case presentation- a pediatric neurological case..!!
DESCRIPTION
As a student- Ive tried to analyze a pediatric neuro case as per my clinical experience and base of knowledge...!! Hope it is informative..!TRANSCRIPT
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CASE PRESENTATION
Sharmin Susiwala
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Name: Dixit Hasmukhbhai SabhaniAge: 6 yrs 3 months
Gender: MaleDOB: 21st Oct, 2007Weight: 15.9 kgHead Circumference: 47 cm Height/
Length:Address: KatargamChief complaint:
–Unable to walk–Falls frequently while walking–Unable to speak
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HISTORY:Prenatal History= His mother Mrs Joshanaben Sabhani was 22 years
old when she got married. She conceived 5 times. 5th time- Dixit. Confirmation of pregnancy was done through
missed periods. Didnt undertook any antenatal checkups. No H/O infection or fever No H/O trauma or stress No co-morbid conditions present Proper Weight Gain No H/O any addiction.
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Natal History=Term: 36 weeks+2 daysPlace of delivery: HospitalTime of delivery: 7:00 pmType of delivery: NormalPresentation: Head firstBirth weight: 2.5 kg
Postnatal History= Delayed birth cry- 5 minH/O meconium stained liquor aspirationCyanosisNICU admission- 5 days
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Around 4-5 months, Mother observed that Baby is not doing any activity at all Not keeping his head in midline Head was completely laging Around 6-7 months, she observed that Dixit used to sleep more on right side Uses his left side little less than right At 7 month- Ahemadabad to consult Dr. Darshana
Naik.Dr. told parents that dixit's brain has been
damaged. Investigation: EEGDr advised for PT so they stayed there for 1 week. Returned to surat-Started PT at Ayurvedic Hospital for 2 yearsDuring this time, he achieved head control and
sitting with supportDiscontinued PT after 2 years.
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At homeMother used to give massage Continued for 1 yearWhen dixit was 3 years old, Their neighbour referred them to some Dr
near their residence for exerciseShe took dixit there and continued for 2
and 1/2 yearsDuring this time, he achieved standing
with supportWhen dixit was 5 and 1/2 years old, he
started coming to our department.
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Before 6 months, he got attack of seizure.
1.On 28 Aug 2013, at 2:00 pm- had high grade fever
Attack: There was sudden contraction of his limbs (L>R), eyeballs rolling and frothing at the mouth followed by unconsciousness. On the way to the hospital, he soiled himself.
Lasted for 10 min
1.On 23 Nov 2013, at 10-11 pm- deep sleep Attack: Sudden contraction and relaxation of his
limbs (L>R), eyeballs rolling, deviation of face to one side and frothing at the mouth.
Lasted for 15 min
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3. At night- he was conscious Attack: Little less intensity. Lasted for 15
min.
4. On 17th Jan 2014 in afternoon-while watching TV
Attack: Rapid contraction and relaxation of limb muscles (L>R). No frothing at the mouth. Lasted for 10 min.
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DIFFERENTIAL DIAGNOSIS:
•Developmental Delay•Hypoxic Ischemic Encephalopathy
•Hemiplegic CP
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Family History:Father's Age: 33
Mother's Age: 38
13 Years
Dixit6 Yrs 3 mnths
Abortion3 months
DNC3 months•No H/O consanguinity.
•No H/O convulsions or any congenital deformities.•No H/O MR.
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Socio-Economic Status: Fair
Feeding History:• All types of food given.• No preference to any particular food.• Able to swallow normally.• He is able to chew from both sides
but comparatively less on left side.
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ON OBSERVATION:Posture and Movement:1.Supine:• Head in midline.• Attempts to look around him.• Midline Activities- Present• Eye Hand coordination- not very accurate• Tracks objects vertically and horizontally• Rib Flaring- Absent• Transitions- Supine- Sidelying- Side-Sitting
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Position of limbs in supine:Left UE: Shoulder Abduction + ER Left LE: Hip neutral or ER Elbow Flexion Knee Extension Wrist neutral Ankle Plantarflexion Fingers flexion
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2. Prone:• Head Control is present• Point of support- mostly chest and upper abdomen• Weightbearing on forearm• Trunk Extension- for a short period• Position of limbs:Left UE: Shoulder abduction + IR Right UE: Shoulder
abduction + IR Elbow Flexion Elbow
Flexion Forearm Pronation Forearm
Pronation Fingers flexed Fingers
ExtendedLEs are placed away from each other.• Transition:
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3. Sitting:• Posture: Sitting on the
couch with feet unsupported
• Head control is present• Position: Rt shoulder is
elevated than Lt Shoulders are
protruded Back is
rounded• Able to do reach outs
in sitting
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4. Standing:• Posture: Head control presentTrunk- Forward Trunk LeanUL- Left: shoulder
protraction + IR elbow flexion forearm pronation wrist flexion finger flexionLL- Left: hip
flexion+abduction+ER knee extensionRight UL and LL exhibits
normal posture • Weightbearing: Left-
medial weightbearing
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Developmental Assessment:GROSS MOTOR FUNCTION:
MilestonesAge by which they appear
Social Smile -
Follow with eyes -
Head Holding 1 year
Reaches out for a bright object and gets it
1 year
Rolling Over 1 and 1/2 years
Sitting without support 1 year
Crawling -
Stands with support 2 and 1/2 years
Stands without support
Walking
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FINE MOTOR FUNCTION:Kind of Grasp:1.Power Grip Cylindrical Grip=Forearm pronation/ Wrist
flexion and Ulnar deviation/ MCP flexion and abduction/ Fingers Extension/Fingers parallel to each other/ Thumb Extension.
Spherical=Forearm Pronation/ Wrist Flexion/ MCP abduction and Flexion/ Spread fingers to Approach object/ Grasps object/ Thumb Extension.
Hook Grip=Forearm Pronation/ Wrist Flexion and Ulnar Deviation/ MCP flexion and adduction/ PIP flexion/Thumb flexion and adduction
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2. PrehensionPad to Pad( Palmar prehension)=
Forearm Pronation/ Wrist flexion/ Index and middle finger extended at IP joints/ MCP extension and adduction/ Thumb adduction and extension.
Tip to TipPad to Side
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ON EXAMINATION1.SENSORY SYSTEM:Touch Pain
2. MOTOR SYSTEM:• Joint ROM- Passively full• Tone- Normal• Clonus- Absent
Normal
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•Primitive Reflexes:Neonatal - Sucking Rooting Swallowing UL and LL placing Automatic Walking Moro's Reflex GraspSpinal level - Flexor Withdrawal- Present Extensor Thrust- Present Crossed Extensor Thrust-
Integrated
Integrated
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Brainstem level - ATNR STNR TLR Positive supporting-
Present Negative SupportingMidbrain level - Optical- Present Labyrinthine Neck Righting Body on BodyAutomatic Reactions- Landau's Reflex-
Integrated Gallant's trunk
incurvatum- Integrated Parachute- Present
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•Deep Tendon Reflexes:Reflexes Rt Lt
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
Plantar Response:Left: Babinski Response presentRight: Plantar Response present
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•Muscle Power:VOLUNTARY CONTROL GRADING-UL- FairLL- PoorTrunk- PoorPelvis- Oromotor- FairHead and Neck- Fair
•Limb Length Discrepancy:LLD Rt Lt
True
Apparent64 cm
63.5 cm
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•Involuntary Movement: Absent
•Muscle Tightness: Left LL: -Hip Flexors- Mild Hamstrings- Moderate Calf (Gastrocnemius)- ModerateLeft UL:- Supinators- Mild Wrist Flexors- Mild
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3. BALANCE:
PostureStatic
Dynamic
Sitting Good Fair
Standing Poor
Tandem Walking
Poor
Standing on one Leg
Poor
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4. GAIT EXAMINATION:
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5. COGNITVE EVALUATION:• Behaviour: Alert but sometimes irritable.No self- injurious behaviour present.Sense of common danger such as fire.
• Attention: Good
• Emotional Status: Abnormal
• Cooperation in ADL skills: Poor• Indication for micturition: Absent
• Sleep: Normal
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6. SPECIAL SENSES:• Vision: Attempts to look around.Shifts his vision from one person to another.• Auditory:Turns head in direction of sound.Able to hear.• Verbal:Communicates with mother through Mono-
syllables.Understands anything spoken to him. Indication of need through gestures, sounds or
finger pointing.
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PROBLEM LIST• Weakness of left side of body• Difficulty with walking• Difficulty with balance during
standing and walking• Difficulty in performing gross and
fine motor tasks• Behavioural problems
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PROVISIONAL DIAGNOSIS
• Weakness of left side of body with difficulty in walking
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PLAN OF TREATMENT•Aims:
Muscle Re-educationStrengthening of weak musclesPreventing Contractures and deformitiesImprove balanceTo improve efficiency of gaitEnhancement of hand Function Improve Functional SkillsParental Counselling