PAEDS TUTORIAL

CEREBRAL PALSY
PRESENTERS: MISHECK ZULU
MUSUNKUMUKI KADOCHI

MODERATOR: DR MAPANI
Hx

 Name: Abigail Mbewe

 Sex: F
 Age: 1yr, 3 months
 Address: Helen Kaunda
 Tribe: Tumbuka
 Religion: Christian, Pentecostal
 DOA: 28-04-07
 Informant: Mother, hx taken in
english/bemba/nyanja
P.C

 Body hotness – 2/7

 Coughing – 2/7
HxPC

 The pt is a known cerebral palsy pt.

 On the day of admission the child was well
that morning. Was given porridge around
08:00hrs and milk at 10:00. Around
11:00hrs the child gave on exaggerated
prolonged yarn which was followed by
coughing as though she had been chocking.
This was followed by vomiting.
 The coughing and prolonged yarning
episodes continued.
 Two hours later the child developed body
hotness.
 Each yarning episode was described as
opening the mouth extremely wide with eye
ball rolling upwards (iris would disappear),
the upper limbs would be stretched and
rigid, this lasting 30 sec to 1 min.
 After this the child would become normal
but would breath fast. She would have
several yawning episodes per hour.
 There is no hx of fainting.
 The pt had vomited only once, vomitus
consisted mainly of porridge. No hx of
diarrhoea or constipation, but hx of
increased appetite.
ROS

 CNS, RS and GIT as in the HOPC.

 CVS: Pt is able to lie down flat
No hx of sweating while feeding
 GUS: Urine output is normal
No blood in urine
Does not cry while urinating
 MSS: No skin rash
No joint pains/swelling
PMHx

 This is the pt.’s 2nd admission

 1st admission was 2/52 ago for vomiting,
difficulties in swallowing and excessive
crying.
 The diagnosis of CP was made 7/12 of age
when mother brought child to UTH for lack
of development. No neck control, failure to
sit even with support and stiffness of limbs
 when passively stretched associated
with crying. And was unable to move
limbs as a normal baby would.
 Hx of twitching of one eye and jerking
movements of the arm and leg of the
same side.
Drug hx

 Was given some tablets at 7/12 to

stop the excessive crying.
Birth Hx

 Pt was born at UTH.

 Mother had HTN during pregnancy and baby
was born via C/S.
 The birth weight was 3.8Kg. Did not cry at
birth and was taken to D-block. A few days
later, while still at D-block, an LP was done
for suspected meningitis. However, nothing
was found.
FAMILY Hx

 No similar illness in the family.

 There is no family hx of SCD, DM or
HTN, Epilepsy
Socio-economic Hx

 The patient is the 2nd born of 2 children.

 The first born is male, 4yrs and is well.
 Parents are well. The father works as an
intelligence officer.
 Mother is a business woman ( but has been
has at home since the birth of this child)
 They live a three bed roomed house with
piped water and use a flush toilet.
Summary

 Pt A.M 1yr 3 months old female, a

known case of CP, who presented with
choking, coughing, vomiting, body
hotness and abnormal episodes of
yarning for 2/7. Pt has delayed
milestones with hx of diff. in feeding.
and seizures.
Impression

 Aspiration pneumonia and seizures in

a pt with cerebral palsy to R/O malaria

 Differencial diagnosis: - Spinal cord

tumour.
- Muscular
dystrophy.
O/E

 General: The pt was lying in bed in

opisthotonus position, wasted and
with an NG tube. Was lethargic, febrile
to touch, not in obvious respiratory
distress.
 Had no clubbing, jaundice, pallor, LN
or oedema
 No distended head veins
 VITALS:
R.R – 56b/min, tachypneic
H.R – 160b/min, tachycardic
Temp- 39.4
 ANTHROPOMETRY
Wt: 5.9kg
Length : 59.7cm
MUAC: 13.1cm
HC: 41cm
CNS
 The pt’s was in opisthotonus position with head lag.
 A-F closed ( mother said it closed at 7/12)
 No separation of sutures.
 No neck stiffness
 No choreiform or athetoid movt.
 Cranial nerves tested were normal – II, III, IV, VII,
VIII and XII.
 Limbs were flexed and feet in the position of talipes
equinovarus.
 Muscle tone increased in upper limbs and right
lower limb. Normal in left lower limb.
CNS cont.

 Babinski +ve
 Tendon reflexes were exaggerated
CVS

 The precordium was not hyperactive.

 Pulse was rapid, regular and full
volume with no R-R or R-F delay.
 Apex beat was palpable in the 4ICS
LMCL.
 S1 S2 normal, no added sounds
RS

 Chest was symmetrical, moving with

respiration.
 Slight subcostal recession.
 Trachea was central.
 Chest expansion equal bilaterally.
 Percussion note was resonant
 Normal vesicular breath sounds were
heard.
P/A

 Abdomen was flat.

 Soft and non-tender on palpation.
 No organomegaly
 Tympanic on percussion.
 Bowel sounds normal.
 Genitalia consistent with that of a
female.
MSS

 There was no skin rash,

 No joint swelling
Summary

I examined ill-looking patient lying in

bed with her head in opisthotonus
position with an NG tube. She was
small for age, microcephalic, febrile, in
respiratory distress with tachycardia.
The limbs were flexed with the feet in
talipes equinovarus position, there was
hypertonia, hypereflexia and a +ve
Babinski sign. No hepatosplenomegaly.
Impression

 Aspiration pneumonia in a pt with

cerebral palsy – Spastic quadriplegic
with microcephaly.
To R/O malaria
THEORY

 CP is a static encephalopy that may be

defined as a non-progressive disorder
of posture and movement associated
with epilepsy and abnormalities in
speech, vision, intellect, resulting from
a defect or lesion of the developing
brain
Causes

 Prenatal
 Peri-natal
 Post-natal
Physiologic Classification

 Spastic
 Athetoid
 Rigid
 Ataxic
 Tremour
 Atonic
 Mixed
 Unclassified
Topographic Classification

 Monoplegic
 Paraplegic
 Hemiplegic
 Triplegic
 Quadriplegic
 Diplegic
Investigations

 MPS
 Chest x-ray
 EEG
 CT scan
 Tests for hearing and visual function.
Mx of aspiration pneumonia

 Suctioning of airway
 Administration of oxygen
 Endotracheal intubation
 Prophylactic antibiotics
X-pen, Gentamycin
Mx of CP

 Mx is multidisplinary
 Main aim is to make child as functional as
possible.
1. Physiotherapy: To reduce muscle tone
improve functionality.
2. Speech therapist: Help in not only speech
and language but also in feeding
difficulties.
3.Medical Mx
*Reduction of muscle tone:
-Diazepam (2-40mg daily)
-Baclofen (0.75-2mg/kg daily
*Seizures:
-Phenobarbitone (5-10mg/kg/day)
4. Surgical Mx:
-Tendon Lenghthening
-Posterior Rhizotomy