Cerebral palsy

Cerebral palsy
Cerebral palsy (CP), defined as a nonprogressive disorder of
posture or movement due to a lesion in the developing brain.
Types of CP are given different names based on the type of movement
problem and the areas of the body affected:
Spastic

Ataxic
Dyskinetic
Mixed
Quadriplegia
Diplegia
Hemiplegia

 The brain damage that causes cerebral palsy is a result of either:

Prenatal disturbance of brain cell migration

Prenatal poor myelination (insulation) of developing nerve cell fibers
Perinatal brain cell death
Postnatal non-functional or inappropriate connections (synapses)
between brain cells

 CLARIFYING TERMINOLOGY ( Causes )

Brain development
Brain defects
Brain malformations
Brain lesions

 In most cases, the cause of congenital cerebral palsy is

unknown. Some possible causes are:

Infections during pregnancy

Severe jaundice in the infant.
The physical and metabolic trauma of being born.
Severe oxygen deprivation to the brain or significant trauma to
the head during labor and delivery.

 Signs and Symptoms

Other symptoms of CP related to movement can include:

Tight muscles that worsen with stress, illness, and time

Tight joints that do not bend or stretch all the way, especially in the hands,
elbows, hips, knees, or ankles

Muscle weakness, or a decline in movements that the child had already been
performing

Lack of efficient movement of the legs, arms, trunk, or neck

Lack of coordination
"Floppy" muscles, especially in the neck or trunk
Muscle tremors

Other symptoms of CP related to movement can include:

Tight muscles that worsen with stress, illness, and time
Tight joints that do not bend or stretch all the way, especially

in the hands, elbows, hips, knees, or ankles

Muscle weakness, or a decline in movements that the child
had already been performing
Lack of efficient movement of the legs, arms, trunk, or neck
Lack of coordination
"Floppy" muscles, especially in the neck or trunk
Muscle tremors

Diagnosis

lack of alertness
Abnormal, high-pitched cry
Trembling of the arms and legs
Poor feeding abilities secondary to problems sucking and swallowing
Low muscle tone
Abnormal posture, such as the child favoring one side of the body
Seizures, staring spells, eye fluttering, body twitching
Abnormal reflexes.

Diagnosis
Testing motor skills and reflexes,
Looking into medical history, and
Employing a variety of specialized tests.

Demographic Information:

Initial Evaluation
History of Present Illness
Past Medical History
Personal, Social and Environmental History
Family History
Physical Examinations
Problem List
Treatment Plans and Management
Home Instructions, Progress notes and discharge plan.

Initial Evaluation

Name: Melissa Wingerd

Age: 5 y/o
Sex: Female
Martial Status: Single
Address: 1306 Winding Walters Circle, Coral Springs,
Florida.
Occupation: None

Therapy/Education
Present Therapy Schedule:School program offers OT, PT and ST 3 X / week

each, for 30 minute sessions.

School Program:Upcoming school year she will be in a multidisciplinary
program at Maplewood Elementary. It is like a second year of preschool. They
actually are in Coral Springs Elementary School district, but all four kids are
going to return to Maplewood at least for one more year, so they can be at same
school.
Summer School Schedule:Goes to daycare.
After School Care:Goes to daycare after school.
Transportation To/From School:Mom will take them to school and daycare
will pick them up.

Rehabilitation Program(s)
[In/Outpatient Since Injury]:

She was initially transferred from North Broward Medical Center to Broward General
Hospital on March 24, 1999. She remained in Broward General until the end of April, when
she went back to North Broward Medical Center where she remained for approximately one
week. She was then transferred to Chris Evert Childrens Hospital where she stayed from
5/18/99 8/17/99. She began some OT and PT while in All Childrens. Discharge summary
noted the following:
31+ week Quadruplet B.
Congenital hydrocephalus.
Tetralogy of Fallot.
Cleft palate.
Apnea.
Retinopathy of prematurity (Resolved).

Gastroesophogeal reflux.
Enterococcus sepsis.
IV Infiltrate right foot.
Paralyzed left diaphragm.
Small residual ventricular septal defect, mild residual pulmonic
stenosis, mild to moderate pulmonary regurgitation.
Hypochloremic metabolic alkalosis.
Nephrocalcinosis.
Nasopharyngeal reflux.

Current Disability

Disabling Problems: (By client/family history and report. No physical examination occurred).

Chief Complain.
Nora(Mother): My understanding with the hydrocephalus is she will have the

shunt for the rest of her life. As a result, when she has a headache or a fever I
watch a little closer because I never know if it is shunt related or not. As for
the developmental delays, no one has been able to tell us what that will really
mean and only time will tell. I know they are there because I have three
others to compare her to. Her analytical skills, her reasoning skills, even the
way she plays are just not like the other children. Melissa is consistently six
plus months behind where the other children are in play activities even when
she has the other children to mimic. I see a lot of discrepancies with her fine
motor skills. Her sisters and brothers can write their names, while Melissa
can spell her name, but she cant even trace her name. Her siblings can color
in the lines, but Melissa simply cant. With some of her gross motor skills, she
shows a problem with her balance. In hopping on one foot, riding a bike,
using the trampoline, she has balance problems. In other skills, she is
emerging but very much behind her siblings. She has constant problems with
her asthma, especially with weather changes or if she develops a cold. She is
being monitored on an annual basis for her heart, but right now everything

Past Medical History

Shunt surgery at five weeks of age. Revision done one week later. She had a
shunt infection in November of 1999 with a revision and she had a shunt
malfunction in May of 2000 with a revision. Cleft palate surgery done February
of 2000. She has had follow-up Flap surgery done in relation to the cleft palate
in February of 2004
She had one heart surgery to correct the Tetralogy of Fallot. This was
successful.
She has had repetitive ear infections and could not pass hearing exams. So she
had tubes placed in her ears.
She had eye muscle surgery done in December of 2003. This was to correct
crossed eyes

Developmental Delay
Seizure Disorder
Type: None

Surgeries
Performed: Shunt and shunt revisions, tonsillectomy, tubes in ears,
gastrostomy when she was a baby, strabismus surgery and cleft palate
surgery.
Anticipated:Possible shunt revisions if malfunctions. 50% of
strabismus surgeries have to be repeated.

Daily Care
Current Attendant and/or Nursing Care:Parental care and daycare.
Bowel/Bladder Program:Potty trained. She will wear a pull-up at night.
Self-stimulating Behaviors:None.

Motor Skills
Bring Hands to Midline:Yes.
Grasp (Left/Right):Intact.
Grasp with thumb & forefinger:Yes.
Voluntary purposeful movements (upper & lower extremities):Yes.
Sit unassisted:Yes.

Hold head erect:Yes.

Roll front to back:Yes.
Roll back to front:Yes.
Pull self upright:Yes.
Drink from cup:Yes.
Drink from bottle:No.
Tube feeding schedule:No.
Ambulate:Wide based gait with some balance deficits

 Assist in dressing:Yes.
Perform household chores:No, not even at an age
related level. It is difficult for her to follow multi-step
instructions.
Perform personal hygiene:She can bathe herself with
assistance.
Crawl:Yes.
Ascend/descend stairs:With hand-holding assistance.

Social Skills

Smile:Yes.
Laugh out loud:Yes.
Dintinguish family from strangers:Yes.
Demand personal attention:Yes.

Long-Term Care Options

Facility/Home Care:Home care.
Anticipated Treatments: Nothing scheduled as far as
treatment interventions. She has her regular physician
visits scheduled and those will continue.

Physical Limitations
Loss of Tactile Sensation:Tactile sensation is intact. She is very sensitive on

bottoms of her feet.

Reach:Normal reaching ability with full range of motion.
Lift:She does not have the muscle strength to lift at a peer related ability. She can
lift, but weight amount is limited.
Prehensile/Grip:Normal grip strength.
Sitting:Normal ability to sit. She does have difficulty sitting still for long periods of
time.
Standing:She can stand at a age appropriate level.
Walking/Gait:She does walk with a somewhat wide based gait. She has some
balance deficits. Gait is not smooth. Running is more difficult. She does fall frequently.

 Bend/Twist:Bending and twisting at the waist is an emerging skill, but at this

time she will primarily bend at the knees and stoop to pick something up.
Kneel:She can do this at age appropriate level.
Stoop/Squat:She can do this at age appropriate level.
Climb:She can climb stairs, but she needs standby assistance and usually hand
holding. Descending stairs is much more precarious than ascending.
Balance:Balance deficits. Balance is fair, but improving.
Breathing:She has Asthma. Bronchial Pulmonary Dysplasia. When she gets a
cold it compromises her breathing. Seasonal allergies. Nebulizer used during
colds and seasonal allergies only. Mom estimates episodes requiring Nebulizer
treatments about six times per year.

 Headaches:She has recently complained of headaches. This was the first time

she had ever complained of a headache. They went to ER and the shunt was
checked and it was functioning well.
Vision:She has had eye muscle surgery for strabismus in both eyes. She does
not wear glasses, vision tested and they feel she is near sighted but not bad
enough to require corrective lenses at this time. Monitoring every 6 months.
Hearing:She has PE tubes in both ears. She has a mild hearing loss in both ears.
Not sure what level. No need for correction at this time.
Driving:Possible candidate in the future. Will need handicapped evaluation.
Physical Stamina (average daily need for rest or reclining):She tires much
more easily than her siblings. She has to have a nap.

Environmental Influences
Problems on exposure to:
Air Conditioning:No.
Heat:Yes, sweats profusely.
Cold:No.
Wet/Humid:Yes, Asthma.
Sudden Changes:Yes, Asthma.
Fumes:Yes, Asthma.
Noise:Yes, very short attention span in noisy environments.
Stress:No, very social child.
Other:She has more difficulty interacting with peers than she does with
adults.

Medical Summary
Melissa Wingerd is a 5-year-old Caucasian female who
was born with Tetralogy of Fallot, hydrocephalus and a
cleft palate. She was one of quadruplets conceived
through invitro fertilization. She has a VP shunt in place
and is developmentally delayed.