As a student- Ive tried to analyze a pediatric neuro case as per my clinical experience and base of knowledge...!! Hope it is informative..!

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