2. Master. Idriss 3 ½ years /Mch
DOB – 11/7/19 .
Informant – mother ; reliability – good.
From Washermanpet .
First born to NCM parents, brought with complaints of not
attaining age appropriate milestones noticed by the mother
since 8 months of age.
3. ANTENATAL HISTORY
Menarche @ 13 years, Regular cycles
LMP : 25.11.2018 ; EDD : 2.9.1019
Mother got married at 20 years of age.
Conceived in the same year (spontaneous )
No previous miscarriages
Pregnancy confirmed by UPT at around 45 days of
amenorrhoea.
4. FIRST TRIMESTER
Registered in nearby PHC.
Immunised with 2 doses of TT.
Dating scan done at 8 weeks – Normal.
No h/o any chronic drug intake.
No h/o irradiation
No h/o fever with rash , joint pain ,painful swellings behind
the ear , pets at home
No h/o excessive vomiting requiring hospitalisation .
No h/o bleeding / draining PV .
5. SECOND TRIMESTER
Took IFA regularly.
Quickening felt at around 5 months of gestation .
AN Scans – Anomaly scan said to be normal
Low lying placenta + , advised bedrest.
h/o PIH diagnosed at 7 months and started on oral
medication .
No h/o GDM , Epilepsy, UTI , thyroid dysfunction , foul
smelling vaginal discharge.
No h/o bleeding / draining PV
6. THIRD TRIMESTER
Continued to perceive fetal movements
No history s/o malpresentation or abnormal lie.
Around 32 weeks of gestation , She was admitted in IOG with
complaints of abdominal pain & draining PV . Hospitalised for 7
days . Saline infusion given vaginally and then discharged on
8.7.2019
No bleeding PV
No h/o Fever with rash, GDM, Epilepsy, Thyroid disorders, Foul
smelling vaginal discharges, Blood transfusions
Weight gain – 10 kg.
7. NATAL HISTORY
On the next day of discharge, she developed severe headache , vomiting
and was again admitted in IOG. She was found to have increased BP ,
advised for termination of pregnancy for the sake of the mother .
Labour was induced on 9/7/19 – 1st with a tube , then with a gel kept
vaginally .
Developed labour pains at around 7 pm on 10/7/19
Delivered a live male baby ( preterm ) on 11/7/19 around 5 am
Baby cried immediately at birth .
Birth weight : 1.750 kg
Was then shifted to NICU
8. NEONATAL HISTORY
Baby was admitted for preterm /LBW care in NICU.
Mother saw the baby on day 3 of life she was informed that the baby is a preterm/ LBW and
adequate care must be taken.
On day 3 of life, baby on oxygen support via nasal cannula.
Feeds started through tube in mouth from 4 th day.
Baby was kept in blue light for jaundice from 5th to 7 th day.
From day 5 of life , baby developed abdominal distension and vomiting
Mother was informed that the baby developed some abdominal infection and feeds should be
stopped & IV fluids and IV medications given , baby kept NPO for 1 week. Gradually abdominal
distension reduced ; tube feeds restarted from day 15 of life.
No h/o neonatal seizures / hypoglycemia / bleeding manifestations.
Baby was not able to suck properly and hence paladai feeds were taught to the mother. KMC
care were taught.
Discharged after 25 days of NICU stay with supplements.
Discharge weight : 1.700 kg
9. Postnatal history
H/o poor sucking present
Confined with paladai feeds till 3 months of age & DBF given till 1 year of
age.
No h/o seizures, hypoglycemia, bleeding manifestations.
10. HISTORY OF PRESENTING ILLNESS
DEVELEOPMENTAL DELAY AND MOTOR PROBLEMS
Since this was her 1st child and she was not aware of normal development
milestones , she thought her child was normal.
She became concerned only at 8 months of age when the child did not attain
head control and has no social smile.
She also noticed that her child always keeps his legs straight and stiff.
H/o scissoring of both lower limbs present and she found it difficult to change
diapers.
He also keeps his hands closed tightly most of the time.
Child was not very active and reduced movements in all 4 limbs (LL>UL)
11. For the above complaints , he was initially taken to ICH . He was admitted and investigations
done.
Mother was informed that her child had brain damage and developmental delay . The disease is
not curable and but can be improved with physiotherapy and advised regular follow up.
Then lost follow up in ICH. He was brought to Stanley at 1 year 3 months of age , was registered in
our DEIC and is on regular follow up since then.
Child is aware of surroundings
Child recognises mother & responds to mother when called.
Child will be interested in surrounding & plays with toys well & Looks into objects when shown.
Child able to speak one or 2 word meaningful words to the mother.
No h/o violent behaviours /sleep disturbances
Able to appreciate smell
Able to identify alphabets and different colours.
h/o deviation of right eye towards midline, noticed by the mother since early infancy.
No h/o loss of sensation of face.
No h/o difficulty in closing the eyes while sleeping , no h/o facial asymmetry
12. He turns to the side of sound stimuli.
h/o drooling of saliva from early infancy.
h/o recurrent episodes of aspiration with regurgitation of feeds since infancy. No
h/o voice change
No h/o difficulty in turning head side to side.
No h/o difficulty in protruding tongue.
Child always keeps his legs straight and stiff.
H/o difficulty in lifting head above the bed & getting up from sitting and lying positions
H/o difficulty in turning to one side from lying posture.
H/o difficulty in holding objects in hands
H/o tightness noted in all 4 limbs (LL>UL) since early infancy & h/o scissoring of both
lower limbs present, it was difficult to change diapers.
H/o weakness in all 4 limbs (LL>UL)
Can’t able to walk normally.
13. Able to appreciate clothes over his body
Able to differentiate hot and cold water,
Cries during immunisation .
No head nodding , abnormal eye movements .
No h/o tremors.
No h/o involuntary movements.
No h/o bowel bladder incontinence @ present
No h/o flushing of skin, excessive sweating
No h/o bed sores / constipation
No h/o sleep disturbances / incessant cry.
No h/o spinal deformities.
14. H/o seizures – 3 episodes, from 2 years 3 months of age in the form of tonic
clonic movements of left upper limb , lower limb. For every episodes, child
got admitted in ISP and treated with IV medications & oral drugs
Now the child is on 2 AED syrup , compliance is good and is on regular follow
up in paed neuro OPD. Currently, child is seizure free for last 1 year.
Mother feels her child is not gaining adequate weight and height compared
with peers
h/o recurrent RTI present – treated on OPD basis.
No h/o previous blood transfusions.
15. DEVELOPMENT HISTORY
GROSS MOTOR EXAMINATION
Head control – 1 year 8 months
Rolls over - 1 year 10 months.
Sits with support – 2 and half years.
Sits without support – 2 years 8 months.
Stands with support – 3 years.
Developmental age : 1 year
DQ : 33
FINE MOTOR EXAMINATION
Bidextrous grasp – 2 yrs
Uni dextrous grasp – 2 yr 3 months
Transfers objects -2 and half years.
Holds chalk , scribbles – 3 years.
Draws line - 3 and half years.
Developmental age : 1 ½ years
DQ : 50
16. SOCIAL
social smile – 5 months
Bye bye – 1 year.
Interacts with peers – 2 years.
Asks for food, drink – 2 ½ years
LANGUAGE
Cooing – 4 months
Monosyllable – 8 months
Bisyllable – 1 year 2 months.
3- 6 words – 1 and half years.
2 word sentences – 2 years.
Tell name & rhymes – 3 years.
17. Currently child is on regular follow up in DEIC, ISP for Physiotherapy , Speech
therapy & Occupational therapy. Child’s symptoms gradually improving after
starting therapies.
Now at 3 and half years , he is
Able to lift head up when lying supine.
Able to get up from lying position with one elbow supported.
Able to sit without support and stands with support for few minutes.
Able to lift his arms above head , and is able to take food to his mouth
without difficulty .
Able to take tiny objects with two fingers in both hands
Tightness in extremities improving and drooling of saliva from mouth have
became better.
No history of regression of previously attained milestones.
18. DIET HISTORY
Exclusive breast feeding till 1 year , Complemetary feeds started only after 1
year .
Now child consumes mixed diet with predominant vegetarian based diet.
Expected Child taking Deficit
Calories 1250 k cal 720 k cal 530 k cal
proteins 22 gm 15 gm 7 gm
19. IMMUNISATION HISTORY
Immunised upto age according to National Immunization schedule .
Last vaccination at 1 and half years.
FAMILY HISTORY
Non consanguinous marriage.
Single child to the mother.
No h/o development delay in family.
No h/o seizure disorder.
No family h/o early infant death .
SOCIOECONOMIC STATUS
Mother – VIII , Housewife
Father – X , Doing own business earning 15000/ month
Lower middle class.
ALLERGY HISTORY / CONTACT HISTORY : Nil significant
20. SUMMARY
3 ½ years old 1st male child born to NCM parents who is a NICU
graduate (preterm / LBW with Complications- NEC /
Now brought with predominant motor delay and stiffness of all 4 limbs
(LL > UL), improving with physiotherapy with right eye squint and
drooling of saliva with seizure disorder , probably a case of cerebral
palsy , I would like to to proceed with examination to confirm my
diagnosis and to localise the lesion .
21. GENERAL EXAMINATION
Child is alert , looks around , interested in surroundings .
Afebrile
Hydration adequate
Not anaemic / icteric
No cyanosis / clubbing
No pedal edema / significant generalised lymphadenopathy.
VITALS :
PR – 100, Regular in rhythm, Normal volume, No specific character, No RR or RF
delay
RR- 24/min, Abdominothoracic type
BP – 90/60 mm hg, measured in right upper arm in sitting position
TEMP – 98.4 F
Spo2 : 98 % in room air
24. HEAD TO FOOT EXAMINATION
Head – shape normal , microcephaly present. AP/PF – closed , No over riding of
sutures.
Hair – normal
Face – no dysmorphic facies
Eyes – right eye squint , no cataract / nystagmus /ptosis. No signs of vitamin A
deficiency.
Ears – normal ; no discharge
Mouth – no cleft lip/palate
no ulcers , no thrush / caries.
drooling of saliva present
Neck – normal
Chest/ abdomen - normal
25. Spine – no kyphoscoliosis.
Limbs – no deformities / contractures
No bedsore / callus
Skin – No neurocutaneous markers.
BCG scar : present
CENTRAL NERVOUS SYSTEM EXAMINATION
HIGHER FUNCTIONS
Alert , interested in surroundings, Looks at the examiner while examining
Speech and language – Understands commands, comprehension present , replies in
sentences of 3-4 words, pronounciation – Not clear.
Memory – able to recollect immediate and recent memory
Intelligence – not tested
26. CRANIAL NERVES EXAMINATION
1 – Not tested
2 – Able to follow and fix objects , BPERL +
Direct and indirect Light reflex – present
Fundus : not cooperative
3, 4, 6 – right eye convergent squint + , Able to follow objects ; no nystagmus.
5 – sensation over face – Present ; able to chew food ; Jaw jerk ++
7 –able to close eyes tightly , no deviation of angle of mouth while talking/smiling ; No obvious
facial asymmetry ; Drooling of saliva present on right side
8 – Turns to the side of sounds ; understands and responds to speech ,
9,10- Uvula in midline ; Gag reflex – not tested
11- able to turn head side to side.
12-able to protrude tongue outside . No deviation .
27. MOTOR SYSTEM
Examined with the patient on the couch in supine position
POSTURE – both LL extended and UL flexed.
Ankle dorsiflexed
BULK – RIGHT LEFT
Upper arm 14 cms 14cms
Upper thigh 22cms 22 cms
TONE
RIGHT LEFT
UPPER LIMB -
LOWER LIMB -
POWER
UPPER LIMB - 4/5 4/5
LOWER LIMB - 3/5 3/5
28. REFLEXES
Abdominal reflex + on both sides
Conjunctival reflex + on both sides
RIGHT LEFT
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee +++ +++
Ankle +++ +++
B/L plantar Extensors
No Clonus
No primitive reflexes.
SENSORY
Pain , pressure and temperature – intact bilaterally
Joint position and vibration – not done
29. CEREBELLAR
No hypotonia , nystagmus , intentional tremors , Pendular knee
jerk.
No involuntary movements .
No signs of ANS dysfunction.
No kyphoscoliosis
No signs of meningeal irritation.
OTHER SYSTEMS - Normal
30. SUMMARY
3 ½ years old male child – 1st born NCM ; NICU graduate – 25 days NICU stay .
Preterm / LBW
Presenting with predominant motor delay on physiotherapy , non progressive ,no
regression of milestones.
Seizure disorder – on AED
EXAMINATION REVEALED – spasticity of all limbs , LL > UL , exaggerated DTR , no
involuntary movements.
Right eye squint , normal vision & hearing
31. DIAGNOSIS
A case of Static encephalopathy, spastic diplegia cerebral palsy – ( LL
> UL ), GMFCS – IV
Associated with seizure disorder., right eye squint.
Chronic malnutrition , apparently normal vision & hearing.
Probable etiology being – Preterm / hypoxic insult / postnatal
infection .
