Case Report Microcephaly (1)

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    Case Report

    Handicapped Patients

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    History

    On 2-11-06 a 25 year old black male presented to

    the Palmer Clinics with a chief complaint of neck

    discomfort. His mother is being seen in the

    Clinic for neuromusculoskeletal conditions andwould like to have her son seen as well.

    Complicating Factors:

    Patient suffers from mental retardation and doesnt speak.

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    History

    Parents first noticed a developmental problemwhen he was 2 years old. Prior to this he hadbeen on penicillin for almost one year fortreatment of otitis media. At this time they weretold his brain was growing slower than normal.

    He doesnt speak but does understand words andcan locate the source of sound.

    His mother would like to see if we can help him.He had received chiropractic care in the past and

    had some improvement in his demeanor. Theystopped going however, because he didnt likethe HiLo table and was afraid of the doctor.

    He has been complaining of neck pain lately.

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    Initial Differential Diagnosis

    Please list at least 2 Differential Diagnoses

    Neck Pain Mental Retardation

    Not speaking

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    Examination

    Pronating Gait

    Head Circumference isobserved to be smallerthan normal

    Right Head tilt Left Shoulder and hip tilt

    BP: 130/80

    Brachioradialis Reflex+4/2

    Could not preformorthopedic exam orcervical ROM due topatient comfort

    Fasciculations increasewith left sided sensorystimulation

    Hypertonic trapeziumcervical musculature onthe left

    Patient can Follow basicinstructions

    Can recognize source ofsound

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    Examination

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    What does this mean?

    Cause of cervical pain?

    Mental Retardation?

    Fasciculations? Not speaking?

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    Patient Management Plan

    As of 2-17-2006 patient is seen for Cervical

    subluxation (739.1) with associated

    cervicalgia (723.1), Complicating factors

    include Microcephaly (742.1) and MotorAphasia (784.5); at 1 time per week for 4

    weeks, followed by 2 times per month for 6

    weeks to decrease neck discomfortintensity, frequency and duration.

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    Microcephaly

    Definition: describes a head size (measured asthe distance around the top of the head)significantly below normal for a person's age andsex, based on standardized charts.

    Considerations: Microcephaly most oftenoccurs because of failure of the brain to grow ata normal rate.

    Conditions affecting brain growth that can causemicrocephaly include; infections, geneticdisorders, and severe malnutrition.

    Dorland's Illustrated Medical Dictionary

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    Microcephaly can be present atbirth or it may develop in the firstfew years of life. It is most oftencaused by genetic abnormalities

    that interfere with the growth ofthe cerebral cortex during theearly months of fetaldevelopment.

    It is associated with Downs

    syndrome, chromosomalsyndromes, and neurometabolicsyndromes. Babies may also beborn with microcephaly if, duringpregnancy, their mother abuseddrugs or alcohol, became infectedwith a cytomegalovirus, rubella(German measles), or varicella(chicken pox) virus, or wasexposed to certain toxicchemicals.

    National Institute of Neurological disorders and Stroke

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    Depending on the severity ofthe accompanyingsyndrome, children with

    microcephaly may havemental retardation, delayedmotor functions and speech,facial distortions, dwarfism orshort stature, hyperactivity,

    seizures, difficulties withcoordination and balance,and other brain orneurological abnormalities.

    Some children withmicrocephaly will havenormal intelligence and ahead that will grow bigger,but they will track below thenormal growth curves forhead circumference.

    National Institute of Neurological disorders and Stroke

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    There is no treatment for microcephaly that can return achilds head to a normal size or shape.

    Treatment focuses on ways to decrease the impact ofthe associated deformities and neurological disabilities.Children with microcephaly and developmental delaysare usually evaluated by a pediatric neurologist andfollowed by a medical management team.

    Early childhood intervention programs that involvephysical, speech, and occupational therapists help tomaximize abilities and minimize dysfunction.

    Medications are often used to control seizures,hyperactivity, and neuromuscular symptoms. Genetic

    counseling may help families understand the risk formicrocephaly in subsequent pregnancies

    National Institute of Neurological disorders and Stroke

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    What is the prognosis?

    Some children will only have mild

    disability. Others, especially if they are

    otherwise growing and developing

    normally, will have normal intelligence andcontinue to develop and meet regular age-

    appropriate milestones.

    National Institute of Neurological disorders and Stroke

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    History with our Patient

    Diagnosed at the age of 2 with

    Microcephaly

    Prior to his diagnosis he was prescribed

    penicillin for over a year to treat chronic

    otitis media.

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    Motor Aphasia

    aphasia (aphasia)(-fazh) [a-1 + Gr.

    phasis speech] any of a large group of

    speech disorders involving defect or loss

    of the power of expression by speech,writing, or signs, or of comprehending

    spoken or written language, due to injury

    or disease of the brain or to psychogeniccauses. Less severe forms are known as dysphasia. See alsoagrammatism, dysphasia, andparaphasia.

    Dorland's Illustrated Medical Dictionary

    http://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_d_24zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_d_32zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_20zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_43zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_p_05zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_p_05zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_43zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_20zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_d_32zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_d_24zPzhtm
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    Motor Aphasia

    motor a. aphasia in which there isimpairment of the ability to speak andwrite, owing to a lesion in the insula and

    surrounding operculum, including Broca'smotor speech area. The patientunderstands many written and spokenwords but has difficulty uttering the words.Cf. receptive a. Called also Broca's a., expressive a., frontocorticala., nonfluent a., and logaphasia.

    Dorland's Illustrated Medical Dictionary

    http://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_59zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_59zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_52zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_52zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_52zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_52zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_52zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_52zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_l_14zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_l_14zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_52zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_52zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_52zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_52zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_52zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_52zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_59zPzhtmhttp://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_a_59zPzhtm
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    Fasciculations

    An upper motor neuron lesion indicates

    pathology in the cerebral hemispheres,

    brain stem, or spinal cord. Interruption of

    the inhibitory influences eventually leadsto increased reflexes and an increase in

    muscle tone and spastic paralysis;

    pathologic reflexes appear.Differential Diagnosis and Management for the Chiropractor

    Tomas A. Souza

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    Office Visits

    Visit 1: Patient showed interest in the HiLo

    but wouldnt ride on it and wouldnt lie

    down on it.

    He didnt like to have his neck touched and

    wouldnt sit still.

    He did lie on the toggle table but didnt like

    the nose of the table

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    Office Visits

    Visit 2: Patient didnt want to have is neck

    touched and wouldnt lie still long enough

    for an adjustment.

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    Visit 3: Positive palpation findings for Atlas

    fixation. Patient has difficulty in trusting

    doctors. We moved to a padded side

    posture table and used a speeder boardfor the adjustment. After the adjustment

    was given the room would applaud in

    order to give positive reinforcement to thepatient for getting adjusted.

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    Office Visits

    Visit 4: He missed an appointment due to

    scheduling difficulties but his parents

    report he has been more mischievous

    lately and more active. He is watching alot of basketball (March Madness). He is

    allowing it to be easier to palpate his neck

    but continues to get confused easily anddoesnt completely trust the doctors.

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    Points of consideration

    We have noticed it easier to approach the

    patient when we dont wear the white

    coats.

    First and foremostpatient comfort!

    Dont rush things, hurry with the

    adjustment.