coma
(No ict signs)
Other systems :cvs ,respiratory system no symptoms
seen
PAST HISTORY :
H/o seizure on 3rd day of life for which baby was shifted to
NICU and was on anti convulsant treatment for 3months
H/o seizures 2-3 episodes in past 2 yrs
last episode was 6 months ago - generalised tonic clonic
type - lasted about 3 minutes which was associated with
up rolling of eyes and drolling of saliva subsided by
midazolam
seizures are probably due to missed dose of anti
convulsant medication

FAMILY HISTORY :
Consanguineous marriage 2nd Degree
No similar complaints in the family
No H/o contact with TB

4yrs 2yrs
Consaguinous marriage may lead to autosomal recessive
disorders like
METABOLIC: cystic fibrosis, phenyl ketonuria,
galactosemia, glycogen storage disorders.
HEAMATOPOIETIC :sickle cell anemia ,thalassemia
ENDOCRINE:congenital adrenal hyperplasia
SKELETAL:alkaptonuria
NERVOUS:friedrich ataxia, spinal muscular atrophy
IMMUNISATION HISTORY:

Age Inference
National
Immunization
Programme
BCG, OPV0, Hep 0 (At birth) Taken
B0
DTwP1, OPV1, 6 weeks Taken
Hep B1, Hib1
DTwP2, OPV2, 10 weeks Taken
Hep B2, Hib2
DTwP3, OPV3, 14 weeks Taken
Hep B3, Hib3
Measles, 9 months Taken
MMR 15 months Taken
DTwP B1, OPV 24 months Taken
B1
NUTRITIONHISTROY :

Exclusive breast fed till 6 months

Complementary feeds started at 6 months of age with
household soft food
Breast fed up to 1 ½ years

Meal Items Calories Proteins

Break Fast 1 Idly 86 K Cal + 1 gm +
1 cup 25 K Cal + 1 gm +
Chutney 46 K Cal 1 gm
1 cup = 157 K Cal = 3 gm
Cerelac
Lunch 1 cup Rice 108 K Cal + 1 gm +
1 cup Potato 93 K Cal 1 gm
curry = 201 K Cal = 2 gm
Snacks 6 Salt 132 K Cal + 1 gm +
(whole day) biscuits 116 K Cal + 1 gm +
1 Banana 46 K Cal 1gm
1 cup = 294 K Cal = 3 gm
Cerelac
Dinner 1 cup Rice 108 K Cal + 1 gm +
½ cup Dhal 52 K Cal 3 gm
1 cup Veg = 160 K Cal = 4 gm
Curry
Total = 812 K Total = 12
Cal gm
 Expected Observed Deficient
Calories 1300 K Cal 812 K Cal 488 K Cal
Protein 20gms 12 gms 8gms

Inference: Calorie as well as protein gap

SOCIOECONOMIC HISTROY :

Head of the family – Father

Education 10th class
Occupation – Shop Keeper
Income 10,000/month
According to kuppuswamy classification belongs to Lower
middle class

ALLERGIC HISTORY :
No known allergic history

TREATMENT HISTORY :
Taken anticonvulsant medication(? phenobarbitone ) for 3
months after birth for seizures
GENERAL EXAMINATION :

Child is conscious , non coherent , non co - operative

looks undernourished for age , not alert.

Pallor + , Icterus - , Cyanosis - , Klubbing -,

Lymphadenopathy - , Edema -

VITALS :
Pulse:98bpm< normal rate rhythm & volume no radio
radial delay / radio femoral delay
RR : 26 / min
BP : 100 / 70 mm hg
TEMP : 98.6 F Afebrile

ANTHROPOMETRY:

OBSEVED EXPECTED DIFFERANCE %

HEIGHT 90CM 101CM 11CM 11
WEIGHT 9KG 16KG 7KG 44
CHEST 40CM 47CM 7CM 15
CIRCUMFERANCE
HEAD 43CM 50CM 7CM 14
CIRCUMFERANCE
MAC 12CM 14CM 2CM 14
Grade of malnutrition 9/16 100 = 55 % Grade III
Malnutrition

NOTE:
Expected Weight:
3 – 12 months: (Age * months + 9)/2
1- 6yrs ; Age in years *2+8
7-12 Years:( Age in yrs*7)-5/2
Expected height = (Age*6) + 77
SUMMARY
A 4 yr old male child vikrath resident of suncity came with
complains of not attained walking , difficulty in changing
diapers, with significant birth history , with developmental
delay mental retardation , immunized till date with
nutritional deficiet 488 k cal belonging to lower middle
class
HEAD TO TOE EXAMINATION :

Head size; Small in size

Face : Normal , No deviation ,flat nasal bridge
Eyes : Rt Squint, Pallor +
Skin : No Purpura/Neuro cutaneous markers
Mouth : Normal, High arched palate
Dentition : Irregular no of teeth- 20
Tongue : Normal, No deviations/Abnormalities
Extremeties : No other dysmorphic features noted.

Attitude :
Upper limbs - good
Lower limbs - weak extremely rotated at hip joint and
flexed at knee joint

Posture : asymmetric

SYSTEMIC EXAMINATION :
Higher functions;
Oreintation- Not oriented to time and place
Memory– Cannot recall
Intelligence - Subnormal
Speech – Can speak one or two words
No fluency in speech
Difficulty in speaking sentences
CRANIAL NERVES :
CN -1 Olfactory could not be assessed

CN- 2 Optic grossly N visual aquityN

Light reflex + in both eyes
Field of vision, colour vision could not be assessed
Funds- no papilloedema, noexudates

CN -3,4,6 Oculomotor, Trochlear and Abducent

ocular alignment N , eyelids N
eye movements in all directions present
Nonystagmus
Rt side convergent squint noted

CN - 5 Trigeminal corneal&conjunctival reflex N

temporalis over the face appears N
jaw jerk N

CN- 7 Facial wrinkles seen

No deviation of angle of mouth
Orbicularis oculi &orisN
Blow air - buccinatorN

CN - 8 Auditory N
CN – 9 glossopharyngeal nerve – gag reflex cannot be
elicited

CN – 10 vagus nerve --- no deviation of uvula, gag cannot

be elicited,
CN - 11 Spinal accessory N- able to sling shoulders
CN - 12 Hypoglossal - no wasting / fasciculation’s of
tongue ,no deviation of tongue

MOTOR SYSTEM

BULK RIGHT LEFT

MAC 12CM 12CM
MID FOREARM 11CM 11CM
MID THIGH 22CM 22CM
MID CALF 16CM 16CM

INF: Reduced bulk in both limbs

TONE

UPPER LIMBS HYPERTONIA HYPERTONIA

LOWERLIMBS HYPERTONIA HYPERTONIA

Spastic type
Spasticity:
 Seen in pyramidal tract lesions

 Classically termed ‘Clasp knife spasticity’ – more tone

during the initial part of movement – as in opening a

pocket knife
 It is velocity dependant – should be elicited by fast

movement of the muscle groups involved

Rigidity:
 Seen in extrapyramidal lesions – like parkinsonism

 2 subtypes

 Cog wheel rigidity – Tremor superimposed on

hypertonia – resulting in intermittent increase in tone

during the movement – felt as jerks
 Lead pipe rigidity – Uniform increase in tone

 Velocity independent – does not vary with speed of

movement of muscle groups involved

POWEROF ALL
JOINTS UPPER LIMB

SHOULDER IN 4/5 4/5

ALL RANGE
MOVEMENTS
ELBOW 4/5 4/5
WRIST 4/5 4/5
 LOWE LIMB

KNEE 2/5 2/5

ANKLE 2/5 2/5

No involuntary movements seen

Co -ordinations finger nose test +

REFLEXES :

SUPERFICIAL :

RT LT

CONJUCIVAL ++ ++
CORNEAL ++ ++
ABDOMEN ++ ++
CREMASTERIC ++ ++
PLANTAR ++ ++
Other methods for eliciting plantar:

 Cornell sign – scratching along the inner side of

the extensor hallucis longus tendon
 Chaddock sign – stroking the lateral malleolus
 Gonda sign – flexing and suddenly releasing the 4th toe
 Gordon sign – squeezing the calf muscle
 Moniz sign – forceful passive plantar flexion of the ankle
 Oppenheim sign – applying pressure to the medial side
of the tibia
 Schaeffer sign – squeezing the Achilles tendon

DEEP REFLEXES :

UPPER LIMB
RT LT
BICEPS 3+ 3+
TRICEPS 3+ 3+
SUPINATOR 3+ 3+

LOWER LIMB

RT LT
KNEE JERK 3+ 3+
ANKLE JERK 3+ 3+
No ankle or Patellar Clonus

NEONATAL REFLEX :
persisting neonatal reflexes

SENSORY SYSTEM :
Superficial sensations - Touch, Superficial pain and
temperatutre - Intact

Deep sensations: Deep pain ,PresurePosition, vibration

and joint sensations - Intact

SIGNS OF MENINGEAL IRRITATION :

No signs of kernigs sign

No signs of brudinzski

NO SIGNS OF RAISED ICT

SKULL &SPINE ;
No deformities

GAIT :
Scissoring gait (Walking on toes when trying to walk on
with support )
SUMMARY

A 4 yr old male child vikrath resident of suncity came with

complains of not attained walking , difficulty in changing
diapers, with significant birth history , with developmental
delay, mental retardation , immunized till date with
nutritional deficiet 488 k cal belonging to lower middle
class ,with no orientation to time & place , h/o change in
behavior , no fluency in speech , increased tone in all
limbs spastic type , with brisk reflexes without signs of
Meningeal irritation & increased ICT

PROVISIONAL DIAGNOSIS :

Chronic non Progressive Quadriparesis of UMN type of

diplegia variant with mental retardation with Recurrent
sezieures and grade lll malnutrition probably cerebral
palsy

ANATOMICAL;
probably involves bilateralcortex
ETIOLOGY ;
Probably due to pregnancy induced HTN in the
3rdTrimester

MANAGEMENT :
Aim of Treatment is not to cure but to alleviate disability
,prevent deformities, achive maximum possible functions
in terms of communication, mobility indepence, education
and to lead a nearnormal life
1.CHILD IS ASSESSED FOR CAPABITILES AND
DISABILITIES;

- Behaviour modification

2. ADVICE OF MORBID CONDITIONS - REDUCTION

OF CONVULSIONS AND SPASM BY
PHARMACOTHERAPY

-Drug of choice seizure controllorazepam

,midazolam,diazepam

3.DEVELOPMENTAL ACTIVATION AND DISABILITY

LIMITATION

4.EARLY INTERVENTION
- physiotherapy and postionallyprogrames needed to
prevent sequel such ascontractutres

5.APPROPRIATE SCHOOL PLACEMENT

6.APPROPRIATE TRAINING FOR SELF EMPLOYMENT

7.CORRECTION OF ASSOCIATED DEFECTS

- any refractive error/squint/hearing loss.
REHABILITATION

Parentalcounselling - aims to help the parents to cope up

with psychosocial stress

social awareness aims to make child as independent as

possible

counselling for CP children - need psychiatric

intervention for near normal/ normal IQ children
vocational support

Drug for seizures:

5-15min ivacces

1STLINE OF DRUG;
1) lorazepambuccal/PR0.1mg /kgMax 4mg
2)midazolambuccal 0.5mg/kg max10mg
intranasal 0.2 mg/kg max 5mg /nostril
intramuscular 0.2 mg /kg
3) diazepam pr 0.2 mg- 0.5 mg/kgmax20 mg/dose

can be repeated if seizures did not stop after 5 min

2ND LINE OF DRUG;

1)phenytoin 20 mg/kg in ns over 20 min

max100mg@1mg/kg/min
2) fosphenytoin 20 mg /kg in ns over 5-10 min max
100mg/kg
Q Definition of CP?
A: Cerebral palsy is defined as a non progressive
neuromotor disorder ranging from minor incapacitation to
total handicap of cerebral origin
Q Classification of CP?
A: Spastic cerebral palsy
a. Spastic quadriparesis
b. Spastic diplegia
c. Spastic hemiplegia
Hypotonic ( atonic) cerebral palsy
Extrapyramidal cerebral palsy
Mixed type
Q Incidence of CP ?
A:1-2 per 100 live births
Q complications of CP?
A: Recurrent seizures leading to aspiration pneumonia
Bed sores
Contractures
UTI
 Constipation
Q Differential diagnosis?
A: Neurodegenerative disorders
Hydrocephalus and subdural effusion
Brain tumors (or) space occupying lesion
Muscle disorders - congenital myopathies
- Muscular dystrophies
- Muscle eye brain disease
Ataxia telengectasia
Q Circle of willis ?
Q Pyramidal tract representation?
A:
Q Prevention of CP ?
A: Prevention of maternal infection
Prevention of fetal (or) perinatal insults
Good maternal care