MEDICAL
REPORT
P. M , 7 YEARS, MALE
WCA/6069/2023
Diagnosis:
Cerebral Palsy
The above-named was on
his usual state until 2yrs ago when he his temperature got high at school and
had convulsions which was generalized tonic clonic seizure associated with
rolling eyes, gnashing teeth and urinated on himself with lost of consciousness
for almost 2months after which he regained consciousness on hospital admission
which was immediately after hospital admission. He woke up with inability to
move his eyes, talk and walk after which he was started on speech therapy and
physiotherapy and subsequently started to move his eyes, talk in words and
started grabbing things to stand with support. Until after 8months another convulsion occurred which it
has permanently changed his abilty to talk and walk. Since after then there’s
no any change with his condition despite the therapy.
Neurological
Examination: global hypertonia, hypereflexia,
sustained clonus
The above
features is in keeping cerebral palsy. It has been confirmed with MRI which
shows extensive volume loss
MRI Brain shows extensive Cerebral Atrophy
Plan: Counsel
parent – no room for neurosurgical intervention
Continue with Pediatric Neurologist
Refer to Angelic Care Hospital for
Pediatric Care
Thank you for usual cooperation and
please
kindly revert, if need be, for further clarification.
Sincerely yours,
Dr.
Halima Ibrahim
For
Team Wellington Clinic