1. Short Case Pediatric: Approach to Cerebral Palsy
By: Mat Ali AAA, AR Muhamad Na'im, Maznon MH, Wahab F, Ab Wahid MN, Ismail AM.
Notes: this is the examples of approaching Cerebral palsy patient in short case examination for
professional III M.D Universiti Sains Malaysia.
On inspection
- Position of the patient
- Patient is conscious and alert (or sleeping*quite common in CP cases)
- If patient is conscious (I can/can not built a rapport with him. Eye contact can be/ not be
established. He is playing/ not playing with the toys)
- No respiratory distress
Or respiratory distress by evidence of tachypnoe, flaring of the nose, pursed lips,
intercostal recession and usage of accessory muscle
- The head appears to be small but I will confirm it by plotting the head circumference
chart.
- Size is appropriate/not appropriate for his age but I will confirm it later by plotting the
growth chart.
- On nasogastric tube (if present)
- Look for wheelchair or stroller (indicate walking difficulties)
- Hydrational and nutritional status is clinically adequate.
- There is a minimal movement at left upper limb... Others: ________________.
- Abnormality; fisting of the hands, flexion of the extremities, scissoring of the leg should
be noted)
- The muscle bulk is normal
- There is no abnormal movement (abnormal movement should be noted. Most commonly
choreo-athetoid movement. *Don’t say chorea as only 2 common cause of chorea
present- Sydenham chorea and Huntington chorea.)

2. Upper motor neuron lesion
- Hypertonic
- Hyperreflexia
- Clonus
- Babinski (+ve)
- No muscle wasting/
fasciculation
Examples of presenting CP case
Examiner: Look at this patient and tell me what system you want to examine
Answer: I would like to do general inspection and examine motor system of this patient.
Examiner: ok. Do motor examination of the lower limb.
This girl is lying supine supported with one pillow. She appears to be sleeping therefore I could
not establish an eye contact with her. She does not look in respiratory distress and not in pain.
There is a wheel chair by the bed. She looks small for her age but I will confirm it later by
plotting the growth chart. There is present of microcephaly. Hydrational and nutritional status
clinically adequate. There is fisting of bilateral arm with flexion of the arm and elbow joint. Her
leg is in scissoring posture. There are no abnormal movement and no other attachment to the
body
On examination of the lower limb, there is present of bilateral upper motor neuron lesion
evidence of hypertonic, hyper reflexia and positive Babinski sign. Apart from that, patient also
has dislocation of the left hip and contracture at lateral and medial hamstring muscle.

3. Definition of cerebral palsy
- Disorder of movement and posture
- Due to non progressive lesion/ insult
- In developing brain.
Types of cerebral palsy (based on lesion)
1) Spastic (70%)- at pyramidal
o Quadriplegic (all limbs)
o Paraplegic (more lower limb)
o Diplegic (more upper limb)
o Hemiplegic
2) Ataxic (10%)
3) Dyskinetic (10%) – at basal ganglia
4) Mixed (10%)
Causes of insult
1) Antenatal
- Vascular occlusion
- Congenital infection (TORCHES)
2) Intrapartum
- Perinatal asphyxia
- Hypoxic ischemic encephalopath
3) Post partum
- Periventricular leukomalacia
- Meningitis/ encephalitis
- Kernicterus (causing dyskinetic)
- Non accidental injury
Management
1) It should be managed by multidisciplinary approach
2) For spasticity
a) Beclofen (oral or rectal)
b) Clonazepam
c) Botolinum injection (BOTOX)
3) Physiotheraphy/ limb exercise
4) For constipation- lactulose syrup
5) GERD- anti reflux medication. (ranitidine)
6) Psychosocial support (councelling, Jabatan Kebajikan Masyarakat, CP group
supports/association)