CASE PRESENTATION

Presenter: Dr.Swetha P
Final year pediatric resident .
Ramaiah medical college.
• Name : Monisha
• Age: 5 Years 6 Month
• Dob :12/06/2017
• Gender: Female
• Address: Tumkur
• Informant: Mother
• Reliability : Good
CHIEF COMPLAINTS

C/O stiffening of upper and lower limb with up rolling of eyes lasting for 2 to 3 min
( 2-3 episodes) 2 days back

C/o left sided weakness of upper & lower limb since 2 days
HISTORY OF PRESENTING ILLNESS
• A 5 ½ old female child who was apparently normal 10 days back ,currently brought with
complaints of stiffening of B/L upper & lower limb with uprolling of eyes ,frothing in mouth ,no
voluntary passage of urine & stools lasting for 2-3 minutes associated with loss of consciousness
for 1-2 min ,followed child was drowsy.

• Child presented with similar episode for which child was treat with iv medication ( antiepileptics) .
child was said to be drowsy in between the episodes.

• Child had no further such episodes following iv medication, regained consciousness .

HISTORY OF PRESENTING ILLNESS
• Following convulsion ,mother noticed paucity of movements in left upper and lower limb . It was
sudden in onset in the form of not moving left upper & lower limb , was not able to grasp the
objects when placed & not able to lift hand above head, noticed that the child is moving left arm
along the bed . Mother also gives a history that the child was using only the right hand to approach
&grasp objects.

• Mother noticed child is able to lift leg above the bed , but noticed dragging of left foot while
walking & difficulty in holding slippers , which was not noticed in right foot .

• Able to lift head off from the bed and roll over to side & able to sit on her own
HISTORY OF PRESENTING ILLNESS
• Child is able to fix on objects ,follow ,able to identify colors ,objects both near &
far.
• No h/o abnormal movements of eyes.
• No h/o drooping of eyelids ,drooling of saliva, facial symmetry, deviation of
angle of mouth.
• Child is able to turn towards sound & respond appropriately when spoken to or
asked questions.
• No h/o regurgitation of feeds ,difficulty in swallowing of foods.
HISTORY OF PRESENTING ILLNESS
• No h/o difficulty in answering to mother questions fluently
• No h/o clumsiness /involuntary movements.
• Able to perceive clothes, warm and cold water
• No h/o numbness or tingling sensation
• No h/o difficulty in perceiving fullness of bladder , drippling of urine ,diarrhea,
constipation.
• No h/o excessive sweating ,palpitations ,flushing
HISTORY OF PRESENTING ILLNESS
• At 4 ½ years ,H/o red spots over tongue,, bleeding from gums , no joint swelling . she was evaluated &
treated with oral medication ,following her symptoms improved. H/o similar bleeding occurred after 1
month, improved with oral medication and on regular follow up .No history of any bleeding
manifestation at present
• No h/o fever with rash & chronic ear discharge ,neck stiffness, vomiting ,blurring of vision
• No h/o head injury & intra oral injury
• No h/o recent vaccination
• No skin rash , joint pain ,swelling of joints .
• No h/o hematuria ,facial puffiness ,reduced urine output
• No h/o sudden onset of breathlessness, refusal to feeds ,swelling of lower limb with bluish
discoloration of skin
• No h/o pallor ,abdominal distension,painful fingers,sudden onset of pain abdomen, recurrent leg ulcers.
HISTORY OF PRESENTING ILLNESS
• No h/o bone pain, weight loss, reduced appetite, prolonged fever with night
sweats
• No h/o loose stools ,vomiting with reduced activity &reduced urine output.
Past history
• No h/o similar complaints in the past
• No h/o previous blood transfusion.
• No h/o chronic drug intake , other drug taken for blood disorder
• No h/o previous admission for respiratory distress /altered sensorium
• No h/o surgeries in the past .
Family history
• Ist order born child to 3rd degree consanguious married couple
• No h/o seizure disorder in the family
• No h/o developmental delay in the family
• No h/o TB ,chronic cough in the family
Antenatal history
• Pregnancy confirmed by UPT
• Booked case
• No h/o fever with rash ,painful swelling behind ears, exposure to pets during pregnancy
• No h/o high BP /sugar readings ,thyroid disorder
• No h/o bleeding /leaking pv , foul smelling discharge ,burning micturiation during pregnancy
• No h/o radiation exposure during pregnancy
• Antenatal scans said to be normal ,quickening felt at 5 month of pregnancy
• Said to have taken inj TT ,iron ,folic acids&b calcium supplements
Birth history

• Born at 36 weeks via emergency LSCS i/v/o fetal distress with birth weight 2.2kg
• Baby said to cried immediately after birth, shifted to mother side, initiated breastfeeding within 1
hour. However said to have fast breathing requiring NICU observation and connected to O2
support and shifted to mother side the next day.
• There was no h/o abnormal movements, reduced activity ,lethargy ,refusal to feeds in the natal
period.
• No h/o fever , discharge from the umbilical cord ,delayed separation of umbilical cord.
• Discharged on day 4 of life and DBF continued.
IMMUNISATION HISTORY

• Immunized as per NIS schedule

• Last vaccination was done at 5 ½ years
• BCG scar present
DEVELOPMENTAL HISTORY
Gross motor:
neck holding -3 months
Roll over- 6 months
Sits with support – 6-7 months
Sits without support -9 months
Stands with support -11 months
Stands without support -12 months
Walks without support – 1 year 2 months
Runs-18 months
Comes downstairs- 2 years
jumps on both feet – 2 years 7 months
Rides tricycle- 3 years
Hop on one leg – 4 years 3 months
Jumps backward – 5 years 2 months

Inference –Normal
Developmental age -5 years 6 month
• FINE MOTOR
• Bidextrous reach -6 months
• Unidextrous reach -7-8 months
• Mature pincer grasp -10 months
• Spoon feeding
• Scribbles- 15 months
• Draw lines – 18-20 months
• Draw circle-3 years
copies triangle 4- 5 years

Inference –Normal
Developmental age -5 years 6 month
Social
• Social smile- 4 months
• Recognizes mother 4 months
• Stranger anxiety -9 months
• Waves bye -10-11 months
• Spoon with spiling -1 year 3 months
• Dress ,undress-3 years
• Toilet alone -4 years 6 months
• Independent bathing – 5 years 3 months

• Inference –Normal
• Developmental age -5 years 6 month
Language

• Coos- 3 months
• Monosyllable word- 6 month
• Bisyllable word- 9- 10 months
• 2-3 words with meaning- 1 year
• 2 word sentences -2 years
• Tells his name ,gender – 3 years
• 4 word sentences , stories -4 years
• Says a rhymes- 5 year

• Inference –Normal
• Developmental age -5 years 6 month
• Vision –normal
• hearing – normal
DIET HISTORY
EXPECTED OBSERVED REMARKS

KCALORIES 1400 1250 DEFICIT OF 150

PROTEIN 23G 28G

MIXED DIET
TAKES FROM FAMILY POT
SOCIOECONOMIC STATUS
• Belongs to lower middle class according to modified kuppuswamy classification
• Father -10th std -4
• Occupation driver -4
• Income 20000/month -6

• Total- 14-class III

SUMMARY

• 5 ½ year old female of birth order 1 ,born of consanguineous marriage , with

uneventfull antenatal ,natal history , normal developmental milestones attained as
per age ,immunized ,belonging to class 3 kuppuswamy scale brought with
complaints of GCTS ,followed by left sided weakness of upper and limb ( more
in the upper limb ),my probable diagnosis
• Functional : left sided hemiparesis (UL> LL) with no speech disturbance with no
cranial nerve palsy ,sensory, cerebellar involvement

• Anatomy : Right middle cerebral artery

• Level of lesion : cortical level

• Etiology : Hemorrhagic stroke

vascular eitology
• Platelet disorder
• Hematological – sickle cell anemia, iron deficiency anemia
GENERAL PHYSICAL EXAMINATION
• Child is conscious, alert ,oriented to time ,place and person, examined in both supine and sitting
position.

• VITALS
• TEMP-afebrile
• PR:110bpm,regular volume ,no radioradial/ radiofemoral delay. All peripheral pulses felt well
• RR: 28cpm ,abdominal thoracic type
• BP-90/64mmhg in R UL in supine position
• Spo2 -98% in room air
 ANTHROPOMETRY
EXPECTED OBSERVED CENTILE INFERENCE
WEIGHT 19KG 22 KG 50-75TH Normal
HEIGHT 118CM 112 CM 25-50th Normal
BMI 15KG/CM2 17 KG/CM2 50-75th Normal
HEAD 50 CM 49.5 CM 25th-50th Normal
CIRCUMFERENCE

Appropriate for age and sex

HEAD TO TOE EXAMINATION
• HEAD- normal shape,size ,sutures closed

• HAIR- normal texture ,shiny , non-puckable , black in color

• EYE- no pallor,icterus,coloboma,cataract ,chrioretinitis,cheery red spots ,corneal /conjunctival xerosis ,bitot

spots

• EARS- no low set ears ,no discharge,TM b/l intact

• ORAL CAVITY –lips & tongue –N ,no cheilitis ,stomatitis ,oral ulcers ,uvula central,posterior pharyngeal wall
normal

• NECK- no low hairline,short neck,no lymphadenopathy

HEAD TO TOE EXAMINATION
• CHEST- normal

• ABDOMEN- normal

• EXTERMITIES-no polydactyly, brachy,pedal edema, clubbing

• SPINE- normal

• GENITALIA- normal

• SKIN – no pallor , cyanosis ,neurocutaneous marker

CENTRAL NERVOUS EXAMINATION
• HIGHER MENTAL FUNCTION
• Conscious,oriented to time place ,person
• GCS-15/15
• Memory- distant,recent,immediate-intact
• Speech-normal fluency ,comprehensibility
• Handedness – right
CRANIAL NERVE EXAMINATION
• I- B/L intact,able to smell coffee powder

• II –
visual acuity 6/6 b/l
Color vision –normal
Field of vision –normal
Accomdation reflex,light reflex-normal
Fundus –normal , no cheery red spots,chorioretinitis

• III,IV,VI – b/l eye movements normal in all direction , no squints

CRANIAL NERVE EXAMINATION
• V- b/l sensation over face +
• Corneal & conjunctival reflex+

VII – no loss of forehead creases

No ptosis
No deviation of angle of mouth
Able to blow
Taste sensation present in ant 2/3rd of tongue

VIII- turns to sound, rhines – AC>BC ,webers – no laterization

CRANIAL NERVE EXAMINATION
• IX,X –uvula in central position ,gag reflex +,
• XI-able to turn neck to one side
• No shrugging of shoulder

• XII- no deviation of tongue, no fasciculation

 MOTOR SYSTEM

• BULK – NORMAL , no hypertrophy or atrophy in thenar and hypothenar prominence.

Right Left
• Power
Shoulder ( flexion,extension,abduction,adduction,IR,ER ) 5/5 2/5
Elbow( flexion , extension ) 5/5 2/5

Wrist (flexion,extension, ulnar & radial deviation 5/5 2/5

MCP/IP joints (flexion, extension) 5/5 2/5

Palmar/dorsal interossei 5/5 2/5

Hip ( flexion,extension,abduction,adduction,IR,ER ) 5/5 3/5

Knee ( flexion , extension ) 5/5 3/5

Ankle( dorsiflexion,palmarflexion) 5/5 3/5

 TONE
Right Left
Shoulder ( flexion,extension,abduction,adduction,IR,ER ) Normal Spasticity
Elbow( flexion , extension ) Normal Spasticity

Wrist (flexion,extension, ulnar & radial deviation Normal Spasticity

MCP/IP joints (flexion, extension) Normal Spasticity

Palmar/dorsal interossei Normal Spasticity

Hip ( flexion,extension,abduction,adduction,IR,ER ) Normal Spasticity

Knee ( flexion , extension ) Normal Spasticity

Ankle( dorsiflexion,palmarflexion) Normal Spasticity

REFLEX
RIGHT LEFT
BICEPS 2+ 3+
TRICEPS 2+ 3+

BRACHIORADIALIS 2+ 3+

KNEE 2+ 3+

ANKLE 2+ 3+
PLANTAR Flexor Extensor
ABDOMINAL + +
CREMASTIC + +
SENSORY SYSTEM
• Responds to touch,pain,pressure ,hot & cold
• Not able to asses cortical sensations

• CEREBELLAR SIGNS
• No nystagmus
• Able to perform R finger to nose
• Gait – not able to assess

• MENINGEAL SIGNS – absent

• SPINE – normal
• RESPIRATORY SYSTEM :
b/l equal air entry +,NVBS+ ,no added sounds

• CVS :S1S2 heard normally ,no murmur

• PA :
• Soft ,non tender ,no organomegaly , bowel sounds heard normal.
SUMMARY

• 5 ½ year old female of birth order 1 ,born of consanguineous marriage , with

uneventfull antenatal ,natal history , normal developmental milestones attained as
per age ,immunized ,belonging to class 3 kuppuswamy scale with a known case of
platelet disorder brought with complaints of GCTS ,followed by left sided
weakness of upper and limb ( more in the upper limb ).

• On examination shows left side UL-2/5 power ,LL-3/5 ,with spascity ,with brisk
DTR in left UL &LL with extensor plantar.