Delayed Development : unable to hold up the head, sit, speak and walk since birth

Delayed Development : unable to hold up the head, sit, speak and walk since birth

Name: XXXXXXXX            Age: 5 Yrs                              Religion: XXXX 

Presenting Complaints:

Unable to hold up the head, sit, speak and walk since birth

HOPC:

 At 5 months of the child’s age, the parents observed that he wasn’t able to hold his head up, and was not able to sit up, therefore they seeked medical advice

Mother’s history:

• 3 pregnancies: 1 Male, FTNVD @ hospital, 7 years male
  • 5 yrs Male – the child in question
  • 3yrs male, FTNVD @ hospital
• Age at pregnancy 22 yrs
• Planned pregnancy
• During pregnancy: Cheerful, developed dry cough at 6 months pregnancy, took allopathic t/t
• Only 2 ante-natal visits, in the first trimester, no visits after that ( during any of her visits, her husband didn’t accompany her, therefore she stopped going for ANC)
• No H/O any major illness, aversion or even desire, or even nausea( nausaea was present in her previous 2 pregnancies)
• LABOUR: spontaneous pains, no rupture of membranes, was administered allopathic medicine as the labour was prolonged, excessive bleeding from vaginal orifice was resultant which continued for 4-5 hours, episiotmy given, FTNVD

Child At Birth:

• Wt: 2.9 kg,
• Child did not cry at birth, no spontaneous breathing, pt was resuscitated
• Was on ventilator of 15 days, was diagnosed with Hypoxic Ischemic Encephalopathy
• Mother’s milk was given from 3^rd day
• Child was given to mother at 16^th day, for feeding
• No other neonatal problems

 Past History:

• Chicken pox: 6-7 months
• Vaccination: BCG, DPT-1,2,3, OPV-1,2,3, HPB-1,2
• Teething: 2 erupted before 1 yr of age
• History of epilepsy at 8 months of age( EEG showed abnormal sleep pattern)

 Physical Generals:

Thermal reaction: cannot be ascertained, as the child doesn’t express any of his desires, towards chilly as told by his grandmother

Appetite: decreased, cries when hungry

Thirst: Normal, 2-3 glasses/day

Urine: D4-5 N 2-3

Stool: D1-2, N0-1

Sleep: Normal

Desire: N.S. (Rice, Pulses, Salty)

Aversion: Sweet

Perspiration: Normal

 Mental Generals : Fear of darkness, lights are switched off after he sleeps, wants someone near him, cries when alone, during sleep there is jerking of lower limbs, also startling from sleep, even from slightest noise and also from loud bangs and thunderstorm

Systemic Examination:

Head: alopecia patch on lt aspect

Eyes: Convergent Squint, Pupilary reactiont to light +, Fundus- +

CNS: Sensation of temp –  lost 

                Spasticity – + All movements

                DTR: Brisk

                Muscle tone: Increased

                Wasting: + B/L

                Feet: Plantar flexed

                Neck holding: -ve

                Sitting with Support: +

                Sitting without support: -ve

                Recognition of mother and family: +

                Social smile: +

 Investigations:

 Mother’s USG: at 23 weeks, wt: 559gm, Cardiac Rate: 144 bpm, Presentation: Breech,  healthy live foetus, USG age corresponding with EDD

NCCT Head: Bilateral frontotemporal atrophy with cystic encephalomalacial changes noted in the underlying white matter and right gangliocapsular region. Ex-vaccu prominence of ventricular system is noted

Treatment History:

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• December 4, 2021