AATRAL

Academic forum of IMA MSN Tamilnadu

FINAL YEAR MBBS - RAPID CASE DISCUSSION SERIES

Cerebral Palsy
SONA E
FINAL YEAR MBBS,
TAGORE MEDICAL COLLEGE AND
HOSPITAL,
CHENNAI
● Name: Master Rithwik
● Age: 10 months
● Informant : Mother
● Informant is reliable
Chief complaints
● History of not attaining age appropriate milestones

● Since the complaints started from postnatal period, I would like to start from
antenatal history
Antenatal history:

1st trimester:

3rd degree consanginous marriage

Age of mother while giving conceiving this child 25 years. Spontaneous
conception after 3 months of marriage .Registered and immunised. No h/o
abortions or miscarriage. History of folic acid consumption . No h/o fever with
rashes. No h/o lymphadenopathy. No h/o drug intake/radiation exposure
No h/o blood transfusion .No h/o bleeding or spotting PV
2nd trimester:
● Quickening felt at 20 weeks of gestation .No h/o pedal edema, blurring of
vision, seizures. No h/o gestational diabetes mellitus. NT scan and Anomaly
scan were done and was said to be normal
3rd trimester:
● No h/o bleeding PV
● NO h/o PROM
● No h/o decreased fetal movements
● No h/o foul smelling liqor
● No h/o burning micturition
Natal history:
● Baby was a term baby delivered at 39 weeks of gestation, delivered by
normal vaginal delivery. Weight of baby: 2.3kg. History of prolonged labor –
2nd stage lasted for more than 1.5 hours, delivered by using forceps. Baby
didn’t cry immediately after birth, resuscitation was done ( Bag and mask
ventillation). Admitted in NICU, stayed for 1 week
Postnatal history:
h/o neonatal seizures at 10 hours of life, the neonate was administered
antiepileptic drugs .No history of difficulty in sucking. No h/o neonatal jaundice
No h/o cyanosis. No history of Respiratory distress. Baby was handed over to
mother 24 hours after birth. Child was discharged on Day 10

After discharge from NICU, the child was apparently normal for 3 months, was
feeding well, responding to sound , after which mother noticed that child didn’t
attain social smile and neck control by the end of 3 months, So I would like to
elaborate on Developmental history.
Developmental history
● Gross motor
Ideal achievement When it was achieved

Neck holding 3 months 5 months

Roll over 5 Months 8 months

Sits in tripod position 6 months Not yet achieved

Sitting without support 8 months Not yet achieved

Stands with support 9 months Not yet achieved

● Developmental quotient = 55% ( severe delay)

● Fine motor
Ideal achievement When it was achieved

Bidextrous grasp 4 months 6 months

Unidextrous reach 6 Months Not yet achieved

Immature pincer grasp 9 months Not yet achieved

● Developmental quotient = 44% ( severe delay)

Language milestones:
Ideal achievement When it was achieved

Cooing 6 months 6 months

Monosyllables 9 months Not yet achieved

● Developmental quotient =66%

Social milestones:
Ideal achievement When it was
achieved
Social smile 2 months 4 months
Recognises mother 3 months 5 months
Stranger anxiety 6 months Not yet achieved
Waves bye bye 9 months Not yet achieved

● Developmental quotient = 33%

● h/o difficulty in changing diapers, putting trousers
● h/o Difficulty in washing perineal region
● h/o difficulty in latching the baby on hip
● Child interacts with mother
● Sleeps well throughout night
● Follows light and objects
● No h/o abnormal eye position, drooping of eyelids
● No h/o deviation of angle of mouth, facial asymmetry, loss of nasolabial fold
● Child responds to sounds
● No h/o nasal regurgitation, while feeding, pooling of secretions
● Able to move neck side to side
● No history of abnormal movements of tongue
● Child able to perceive sensation while bathing
● Bowel and bladder control not attained
● No h/o insensitivity to pain
● No h/o bedsores
● No h/o abnormal movements
● No h/o vomiting feeding difficulties
● No h/o constipation, recurrent respiratory tract infection
Diet history:
● Exclusively breast feed till 6 months and still breast feeds
● Complementary foods like boiled vegetables and idili are given
Immunisation history:
● Immunised till date
Socioeconomic history:
● Lower middle class according to Modified Kuppuswamy scale
Treatment history:
● Medical attention was seeked at 6 months of age and the chid is undergoing
physiotherapy currently
Summary
● 9 months old child, 1st born to a 3rd degree consanginuous couple with
significant peripartum issues, with neonatal seizures at 10 hours of life,
delayed developmental milestones, indicating global developmental delay,and
stiffness of limbs for which the child has been receiving physiotherapy.
● I would like to think in term of non progressive motor disorder probably
cerebral palsy of spastic type.
General examination
● Child is alert, awake, quiet in mother’s lap
● Neurocutaneous markers are absent
Posture:

Upper limb:
• adducted at shoulder
• Flexed at elbow
• Slightly flexed at wrist
• Flexion of fingers
• Presence of cortical thumb
Lower limb
• Extended at hip joint and adducted
• Extented at knee joint
• Plantar flexion at ankle joint
• Scissoring of lower limb- positive
Head to foot examination:

● Microcephaly – Head circumference 36cm <3rd percentile

● Anterior fontanelle open – 2*1 cm
● No overriding of sutures
● Hair normal
● No loss of occiput hair
● Eyes – normal
● Ears- startle response to sounds
● Skin – no neurocutaneous markers, bed sores, signs of vitamin defeciency
● Intermittent opisthotonus- positive
● Spine – Normal
● Presence of cortical thumb
● External genitalia normal
● No Pallor, No Icterus, No Cyanosis, No Clubbing, No Lymphadenopathy, No
Edema
Vitals:
● Heart Rate: 110/min, regular in rhythm, no specific character, no radio radial
delay, no radio femoral delay, all peripheral pulses felt
● Respiratory rate: 28/min
● BP: 80/60mmHg measured in right upper limb
● SpO2 : 99%
● Temperature: 98.6F measured at axilla
Anthropometry
Weight:
● 6.5kg against expected of 9kg
● Below 3rd percentile plotted in WHO W/A growth chart
Length:
● 66cm against expected of 73cm
● Below 3rd percentile
Head circumference:
● 36cm against expected of 45cm
CNS Examination
Higher mental function:
● Awake,responds to call, recognising mother

Cranial nerves:
● 1st nerve – couldn’t be checked
● 2nd nerve – able to recognise mother from one end of the room, color vision, field of vision and visual
acuity couldn’t be assessed
● 3rd,4th,6th nerve – eye movements normal
● 5th nerve – conjuctival reflex and pain sensation was ellicitable
● 7th nerve - no loss of forehead wrinkling, no difficulty in closing the eyes, no facial asymmetry while
crying
● 8th nerve- able to respond to sounds
● 9th nerve – regurgitation of feeds absent, uvula is in centre, gag reflex present
● 11th nerve - able to move his head from side to side
● 12th nerve – no fasiculations, wasting of tongue,
Spinomotor system:

● Bulk – equal in both upper and lower limbs

No muscle wasting

Right Left

Tone Upper limb ↑ ↑ Spasticity in

all 4 limbs
Lower limb ↑ ↑

Power Upper limb 3/5 3/5 Best

observed
power

Lower limb 3/5 3/5

Deep tendon reflex
Right Left

Upper limb: Brisk Brisk

Biceps
Triceps Brisk Brisk

Supinator Brisk Brisk

Lower limb: Exaggerted Exaggerted

Knee
Ankle Brisk Brisk
Superficial reflexes

Right Left

Corneal + +

Conjuctival + +

abdominal + +

Cremastric + +

Plantar Extensor Extensor

Primitive reflexes
● Moro reflex – absent
● Asymmetric Tonic Neck Reflex – Present
● No abnormal startle reflex
● Palmar grasp -+ve
● Plantar grasp - +ve
● Suckling - +ve
● Pull to sit - head lag absent
● Ventral suspension head lies above plane of body
● Vertical suspension – scissoring of limbs
Sensory system:
● Child able to perceive pain and sensation
Autonomic system:
● Couldn’t be assessed
Cerebellar system:
● No nystagmus
● Other signs couldn’t be assessed
● No abnormal involuntary movements
● No meningeal signs
Spine and cranium: normal
● 10 months old child with cortical thumb, W/A & H/A below 3rd percentile when
plotted in WHO growth chart, microcephaly, scissoring of limbs, spasticity of
all 4 limbs with best observed power of 3/5 , persistence of Asymmetric tonic
neck reflex, palamar grasp, plantar grasp reflex is probably a case of spastic
quadriparesis type of cerebral palsy
Other systems:

● CVS: Clinically normal

● RS : Clinically normal
● Abdomen : Clinically normal
Diagnosis
● This is probably a case of Spastic quadriparesis type of cerebral palsy with
microcephaly and global developmental delay of functional classification
Grade III, persistent primitive reflexes probably due to Hypoxic ischemic
Encephalopathy sequalae
Investigations:

● Urine screening test

● CSF analysis
● X ray skull, spine
● EMG
● EEG
● USG of cranium
● CT, MRI
● Nerve biopsy
● BERA
● Vision testing every year
Treatment
● Multidisciplinary approach