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7/29/2019 Case Report Microcephaly (1)
1/22
Case Report
Handicapped Patients
7/29/2019 Case Report Microcephaly (1)
2/22
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.
7/29/2019 Case Report Microcephaly (1)
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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.
7/29/2019 Case Report Microcephaly (1)
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Initial Differential Diagnosis
Please list at least 2 Differential Diagnoses
Neck Pain Mental Retardation
Not speaking
7/29/2019 Case Report Microcephaly (1)
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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
7/29/2019 Case Report Microcephaly (1)
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What does this mean?
Cause of cervical pain?
Mental Retardation?
Fasciculations? Not speaking?
7/29/2019 Case Report Microcephaly (1)
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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
7/29/2019 Case Report Microcephaly (1)
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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
7/29/2019 Case Report Microcephaly (1)
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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
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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
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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.