The case presentation involves a 6-year-old boy named Dixit who has developmental delays, difficulty walking, and seizures. His prenatal and birth history indicated complications, including delayed cry and NICU admission. Current assessments reveal muscle weakness, motor skill difficulties, and a plan for treatment focused on muscle re-education and improvement of functional skills.

1. CASE PRESENTATION
Sharmin Susiwala

2. Name: Dixit Hasmukhbhai Sabhani
Age: 6 yrs 3 months Gender: Male
DOB: 21st Oct, 2007
Weight: 15.9 kg
Head Circumference: 47 cm Height/ Length:
Address: Katargam
Chief complaint:
–Unable to walk
–Falls frequently while walking
–Unable to speak

3. 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.

4. Natal History=
 Term: 36 weeks+2 days
 Place of delivery: Hospital
 Time of delivery: 7:00 pm
 Type of delivery: Normal
 Presentation: Head first
 Birth weight: 2.5 kg
Postnatal History=
 Delayed birth cry- 5 min
 H/O meconium stained liquor aspiration
 Cyanosis
 NICU admission- 5 days

5.  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: EEG
Dr advised for PT so they stayed there for 1 week.
 Returned to surat-
Started PT at Ayurvedic Hospital for 2 years
During this time, he achieved head control and sitting with support
Discontinued PT after 2 years.

6.  At home
Mother used to give massage
Continued for 1 year
 When dixit was 3 years old,
Their neighbour referred them to some Dr near their residence for
exercise
She took dixit there and continued for 2 and 1/2 years
During this time, he achieved standing with support
 When dixit was 5 and 1/2 years old, he started coming to our
department.

7.  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

8. 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.

9. DIFFERENTIAL DIAGNOSIS:
• Developmental Delay
• Hypoxic Ischemic Encephalopathy
• Hemiplegic CP

10. Family History:
Father's
Age: 33
Mother's
Age: 38
13 Years Dixit
Abortion DNC
6 Yrs 3 mnths
3 months
3 months
•No H/O consanguinity.
•No H/O convulsions or any congenital deformities.
•No H/O MR.

11. 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.

12. 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

13. 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

15. 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 Extended
LEs are placed away from each other.
• Transition:

18. 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

22. 4. Standing:
• Posture:
Head control present
Trunk- Forward Trunk Lean
UL- Left: shoulder protraction + IR
elbow flexion
forearm pronation
wrist flexion
finger flexion
LL- Left: hip flexion+abduction+ER
knee extension
Right UL and LL exhibits normal posture
• Weightbearing: Left- medial weightbearing

24. Developmental Assessment:
GROSS MOTOR FUNCTION:
Milestones Age 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

25. 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

26. 2. Prehension
Pad 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 Tip
Pad to Side

27. ON EXAMINATION
1. SENSORY SYSTEM:
Touch
Normal
Pain
2. MOTOR SYSTEM:
• Joint ROM- Passively full
• Tone- Normal
• Clonus- Absent

28. • Primitive Reflexes:
Neonatal - Sucking
Rooting
Swallowing
UL and LL placing
Automatic Walking
Moro's Reflex
Grasp
Spinal level - Flexor Withdrawal- Present
Integrated
Extensor Thrust- Present
Crossed Extensor Thrust- Integrated

29. Brainstem level - ATNR
STNR
TLR
Positive supporting- Present
Negative Supporting
Midbrain level - Optical- Present
Labyrinthine
Neck Righting
Body on Body
Automatic Reactions- Landau's Reflex- Integrated
Gallant's trunk incurvatum- Integrated
Parachute- Present

30. • Deep Tendon Reflexes:
Reflexes Rt Lt
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
 Plantar Response:
Left: Babinski Response present
Right: Plantar Response present

31. • Muscle Power:
VOLUNTARY CONTROL GRADING-UL-
Fair
LL- Poor
Trunk- Poor
Pelvis-
Oromotor- Fair
Head and Neck- Fair
• Limb Length Discrepancy:
LLD Rt Lt
True
Apparent 64 cm 63.5 cm

32. • Involuntary Movement: Absent
• Muscle Tightness:
Left LL: -Hip Flexors- Mild
Hamstrings- Moderate
Calf (Gastrocnemius)- Moderate
Left UL:- Supinators- Mild
Wrist Flexors- Mild

33. 3. BALANCE:
Posture Static Dynamic
Sitting Good Fair
Standing Poor
Tandem Walking Poor
Standing on one Leg Poor

34. 4. GAIT EXAMINATION:

35. 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

36. 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.

37. 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

38. PROVISIONAL DIAGNOSIS
• Weakness of left side of body with difficulty in walking

39. PLAN OF TREATMENT
• Aims:
Muscle Re-education
Strengthening of weak muscles
Preventing Contractures and deformities
Improve balance
To improve efficiency of gait
Enhancement of hand Function
Improve Functional Skills
Parental Counselling