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Short Case Pediatric: Approach to Cerebral Palsy By: Mat Ali AAA, AR Muhamad Naim, Maznon MH, Wahab F, Ab Wahid MN, Ismail AM.Notes: this is the examples of approaching Cerebral palsy patient in short case examination forprofessional 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.)
Upper motor neuron lesion - Hypertonic - Hyperreflexia - Clonus - Babinski (+ve) - No muscle wasting/ fasciculationExamples of presenting CP caseExaminer: Look at this patient and tell me what system you want to examineAnswer: 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 couldnot 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 byplotting the growth chart. There is present of microcephaly. Hydrational and nutritional statusclinically adequate. There is fisting of bilateral arm with flexion of the arm and elbow joint. Herleg is in scissoring posture. There are no abnormal movement and no other attachment to thebodyOn examination of the lower limb, there is present of bilateral upper motor neuron lesionevidence of hypertonic, hyper reflexia and positive Babinski sign. Apart from that, patient alsohas dislocation of the left hip and contracture at lateral and medial hamstring muscle.
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 injuryManagement 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)