Happy Lion

Case history

Child’s name: IZSÓ VERONIKA
Date of birth: 15. August 2004.
Diagnosis at Birth:
Neonata praematura g.s. 27.
Acut foetalis distress
Asphyxia perinatalis
RDS
Haemorrhagia plmonum
Decompensatio cardialis
Infectio intrauterina in obs.
Infectiones intercurrentes
Dysplasia bronchopulmonalis
Anamia acuta
Anaemia praematurum
PDA
Haemorrhagia intracranialis gr.IV.l.s.; gr. III.l.d.
Hydrocephalus internus
Leukomalatia periventricularis
Muscle tone disorder (dystoniaROP II-III. (+) o.u.
Osteopenia praematurorum

Veronika was born on 15. August 2004, on gestation’s week 27. She was transfered in lying position, and the umbilical cord was fallen forward. Due to this she was born with Ceserian section. Apgar value was 6/8. The pregnancy was absolutely trouble free. Weight at birth: 940 gramm, (2,0723 pound) (33,158 ounce) Lenght at Birth: 37 cm Head circumference at birth: 27 cm

After birth she had not cried up, was, bradycard. She received the first supply from premature rescue team (Cherny foundation). She was respirated with ambu balloon, then she was intubated and started respiration with machine. Blood pressure was unmeasurabe, so she received a volumen replacement, and started circulatory support. Following above, she was carried at age of 1 hr, in very bad condition, with premauture emergency vehicle to the neighboring (abt 3kms) SOTE Clinic, in Budapest (Semmelweis Egyetem) and to it’s PIC Center (premature intensive care). Her respiratory disorder was cased by a heavy hyalinmembran disorder (IRDS), which was treated with surface active „medicine”. Due to repeated infections, she received antibiotic treatment. Due to high rate anaemia she received transfusion at 11 times. Till age of 2 months, she has received parenteral liquid supply. Per os supply could be started / built up from age of 3 weeks. She had Osteopenia praematurorum which was treated with a higher dose of vitamin D, phosphorus and calcium. At the age of 2days she has suffered pulmonary haemorrhage, and wrong respiratory datas was followed by the increased dose of cardiacums. Haemophilia was treated with FFP. General condition has slowly increased. Her immaturity required machinery respiration (SIMV), due to the bronchopulmonalis dysplasia, caused by the extended respiratory, till age of 2 months (15-08-2004 – 09. 10. 2004), wich was followed by oxigen theraphy for furher 2 weeks. (10-13. 10. 2004. oxigen to the pharynx, and then open cabin with oxigen). At the first day of birth, doctors recognised permicious nervous system symptoms, spasmus, spasm equivalent. They recognised that is has been caused by high rate intracranialis bleeding (intraventricular hemorrhage ) which was followed by hydrocephalus. Due to Posthaemorrhag hydrocephalus internus, from age of 3 weeks, there was a need of chamber punctio,(disraction of head liquid), and besides she received diuretic treatment (Huma-Zolamid). The diuretic treatment was slowly decreased and then stopped. She received different type of antiepileptic (Gardenal, Epanutin), to reduce the permicious nervous system symptoms, spasmus, And then with a slight dose of Sertan treatment she was allowed to go home after 3 moths in PIC. Based on a neurologists opinion, in the lack of syptoms of intracranialis pressure increase, there was no need of neurologic operation or other role, but regular scull X-ray was required. 

Opthalmology

Due to ROP II.-III.(+)o.u. at age of 2 months (on 29.10. 2004.), while she was still in the hospital in the PIC, she underwent a laser eye operation with success (on both sides diode laser 360 degree). Continous opthamological superviion is carried out, she is wearing glasses.

Cardiological status- small, open Botallo line requested seqent contoll on cardiology  – but no any other problem has been recognised.

They found small PDA and foramen ovale aneurisma. At the controll at age of 6 moths (06. 02. 2005.) she was released of any treatment as all result was negative, no prematuraly cardiological problem recognised.

Due to the distribution of muscle tone problems a special treatment has been carried out form age of week 2. It is called, DSGM, (Dévény Speciális Gimnasztika és Mozgásterápiát) A special movement theraphy combined with muscle stimulation –mainly the deep muscles. Carried out by hand.

On the PIC general conditions slowly, but continously improved, she tolerated both breast milk and formula (nutrimentum) well.

At the age of 3 months (22. November 2004) beside stict and regular neurological and opthalmological, orthopedic controll, in a good, seizure-free conditions (with weight 2410gramm, and height of 47 cm) was replaced to a Neurological Clinic, where they are dealing with the neurological development (it is called Svábhegyi Fejlődésneurológia Osztály)

She has been there on a 2 weeks examinaton session, and based on the results she was advised to carry out a special rehabilitation treatment with home exercises to imporve neurological development. (it is called the system of Dr Katona, a well known Hungarian neurologist)

The final diagnosis was:

laesio cerebri progressiva epilepsiamque

Middle of december 2004. beside continous examination of head / scull circumference we recognised the increase of it, and for the help and advice of PIC we have reported ourselves at the Country Neurological Scientific Institute (Országos Idegsebészeti Tudományos Intézetbe), where they recognised the roominess of chambers and diagnosed hypertensiv hydrocephalus internus. Following on 18. december 2004. they carried out an operation of VP shunt. The operation could be carried out without problem, and after a few days, Veronika was allowed to go home.

On the next neurologival controll 07. January 2005. recognised again a chamber roominess and due to subduralis effusio, they inserted a left side subduralis drain, and was drained continously. It has been carried out for a month period, and finally it was completed and could travel home on the 2nd February 2005.

Treatments, controlls, diagnosed, present condition of Veronika.

Neurological:

Diagnose: Laesio perinatalis cerebri. Spastic tetraparesis, overweighted on the right side. The spacmus of the adductor is defenetive. Right upper limb spasiticity. She has started in the PIC from the beginning antiepileptic (Sertan) which was exchanged at the „Svábhegyi Fejlődésneurológiai Intézetben” (Neurological development clinic) to Tegretol. Beside continous controll and good blood result, EEG examination and seizure free condition we stopped Tegretol and had no medicine for epilepsy. Since we have not recognized any sign of ephilepsy or ephileptic seizure. No problem. 

Last EEG examination result (11. January 2007).

The pictures has been carried out with open eyes, Visible middle amplitude 6-7 Hz-es , symmetric, rhythmic theta background activity is extensive over the two hemispheres . There is no change by closing the eyes.. HV, lightexcitation cannot be seen. Background actiity fit for age, difference in sides, epileptiform without signs.

Botox treatments:

04. Jabuary 2007. both sides: gastrocnemius med et lat.

22. February 2007.. 100 unit Botox to spastic leg muscles.

01. August 2007. 100 unit Botox spastic leg muscles.

04. Decemebr 2007. 100 unit Botox spastic leg muscles, right hand, biceps brachi

06. June 2008. Botox spastic leg muscles, right hand, biceps brachii.

After the Botox treatments, the spastic limbs became better temporarly, but caused no significant change in the conditions of legs. Right upper limb’s condition improving. She has not received Botox treatment since 2008.

Neurosurgery:

Diagnose: Normal pressure hydrocephalus

Following the shunt operation (mentionde above) and draining at Country Neurosurgery Science Institute (Országos Idegsebészeti Tudományos Intézetben) (2005. february) there are continous yearly controls, which shows good operation of the shunt (150 mm waterpressure), good position, no deviation at the sides of the shunt, valve is good operational, can be pumped, chambers are narrow, parinaud sympthoms are not present. Vranival nerves are intact. Scaphocephal skull / carinum. Overweighted lower limb spasticus tetraparesis, increased deepreflexes, clonus on the right side.

Left uper limb is medium active, right upper limb increased deepreflexes. Last carium /Skull CT shows shunt at correct position, chambers are narrow, assimetric. Presently no neurosurgery activity needed, continous controll required. Neurologist says, evolving well, theraphy , horse-riding, swimming recomemnded, as done.

Opthalmology:

Diagnose: ROP II.-III.

After a laser surgery on 24. October 2004. október 24 regular controll at Semmelweis Clinic eye sight significant developed. (from -8D to -3D ) since she wears glasses constantly (-3 D) Strabizmus divergens.

Audiometry:

For the recommendation of the „Svábhegyi Fejlődésneurológiai Intézetben” (Neurological development clinic) audiometry has been carried out in 2005. and 2006. in Budapest, Hungary at the Capital Audiological Clinic, Saint Johann (Fővárosi Önkormányzat Szent János Kórház Audiológiai Szakrendelésén). Result is satisfactory, hears and understands well. Further auidometry not necessary.

Orthopaedry:

Diagnose: spastikus tetraparesis overweighted on the right side, tone increase on the right upper limb

Regular orthopadic controlls since March 2006. at the Capitral Ferenc Jahn Hospital Locomotor Rehabilitation Department (Főv. Önk. Jahn Ferenc Dél-pesti Kórházának Mozgásszervi Rehabilitációjára).

Since April 2006. Veronika wears AFO on both legs (JSPD ankle stabilizer)

Both legs have been in an equinus position, she has rotated her lower limbs but with the AFO and the theraphies, it could be overcorrigated. She pulled her legs often out from the aid, (AFO). Without AFO she has been walking on the right side on her outside fleetwide / sole, and the equinus is on the right leg could be corrigated only with big force.

The tibialis anterior on the right leg was indected / retracted.

Taking into consideration the sympthome of Trendelenburg and crossing walking, she received an adduction obstructing Swash.

She has been wearing SWASH since April 2010. Adn since oktober 2011. she also sleeps in it.

Orthopaedric surgery:

On 11. July. 2009. At the Bethesda Hospital she received an Achillotomy and tibialis anterior transplantation on the right lower limb due to equinus varus contracture.

After operation condition of right ower limb defenetively developed, improved, standing in midline position her exploration stabilized.

Last hip X-ray:

6. December 2011.

The valleys cover the head in kb 65 %, hypoplasias. Coxa valga. Femoral heads are strongyly in valgus position, laterated, but not require surgery.

Present motion status:

Muscle tones:

Spastic tone increasement . In upper limbs flexion, in the lower limbs extensive overweight .In the knees a few degree flexios contractura. Both legs palced lateral, lequinus on the left leg can be corrected only with big force.

Actív hip, knees and leg motions are narrowed, her legs are in dorsal flexio. Pes planovalgus present at both lower limb.

Slight spasticity at right biceps brachii

Locomotion, changing position, sitting:

From abdomen to back, from back to abdomen she is turning, from lying position she can sit up. In ground spontenaously sitting between legs. For request she can change position to sitting to cross-legged position, or with extended leg. In strance sitting (sitting with legs in V position) she cannot fully extend her legs her back is kiphotic (bended). On single chair, (without any seatback or hand support) can sit independently. From sitting position, or lying on abdomen, she can easily turning over to kneeing position. Her crowling has fast rythm, assimetric, mostly rabbit-like, both hands and legs moves together, She not extending her arms fully by crawling, most cases has to warn to open fingers on right hand. She pulls up to standing from kneeing position. Standing up is not orderly, supports on feet and not on the rim. She can stand up from a chair if there is an aid, eg cruthes or the table. In standing not able to keep position, but with aid, by clambering she can stand longer period, and can manipulate with hands mintime .

Walking:

She is able to walk with AFOs on her legs and rolling crutches. She wears SWASH. She walks with short steps, and fast, put weights on forefoot, ankle support and rolling on feet is irregular. Sometimes crosses legs, slighly tiptoeing, knees slighly bended, Walking with cruthces, she slightly bends forward on the crutches, hip controll and trunk controll not well developed. She walks with head foreward, spastic kneed, rotated hips.

Manipulation:

Right upper limb has kitted / set shoulder, in elbow fleiso contracture. Due to this fine motoric movements are hard to carry out. Uses right hand as subsidiary, as aid. She is left handed, she can carry out preciuos catchings and holdings. There is a normal tone and strenght in left upper arm. Good hand fuctions.

Right upper limb is slighly in fist position, indexfinger covers the thumb. Right upper limb in elbow bended position. By warning she places down.

Mental ability:

Her intellective maturity is as her age, cooperative, very good communication and social ability. Body shame is developed, aware of directions. Speach is complete, problem free, understandable, clear, grammatically precise, articulation appropriate. She loves speaking, generally comments all activities, asks a lot. Her vocabulary is wide ranged, fit for age, or bit better. She speaks in complex sentences with wide range of vocabulary. Extrimely interested in everything, and well motivated. Attention can be kept for longer period, rule-following and task concentration is developing. Specific, that without instructions, she turns certain situations as task, the lot of controlled situation, conditioning perceptible. Recognises Cause-effect contects. Very good memory. Eats independently, clothing with few help. Uses toilette with help to sit on it, no problem with keeping urine.

Not incontinent but sometimes, when very tired or has a small flu, during play, not wahcing and informs late the need of urination.

Therapies applied from the beginning and carried out today:

- Afore mentioned DSGM (Dévény Anna –féle Manuálterápia) theraphy received already from age of 2 weeks in PIC and is still ongoing theraphy. Weekly twice half or one hr sessions.

- We received a list of exercises from Neurological development clinic (Svábhegyi Fejlődésneurológia Intézetben) which has been followed from 02. December 2004. till July 2006. with the continous controll and help from the clinic.

- We attended sessions weekly 1-2 hrs from September 2005. till June 2008. in Budapest early Developing Center (Budapesti Korai Fejlesztő Központban (1119 Budapest, Bártfai u. 34/a)) on individual locomotive and remedial education.

- Hydrotheraphy sessions at „Budapesti Hidroterápiás Gimnasztika (BHRG) Alapítvány TSMT(Szenzomotoros Terápia)” from September 2005. till May 2008. weekly one hr in pool, and beside home exercises, mainly for balance development theraphy (Ayres therapie). (big ball, roll, pitching, rolling plate, desk, skates, cone)

- From September 2007. 1 year of individual conductive theraphy 2 hrs per session (Pethő- system)

- since March 2006. weekly one hr of Horse theraphy.

- from september 2009 weekly 2 occasion swimmingpool (presently one in the school with teacher, and one by father on Sundays, exersices, straching of muscles, and some play)

- Presently attends a special motordeveloping grammary school, where she receives daily 45 minutes motion theraphy. (1 therapist with 2 children), weekly one hr of swimming, plus weekly 1 hr individual theraphy, and weekly 1 hr dressing theraphy.

- since 2009 she attend weeky 1 hr English lessions (Helen Doron system)

- since september 2010 we attended theraphy session in Poland, Olinek center, where they use a special suit, so called Therrasuit.

One seesion is 2 weeks, twice 2,5 hrs intensive tharphy / day.