Cp omar ali

Dr. KANTA HALDER
Resident (MD;Phase A)
BICH

Particulars of the patient
 Name: Omar Ali.
 Age: 1 year 6 months.
 Sex: Male.
 Address: Purbososhalia, Noakhali.
 Date of Admission: 28.11.2015.
 Date of Examination: 06.12.2015.

Chief Complaints
 Repeated seizure since 2 months of
age.
 No neck control till date.

History of present illness
According to the statement of mother, her
child was suffering from repeated seizure since
2 months of age which was generalized tonic in
nature, persisted for 5 to 10 minutes and
occurred for about 8 to 10 times in a day.
Mother also noticed that her child did not
have neck control yet, developed stiffness of
all limbs and had feeding difficulty since early
infancy.

History of present illness(cont..)
He had no history of head trauma or CNS
infection. With these complaints, they consulted
a local physician who advised some medications
and referred the child to Dhaka Shishu Hospital
for further evaluation and better management.

History of Past illness
He was admitted to Dhaka Shishu Hospital 2
months back due to acute watery diarrhoea.

Birth History
Antenatal : Mother, Rehana Akter was on
irregular antenatal check up. She had no history
of HTN, GDM, fever with rash or taking any
offending drug during her pregnancy period.
Natal : Baby was born by vaginal delivery at
term at home with average birth weight. There
was h/o maternal prolong labour with prolong
rupture of membrane for 2 days.

Birth History (cont..)
Postnatal : Baby did not cry after birth, admitted
to a local hospital and developed seizure at 2
hours of age. He was discharged at 7 days of age
after control of seizure. There was no history of
neonatal jaundice.

Feeding History
Baby was on exclusive breast feeding up to 4
months of age, then formula feeding was
started along with suji.
Immunization History
He is immunized as per EPI schedule.

Family History
He is the only issue of his non-consanguineous
parents.
Socio-economic History
He came from a low socio-economic family.

Treatment History
He was treated with oral phenobarbitone with
adequate dose for about last 4 – 5 months.
After admission, he also got some other
medications along with phenobarbitone.

Developmental Milestone
• No neck control yet.
• No social smile or interaction.
• No babbling, crying sound only.

General Examination :
Appearance: Ill looking, not interested to
surrounding, no facial dysmorphysm.
Anaemia: Mildly pale.
Jaundice:
Cyanosis:
Clubbing: Absent.
Oedema:
Dehydration:

Cont..
Skin: BCG mark present, no neurocutaneous
stigmata.
Lymphnode: Not palpable.
Signs of meningeal irritation: Absent.
Ear:
Nose: Normal.
Throat:

Cont..
Vital Signs:
Heart Rate: 100/min
Respiratory Rate: 32/min
Temperature: 99°F
Blood Pressure: 90/50 mmHg

Cont..
Anthropometry:
OFC: 41 cm (microcephaly).
Weight: 7.1 kg.
Height: 68 cm.
HAZ: -4.6 SD (severely stunted).
WHZ: - 1.40 SD (normal).

Nervous System Examination
 Higher psychic Function :
Conscious, not oriented to surroundings.
 Cranial nerves examination :
No facial dysmorphysm.
Pupillary size and shape was normal, light
reflex was present.
No squint, eye balls moved in all direction.
Drooling was present, swallowing difficulty
was present.

Cont..
 Motor function :
Muscle bulk : Reduced in all 4 limbs.
Muscle tone : Increased in all 4 limbs, more in
upper limbs.
Muscle power : 2/5 in all 4 limbs.
Reflexes : Normal in all 4 limbs.
Clonus : Absent.
Planter response : Bilaterally extensor.
Involuntary movement : Absent.
 Sensory function : Seems to be intact.
 Fundoscopy : Normal.

Developmental Assessment
 Gross motor :
Pulled to sit - Head lags behind the body line.
 Fine motor :
Couldn’t reach and hold object.
No midline activity.
 Cognition :
Recognizes mother’s lap.
No social smile.

Cont..
 Vision :
Fixes and follows coloured object.
 Hearing :
Doesn’t turn to rattling sound.
 Speech :
No babbling, crying only.
Other systemic examination including
Abdominal examination revealed normal
findings.

Salient feature
Omar Ali, 1 year 6 months old male child, only
issue of his non-consanguineous parents, was
admitted with the complaints of generalized
tonic seizures since 2 months of age, stiffness
of limbs which was more in upper limbs and
no neck control with swallowing difficulty
since early infancy. He had definite history of
perinatal asphyxia with seizure, but no history
of neonatal jaundice, low birth weight or any
significant maternal illness during pregnancy.

Cont..
Omar was mildly pale, severely stunted,
having microcephaly, no neurocuteneous
stigmata or organomegaly. Vitals were within
normal limit. His cranial nerves were intact
except swallowing difficulty , muscle bulk &
power was reduced, but tone was increased in
all limbs (more in upper limbs); motor,
cognition and speech delay was present with
impaired vision and hearing.

Provisional Diagnosis
Spastic tetraplegic cerebral palsy with
microcephaly with epilepsy with motor,
cognition and speech delay with impaired
vision and hearing with secondary
malnutrition.

Differential Diagnosis
Neurometabolic disease with microcephaly
with epilepsy with motor, cognition and
speech delay with impaired vision and hearing
with secondary malnutrition.

Investigations
Complete Blood Count :
• Hb%: 11.9 gm/dl
• WBC: Total count: 10,900/cumm
Differential count:
o Neutrophil: 43%
o Lymphocyte: 53%
o Monocyte: 02%
o Eosinophil: 02%
o Basophil : 00%

Cont..
o RBC:Normocytic normochromic
o WBC:Mature with above
distribution
o Platelet: Adequate
• Platelet : 3,48,000/cumm
• PBF:

Cont..
RBS : 3.4 mmol/L.
S. Electrolytes : Na⁺ - 141.5 mmol/L.
K⁺ - 4.0 mmol/L.
Cl⁻ - 103.6 mmol/L.
S. Calcium : 2.26 mmol/L.
SGPT : 40 U/L.

Cont..
CT Scan of Brain : Mildly dilated ventricles
with widened CSF spaces.
EEG : Epileptiform discharge over B/L
temporo-parieto-occipital area.

Final Diagnosis
Spastic tetraplegic cerebral palsy with
microcephaly with epilepsy with motor,
cognition and speech delay with impaired
vision and hearing with secondary
malnutrition.

Management
Multidisciplinary team approach :
Paeditritian/Paediatric neurologist works as a
team leader involving-
• Physiotherapist.
• Occupational therapist.
• Speech-language therapist.
• Psychologist.
• Ophthalmologist.
• ENT specialist.
• Orthopaedic surgeon.
• Special school and teacher & social worker.

Cont..
 Counseling.
 Nutritional management :
NG tube feeding (F - 75).
Multivitamin, folic acid, Vitamin A and zinc
supplementation.
 Management of epilepsy :
Syp Phenobarbitone.
Tab Nitrazepum.

Cont..
 Management of spasticity :
Tab Beclofen.
Physiotherapy.
 For vision & hearing :
Consultation with ophthalmologist and ENT
specialist.
 Neuro-developmental therapy and
stimulation.
 Follow up

Cp omar ali

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Cp omar ali