Cerebral Palsy: Model Clinical Case and Viva Q&A
Detailed Case Study of Cerebral Palsy
Patient Information
Name: Emily Thompson
Age: 4 years
Sex: Female
Chief Complaint
Parents brought Emily to the pediatric neurology clinic due to concerns about delayed motor development and difficulty walking.
History of Present Illness
Emily was born at 32 weeks gestation due to preeclampsia. Her birth weight was 1800 grams. She required mechanical ventilation for 3 days due to respiratory distress syndrome. At 2 weeks of age, she developed necrotizing enterocolitis, which was managed medically. Emily's parents noticed she was not meeting motor milestones at the expected times. She did not roll over until 9 months of age and did not sit independently until 15 months. She started crawling at 18 months but with an asymmetrical pattern, favoring her right side. At 2.5 years, she began to pull to stand but had difficulty maintaining balance. Now at 4 years, she can walk short distances with a walker but has a scissoring gait pattern.
Past Medical History
- Premature birth at 32 weeks gestation
- Respiratory distress syndrome
- Necrotizing enterocolitis
- Recurrent urinary tract infections
Developmental History
Gross motor delays as noted above. Fine motor skills are also delayed; Emily has difficulty grasping small objects and using utensils. Language development is relatively preserved, with Emily speaking in 3-4 word sentences. She demonstrates age-appropriate social skills.
Family History
No family history of neurological disorders or developmental delays.
Physical Examination
- General: Alert, cooperative 4-year-old girl, appears small for age
- Vitals: Within normal limits
- Growth parameters: Weight and height below 3rd percentile, head circumference at 10th percentile
- Neurological examination:
- Mental status: Alert, attentive, follows simple commands
- Cranial nerves: Intact, except for mild esotropia of the left eye
- Motor: Increased tone in all extremities, more pronounced in lower limbs. Power 4/5 in upper limbs, 3/5 in lower limbs
- Deep tendon reflexes: Hyperreflexia in all extremities, sustained ankle clonus bilaterally
- Babinski sign positive bilaterally
- Gait: Scissors gait pattern, toe-walking, requires support to ambulate
- Musculoskeletal: Limited range of motion in hips and ankles. No fixed contractures noted.
Diagnostic Studies
- MRI brain: Periventricular leukomalacia, more pronounced in the left hemisphere
- EEG: Normal, no epileptiform discharges
- Hip X-ray: Mild hip subluxation on the left side
Assessment
Based on the history, physical examination, and neuroimaging findings, Emily is diagnosed with spastic diplegic cerebral palsy, GMFCS level III.
Management Plan
- Physical therapy: 3 times per week, focusing on gait training, balance, and strengthening exercises
- Occupational therapy: Twice weekly, addressing fine motor skills and activities of daily living
- Speech and language therapy: Weekly sessions to support language development
- Orthopedic consultation: For management of hip subluxation and consideration of orthotic devices
- Botulinum toxin injections: Consider for management of lower limb spasticity
- Nutritional support: Referral to a dietitian for optimizing growth and nutrition
- Ophthalmology referral: For assessment and management of esotropia
- Urological evaluation: Given history of recurrent UTIs
- Early intervention educational services: To support cognitive and social development
- Family support and education: Provide resources and counseling to parents
Follow-up Plan
Regular follow-up with the pediatric neurology team every 3 months to monitor progress and adjust management plan as needed. Reassess for additional needs such as assistive devices or potential surgical interventions as Emily grows.
Click here to read about CEREBRAL PALSY: etiology, types, diagnosis and management
Varieties of Presentation
Spastic Quadriplegia
A 3-year-old boy presents with severe motor impairment affecting all four limbs. He has increased muscle tone, scissoring of the legs, and clenched fists. The child cannot sit independently, has poor head control, and experiences frequent seizures. Speech is absent, and he has difficulty swallowing. MRI shows periventricular leukomalacia.
Hemiplegic Cerebral Palsy
A 2-year-old girl shows asymmetrical motor development. Her right arm and leg are weaker and stiffer than the left side. She walks with a limp, favoring her left side, and keeps her right hand fisted. Fine motor skills are impaired in the right hand. MRI reveals a focal infarct in the left middle cerebral artery territory.
Athetoid (Dyskinetic) Cerebral Palsy
A 4-year-old boy exhibits involuntary, slow, writhing movements of his arms, legs, and trunk. These movements worsen with stress and disappear during sleep. His muscle tone fluctuates between hypertonia and hypotonia. Speech is difficult to understand due to impaired control of the tongue and vocal cords. History reveals severe jaundice in the neonatal period.
Ataxic Cerebral Palsy
A 5-year-old girl presents with difficulties in balance and coordination. She has a wide-based, unsteady gait and intention tremor when reaching for objects. Her speech is slow and halting. Fine motor skills are poor, affecting handwriting and self-care activities. MRI shows cerebellar hypoplasia.
Mixed Cerebral Palsy (Spastic-Dystonic)
A 6-year-old boy shows features of both spasticity and dystonia. He has increased muscle tone in his legs with scissoring gait, but also experiences intermittent, twisting postures of his trunk and arms, particularly when attempting voluntary movements. Cognitive function is moderately impaired, and he has strabismus. MRI reveals basal ganglia injury and periventricular white matter damage.
Knowledge Check: Question and Answers for Medical Students & Professionals
This interactive quiz component covers essential viva questions and answers. It includes 30 high-yield viva questions with detailed answers.
