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Approach to Abnormal Gait PowerPoint Presentation

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Description : Case Presentation on a toddler presenting with abnormal gait , early presentation of DMD. Exploring the approach to abnormal gait

Tags : duchenne muscular dystrophy

Published on : Sep 20, 2020 | Views : 1234 | Downloads : 3

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Slide 1-

Team 1 Handover Round 3rd March 2020
Slide 2-

2yr 9mth old Male NKDA PMHx Previously admitted for supracondylar fracture Birth History Term Infant Emergency LSCS for NRFS Born apneic / grunting , required CPAP Followed up by Neonates – given open date Presenting Complaint Difficulty walking for 3 days What are you concerns and what do you want to ask? Started limping after coming back from childcare Takes longer to get up from sitting position MR and FR not aware of any injury/trauma but unsure of any injury in child care Also noted swelling of bilateral calves when gait started getting abnormal but now improving Gait worsened over past few days Unable to stand independently now Sometimes still able to walk but waddles for a few steps then drops down Noted night awakening (cries and points to knee in the middle of leg) Previously able to walk and run with no issues prior to this 3 days
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Further history No intercurrent illness No change in urine colour No weight loss, no loss of appetite No rashes No oral ulcers No joint swelling, joint pain No diarrhea/ constipation No heat/cold intolerance No neck swelling No family history of any muscle problems/rheumatological problems/autoimmune problems (thyroid, bowel)/malignancies No family history of developmental delay or developmental regression No miscarriages previously No regular medications No steroids, no herbal/traditional medicines
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Developmental Milestones Gross motor Able to climb steps one step at atime Hops on 1 foot Under arm pass Able to run and climb over bed Fine motor Stacks cubes Can scribble but MR unsure if can copy circle Speech Can point to things with own hand Knows single words, < 20 words Able to say 'i don't want' Can understand 2 step commands No hearing problem Social When interested in things, brings PR attention to it Able to interact with other children in childcare Dresses unassisted Eats with spoon
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Timeline of Milestones 8 months able to sit supported and stand independently 9-10 months can stand holding on to chair, can pull self up to standing position 15-18 months can stand, can walk with good balance, can pick up objects, has purposeful markings 16-18 months Walk without assistance Able to babble < 1year and say mama papa at 1 year No regression noted
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Physical Examination Alert, comfortable Sitting up in bed Well hydrated, well perfused Moist lips and tongue CRT <2s Non toxic looking Not in respiratory distress Heart S1 S2 heard, no murmurs/gallop Lungs good AE bilaterally , no wheeze, no creps Abdo soft non tender, no guarding, no rigidity, bowel sounds present Ear TM seen bilaterally Nose not congested Throat not injected, no ulcers, no exudates No Rash No goitre No exophthalmos No lid retraction No cervical lymphadenopathy/no axillary lymphadenopathy/no inguinal lymphadenopathy GCS 15 Tone normal Moving all 4 limbs equally against gravity Reflexes 1+ UL and LL bilaterally Spine normal EOM full PEARL 2mm Fundoscopy normal
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Noted bilateral calf hypertrophy Unable to stand from seated on own No tenderness to calves on palpation Not warm not swollen Walks with waddling gait
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What Investigations would you like to do ? FBC PBF CRP ESR LFT TFT LDH Uric Acid Aldolase CK UFEME
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LDH 2951 CK 37372
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Progress in the Ward Referred to Neurology Impression was Muscular Dystrophy , Likely Duchenne’s Muscualar Dystrophy
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Approach to abnormal gait
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Cause of abnormal gait Weakness Pain deformity
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Causes of lower limb weakness
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Causes of limb pain/deformitiy
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Crucial not to miss diagnosis infection malignancy non-accidental injury.
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History Age Timing/duration
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Fever or systemic illness Bruising/bleeding/pallor Preceding illness Morning stiffness, Trauma/seizure/headache/back pain Pain: site, severity, exacerbating/relieving factors, additional sites of pain Medication, toxin
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Examination General appearance: well or unwell, Vitals Posture, abnormal movement, Muscle bulk, deformity Gait assessment (normal walking, heels, toes, outside of feet and running) Neurology examination (tone, power, reflex, coordination, sensation) Abdomen, inguinal Joints
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Quiz Time !!!
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Trivia Quiz DMD is a progressive form of muscular dystrophy that occurs primarily in males True 2. DMD is inherited in an X-linked recessive pattern, it does not occur in people who do not have a family history of DMD False
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Trivia Quiz 3. Muscle Biopsy or Electromyography is required for diagnosis of DMD False 4. Pathophysiology of Calf hypertrophy Calf muscle cells being replaced by fat and connective tissue
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Trivia Quiz 5. Name 5 Complications of DMD Cardiomyopathy Restrictive Lung Disease Cognitive Impairment Scoliosis Oropharyngeal Dysphagia
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Trivia Quiz 6. List 5 types of Childhood Muscular Dystrophies Duchenne’s Muscular Dystrophy Becker’s Muscular Dystrophy Limb Girdle Muscular Dystrophy Facioscapulohumeral Muscular Dystrophy Myotonic Dystrophy Congenital Muscular Dystrophy
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Trivia Quiz 7. Which Anaesthetic Drug is contraindicated in DMD ? Rocuronium Propofol Succinylcholine Midazolam And Why ?
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Trivia Quiz Bonus Qn : Around how many countries / territories are affected by COVID 19 currently ? 95 75 65 55
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Thank you for your participation 