Welcome to clinical meeting

Dr. KANTA HALDER Resident (MD;Phase A)

BICH

Particulars of the patient

Name: Omar Ali. Age: 1 year 6 months. Sex: Male. Address: Purbososhalia, Noakhali. Date of Admission: 28.11.2015. Date of Examination: 06.12.2015.

Chief Complaints

Repeated seizure since 2 months of age. No neck control till date.

History of present illness According to the statement of mother, her

child was suffering from repeated seizure since 2 months of age which was generalized tonic in nature, persisted for 5 to 10 minutes and occurred for about 8 to 10 times in a day. Mother also noticed that her child did not have neck control yet, developed stiffness of all limbs and had feeding difficulty since early infancy.

History of present illness(cont..)

He had no history of head trauma or CNS infection. With these complaints, they consulted a local physician who advised some medications and referred the child to Dhaka Shishu Hospital for further evaluation and better management.

History of Past illness He was admitted to Dhaka Shishu Hospital 2

months back due to acute watery diarrhoea.

Birth History Antenatal : Mother, Rehana Akter was on

irregular antenatal check up. She had no history of HTN, GDM, fever with rash or taking any offending drug during her pregnancy period.

Natal : Baby was born by vaginal delivery at

term at home with average birth weight. There was h/o maternal prolong labour with prolong rupture of membrane for 2 days.

Birth History (cont..) Postnatal : Baby did not cry after birth, admitted

to a local hospital and developed seizure at 2 hours of age. He was discharged at 7 days of age after control of seizure. There was no history of neonatal jaundice.

Feeding History Baby was on exclusive breast feeding up to 4

months of age, then formula feeding was started along with suji.

Immunization History He is immunized as per EPI schedule.

Family History He is the only issue of his non-consanguineous

parents.

Socio-economic History He came from a low socio-economic family.

Treatment History He was treated with oral phenobarbitone with

adequate dose for about last 4 – 5 months. After admission, he also got some other medications along with phenobarbitone.

Developmental Milestone• No neck control yet.• No social smile or interaction.• No babbling, crying sound only.

General Examination :Appearance: Ill looking, not interested to

surrounding, no facial dysmorphysm.Anaemia: Mildly pale.Jaundice: Cyanosis:Clubbing: Absent.Oedema:Dehydration:

Cont..Skin: BCG mark present, no neurocutaneous

stigmata.Lymphnode: Not palpable.Signs of meningeal irritation: Absent.Ear:Nose: Normal.Throat:

Cont..Vital Signs:

Heart Rate: 100/minRespiratory Rate: 32/minTemperature: 99°FBlood Pressure: 90/50 mmHg

Cont..Anthropometry:

OFC: 41 cm (microcephaly).Weight: 7.1 kg.Height: 68 cm.HAZ: -4.6 SD (severely stunted).WHZ: - 1.40 SD (normal).

Nervous System Examination Higher psychic Function : Conscious, not oriented to surroundings. Cranial nerves examination : No facial dysmorphysm. Pupillary size and shape was normal, light

reflex was present. No squint, eye balls moved in all direction. Drooling was present, swallowing difficulty

was present.

Cont.. Motor function : Muscle bulk : Reduced in all 4 limbs. Muscle tone : Increased in all 4 limbs, more in

upper limbs. Muscle power : 2/5 in all 4 limbs. Reflexes : Normal in all 4 limbs. Clonus : Absent. Planter response : Bilaterally extensor. Involuntary movement : Absent. Sensory function : Seems to be intact. Fundoscopy : Normal.

Developmental Assessment Gross motor : Pulled to sit - Head lags behind the body line. Fine motor : Couldn’t reach and hold object. No midline activity. Cognition : Recognizes mother’s lap. No social smile.

Cont.. Vision : Fixes and follows coloured object. Hearing : Doesn’t turn to rattling sound. Speech : No babbling, crying only. Other systemic examination including

Abdominal examination revealed normal findings.

Salient feature Omar Ali, 1 year 6 months old male child, only

issue of his non-consanguineous parents, was admitted with the complaints of generalized tonic seizures since 2 months of age, stiffness of limbs which was more in upper limbs and no neck control with swallowing difficulty since early infancy. He had definite history of perinatal asphyxia with seizure, but no history of neonatal jaundice, low birth weight or any significant maternal illness during pregnancy.

Cont.. Omar was mildly pale, severely stunted,

having microcephaly, no neurocuteneous stigmata or organomegaly. Vitals were within normal limit. His cranial nerves were intact except swallowing difficulty , muscle bulk & power was reduced, but tone was increased in all limbs (more in upper limbs); motor, cognition and speech delay was present with impaired vision and hearing.

Provisional Diagnosis Spastic tetraplegic cerebral palsy with

microcephaly with epilepsy with motor, cognition and speech delay with impaired vision and hearing with secondary malnutrition.

Differential Diagnosis Neurometabolic disease with microcephaly

with epilepsy with motor, cognition and speech delay with impaired vision and hearing with secondary malnutrition.

Investigations Complete Blood Count :

• Hb%: 11.9 gm/dl• WBC: Total count: 10,900/cumm Differential count:

o Neutrophil: 43%o Lymphocyte: 53%o Monocyte: 02%o Eosinophil: 02%o Basophil : 00%

Cont..

o RBC:Normocytic normochromico WBC:Mature with above

distributiono Platelet: Adequate

• Platelet : 3,48,000/cumm• PBF:

Cont..RBS : 3.4 mmol/L.S. Electrolytes : Na⁺ - 141.5 mmol/L. K⁺ - 4.0 mmol/L. Cl⁻ - 103.6 mmol/L.S. Calcium : 2.26 mmol/L.SGPT : 40 U/L.

Cont..CT Scan of Brain : Mildly dilated ventricles

with widened CSF spaces.EEG : Epileptiform discharge over B/L

temporo-parieto-occipital area.

Final Diagnosis Spastic tetraplegic cerebral palsy with

microcephaly with epilepsy with motor, cognition and speech delay with impaired vision and hearing with secondary malnutrition.

Management Multidisciplinary team approach :

Paeditritian/Paediatric neurologist works as a team leader involving-

• Physiotherapist.• Occupational therapist.• Speech-language therapist.• Psychologist.• Ophthalmologist.• ENT specialist.• Orthopaedic surgeon.• Special school and teacher & social worker.

Cont.. Counseling. Nutritional management : NG tube feeding (F - 75). Multivitamin, folic acid, Vitamin A and zinc

supplementation. Management of epilepsy : Syp Phenobarbitone. Tab Nitrazepum.

Cont.. Management of spasticity : Tab Beclofen. Physiotherapy. For vision & hearing : Consultation with ophthalmologist and ENT

specialist. Neuro-developmental therapy and

stimulation. Follow up

THANK YOU