CASE PRESENTATION

Sharmin Susiwala

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

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.

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

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.

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.

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

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.

DIFFERENTIAL DIAGNOSIS:

•Developmental Delay•Hypoxic Ischemic Encephalopathy

•Hemiplegic CP

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.

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.

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

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

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:

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

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

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

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

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

ON EXAMINATION1.SENSORY SYSTEM:Touch Pain

2. MOTOR SYSTEM:• Joint ROM- Passively full• Tone- Normal• Clonus- Absent

Normal

•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

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

•Deep Tendon Reflexes:Reflexes Rt Lt

Biceps ++ ++

Triceps ++ ++

Supinator ++ ++

Knee ++ ++

Ankle ++ ++

Plantar Response:Left: Babinski Response presentRight: Plantar Response present

•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

•Involuntary Movement: Absent

•Muscle Tightness: Left LL: -Hip Flexors- Mild Hamstrings- Moderate Calf (Gastrocnemius)- ModerateLeft UL:- Supinators- Mild Wrist Flexors- Mild

3. BALANCE:

PostureStatic

Dynamic

Sitting Good Fair

Standing Poor

Tandem Walking

Poor

Standing on one Leg

Poor

4. GAIT EXAMINATION:

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

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.

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

PROVISIONAL DIAGNOSIS

• Weakness of left side of body with difficulty in walking

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