CNS CASE PRESENTATION

Name : Devanesh DOA:19/12/18

Age : 21/2 yrs DOE:21/12/18
Address : Dindikal Informant:mother
Reliability:good
Chief complaints :H/o fever for the past 4 days
H/o seizures 4 days back
HOPI :
Natal history
Full term baby born out of 1st degree consanguinous marriage
Mother's age at conception - 22yrs, she was a diagnosed case of oligohydramnios since 7 mon
ths of gestation.
Baby born by elective c-section from a private hospital since cord was around the neck
B Wt. - 1.7kg
Cried immediately after birth, No H/o NICU admission
Breast fed within 1 hr of birth, No H/o feeding difficulties
Post natal history
No h/o neonatal jaundice
No h/o neonatal convulsions
No h/o sepsis

Developmental history
• Head control not attained
• Social smile not attained
• Bidextrous reach is not there
• No h/o making coos
Child developed seizures at the age of 4 months
Recently baby had 2nd attack of seizures, 4 episodes/day each lasting for 2-3
mins. involving both upper and lower limbs,associated with uprolling of eyes a
nd micturition.No h/o loss of consiousness.
History regarding cranial nerves :
• H/o not following light
• No h/o drooling of saliva
• No h/o difficulty in closing eyes
• H/o turning towards sound
• No h/o feeding difficulties
• No h/o regurgitation

History regarding motor system

• H/o difficulty in changing diapers
• Unable to initiate active movements
• Inability to turn from side to side
• Unable to take food to mouth
• Unable to scribble
History regarding sensory system:
• Child can be pacified by mother's touch
Cerebellum:
• No h/o involuntary movement
Autonomic nervous system:
• No h/o constipation
• No h/o difficulty in passing urine

No h/o fever,vomiting,ear discharge,trauma/head injury.

No h/o dog bite
No h/o recent vaccination
Immunization history:
• Vaccination is incomplete-taken upto DPT 2nd dose
Antenatal history
1st trimester
• Pregnancy confirmed at 3 months of gestation,dating scan taken
• No h/o bleeding pv
• TT first dose taken
• No h/o fever with rashes
• No h/o irradiation
2nd trimester
• TT second dose taken
• Quickening felt at 5th month
• No h/o bleeding pv
3rd trimester
• No h/o PIH, GDM
• Oligo hydramnios Diagnosed at 7th month
• No h/o bleeding PV
Family history
Mother is a known case of seizure disorder under control by medication
Diet history
• 3 glasses of milk/day
Total calorie taken =445 kcal
Daily requirement =1100kcal
Calorie deficit = 655 kcal
No protein deficit
GPE
Child is irritable
Pallor :(+), anicteric, no cyanosis, no clubbing, no pedal edema
No neuro-cutaneous markers
No signs of hypovitaminosis
Vitals
PR : 102bpm, Normal volume, no special character, regular in rhythm, felt in all periph
eral vessels, no radio-radial or radio-femoral delay
RR : 32cpm
BP -90/60 mm Hg in right upper arm in lying posture
Temperature : afebrile
Anthropometry
Wt= 6.5kg against 13kg ~55% - Grade lll malnutrition according to IAP
classification
Length = 75cm against 92cm ~ 81% - according to Waterlow's
classification
HC = 30 cm against 48 cm
examination of central nervous system
Higher function :
• child is irritable
• Able to recognize mother
• handedness could not be elicited
• Speech not attained
Cranial nerve examination :
Ist nerve : Can't be elicited
llnd nerve : Doesn't follow light
lllrd, lVth, VIth nerve : Unable to follow light and object
Vth nerve : Corneal conjunctival reflex (+)
VIIth nerve : No deviation of angle of mouth, Nasolabial fold normal on both sides
No drooling of saliva
VIIIth nerve : Turn head to sound
IXth,Xth nerve : Nasal regurgitation
XIth nerve : Turn head to either side
XIIth nerve : can't be elicited
Motor system examination Nutrit
ion
Right Left
Mid arm 13.5cm 13.5cm
Fore arm 10.5cm 10.5cm
Mid thigh 21cm 21cm
Mid leg 16.5cm 16.5cm

Tone
Right Left

UL Hypertonia Hypertonia

LL Hypertonia Hypertonia
Power

Right Left

Upper limb >3/5 >3/5

Lower limb >3/5 >3/5

Reflexes
Superficial reflexes

Right Left
+
Corneal +

Conjunctival + +

Plantar Extensor Extensor

Abdominal Brisk
Deep tendon reflexes

Right Left
Biceps Exaggerated Exaggerated
Triceps Exaggerated Exaggerated
Supinator Exaggerated Exaggerated
Knee jerk Exaggerated Exaggerated
Angle jerk Exaggerated Exaggerated

Neonatal reflexes
Rooting reflex : (+)
Moro's reflex : (+)
 Examination of other systems
CVS : S1,S2 heard, No murmurs
RS : NVBS, No added sounds
Abdomen : No organomegaly, No free fluid

DIAGNOSIS :A case of spastic quadriplegic type of cerebral palsy with fun

ctional grade V with convulsion and visual defects without squint, hearin
g deficit, and of developmental age 2 months with grade IV Protein ener
gy malnutrition, probable aetiology may be antenatal cerebral insult.
Thank you