2010 cp on hydrocephalus
TRANSCRIPT
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BIODATA OF THE PATIENT
Identification data
Name :Master Ashish
Age :7 months
Sex :male
C.R no :1040919
Bed no/ Wad :6/Emergency Ward
Re!igion :Sikh
Nationa!it" :Indian
Date of admi##ion :$%/$$/$&
Diagno#i# :Hydrocehal!s "ith #SMM$
S!rgery %&ot done yet
Con#'!tant :'r(Singhi
Fat(e)# ed'cation :$lass 10
Fat(e)# occ'*ation :)ri*ate o"n +!siness
+ot(e# ed'cation :$lass ,
+ot(e)# occ'*ation :Ho!se"i-e
Adde## %.harad Mohali
Infomant :Mother
CHIEF CO+P,AINTS D-RIN AD+ISSION
he mother gi*es a history o- the child "ith congenital meningomyeloceal "hich kees onenlarging so-t on the lo"er +ack( he child started crying ecessi*ely and +eing irrita+le -or
a+o!t 2 to 6 days the child head is so-t and has +een increasing since 4 month "ith +!lging
-ontanelle
HISTOR OF PRESENT I,,NESS
$hild "as kno"n case o- #SMM$( Mother noticed the increased in head si3e since 4 monthsold "hich "as rogressi*e in nat!re the child "as *ery irrita+le and cry ecessi*ely( hey "ent
to a ri*ate doctor hen re-erred to )I $handigarh -or -!rther management( he child "as
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admitted once at 4months -or the #SMM$ diagnosed as hydrocehal!s discharged and no"
admitted -or s!rgery(
HISTOR OF PAST I,,NESS
She has the no any e*idence o- ast disease +esides the #SMM$ and hydrocehal!s "hich
started at 4 months o- age
PERSONA, HISTOR:0
Antenata! Hi#to": here "as no comlaints d!ring the ante natal eriod(
Bit( Hi#to": 'eli*ered on ,/5/5010 at 16 M$H -!ll term &'( At ,month S "as done
detected as a case o- #SMM$(
De1e!o*menta! Hi#to":&o delay in any milestone( &ormal gro"th and de*eloment ecet
"eakness in lo"er lim+s
Imm'ni2ation Hi#to":imm!ni3ed aroriate to age according to mother +!t no e*idence
FA+I, HISTOR: N'c!ea fami!" 3it( 4 mem5e#
8ather0year Mother 57 year
4 years 6 months
In her -amily &o+ody has any e*idence o- disease s!ch as comm!nica+le :(;(
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;ody +!ilt % Weak
ital signs % emerat!re= , c
% )!lse 10 ;)M
% >esiration 6 ;)M
Weight %10 kg
Height % 6 cm
?8$ % 49 cm
$hest circ!m-erence % 40 cm
Head shae % large head ?8$@ 49 cm +!lging -ontanelle
Eyes % s!nken eyes
#is % &ormal
&ose % &ormal no discharge
Ears % &o discharge &ormal shae
eeth % nil
!ms % )ink color
ong!e % $oated "hitish color
&eck % #ymh nodes not ala+le no neck rigidity
hyroid % &o a+normal gro"th
$hest % &ormal shae
A+domen % So-t normal shae normal so!nd
;ack % )resence o- #SMM$
enitalia % $lean no discharge distended etremities
SSTE+IC ASSESS+ENT
eneral Aearance % #ooks "eak
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)ersonal hygiene % &ot "ell maintained
)ost!re % &ormal
&!tritional stat!s % )oor
$ongenital a+normality % &ot any
Anemia % &ot anemic
$yanosis % &o
8o!l +ody order % &o
8o!l +reath % &o
CARDIO7ASC-,AR SSTE+
&o history o- any cyanotic acynotic congenital heart disease(
&o allor &o cyanosis &o edema(
Heart >ate % 10 ;)M BAicalC
$8 5 sec(
&ormal heart so!nd resent S1 S5(
RESPIRATOR SSTE+
>esiratory rate 6 ;)M
&o h/o 'ysnea rachea in &ormal osition
&o enlargement o- hyroid
&o edema in *oice=+o
&ormal +reath so!nd
ASTRO0INTESTINA, SSTE+
&o h/o omiting Malena
h/o oor -eeding
A+dominal girth 6(2 cm(
;o"el so!nd resent in all -o!r D!adrants
&o organomegaly -o!nd &o tenderness
,+PHATIC SSTE+
&? #ymh node enlargement(
ENTO-RINATOR SSTE+
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&o any congenital disorder
&o h/o I
&o h/o incontinence 'ys!ria Haemat!ria
&o renal calc!li
&o h/o Hernia
Sel- *oiding /? is adeD!ate
Centa! Ne1o'# #"#tem:0
&o h/o o- sei3!res( &ormal >e-lees(
Endocina! #"#tem:0
&o endocrinal dys-!nction is yet noticed(
&o disease related to endocrine system is resent(
NE-RO,OICA, ASSESS+ENT
Interaction "ith eaminer % 8air
Interest in s!rro!nding % )oor
Acti*ity % )oor
Seech artic!lation % $hild +a++les
Hearing % ood
is!al % &ormal
is!al -iation %#'n8en e"e#
?c!lar mo*ement % A+normal
+OTOR F-NCTION
)ost!re % &ormal
ait % $o!ld not +e elicited
Ho % co!ld not +e elicite
M!scle mass % )oor/"eak
M!scle o"er % "eak secially lo"er lim+
M!scle coordination % &ot ood coordination
+-SC-,OS9ETA, SSTE+
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&o any h/o m!sc!losketal disease(
&o any e*idence o- kyhosis #ordosis scoliosis(
&o any congenital disorder s!ch as alies(
INTI-+ENTAR SSE+
&o h/o $yanosis
&o h/o allergy -rom any s!+stance o+ect or medicine
&o h/o rash !tricaria or any other skin disease
Scal clean no dandr!--
&ail F no cl!++ing o- nails
Skin= &ormal t!rgor skin integrity maintained no ress!re sore no edema resent
Skin temerat!re@ , $
DISEASE AS PER ,ITREAT-RE
HDROCEPHA,-S:
Hydrocehal!s is not a seci-ic diseaseG rather it reresents a di*erse gro! o- conditions
that res!lt -rom imaired circ!lation and a+sortion o- $S8 or in the rare circ!mstance -rom
increased rod!ction +y a choroid le!s ailloma( H"doce*(a!'# also kno"n as "ater on
the +rain is a medical condition in "hich there is an a+normal acc!m!lation o-cere+rosinal-l!id:$S8< in the *entricles or ca*ities o- the+rain( his may ca!se increased intracranial
ress!reinside the sk!ll and rogressi*e enlargement o- the head con*!lsion and mental
disa+ility( Hydrocehal!s can also ca!se death( he name deri*es -rom the reek "ords :h!dro=I can e*al!ate -or $hiari mal-ormation or cere+ellar or eriaD!ed!ctal t!mors( It
a--ords +etter imaging o- the osterior -ossa than $( M>I can di--erentiate normal
ress!re hydrocehal!s :&)H< -rom cere+ral atrohy altho!gh the distinctions may +e
challenging( 8lo" *oids in the third *entricle and transeendymal -l!id e!dates arehel-!l( Ho"e*er n!mero!s s!ita+le atients ha*e a +rain attern s!ggesti*e o- atrohy
and small *essel ischemic disease that may !ltimately +e &)H(,!idelines -or imaging
st!dies in s!sected &)H ha*e +een esta+lished(9
$/M>I criteria -or ac!te hydrocehal!s incl!de the -ollo"ing%
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o Si3e o- +oth temoral horns is greater than 5 mm clearly *isi+le( In the a+sence
o- hydrocehal!s the temoral horns sho!ld +e +arely *isi+le(
o >atio o- the largest "idth o- the -rontal horns to maimal +iarietal diameter :ie
E*ans ratio< is greater than 0J in hydrocehal!s(
o ranseendymal e!date is translated on images as eri*entric!lar
hyoatten!ation :$< or hyerintensity :M>I 5="eighted and -l!id=atten!ated
in*ersion reco*ery B8#AI>C seD!encesI s!ggests ac!te
hydrocehal!s(
$/M>I criteria -or chronic hydrocehal!s incl!de the -ollo"ing%
o emoral horns may +e less rominent than in ac!te hydrocehal!s(
o hird *entricle may herniate into the sella t!rcica(
o Sella t!rcica may +e eroded(
o Macrocrania :ie occiito-rontal circ!m-erence 9,thercentile< may +e resent(
o $or!s callos!m may +e atrohied :+est areciated on sagittal M>I
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'i--!sion tensor imaging :'I< is a no*el imaging techniD!e that detects di--erences in
-ractional anisotroy :8A< and mean di--!si*ity :M'< o- the +rain arenchyma
s!rro!nding the *entricles( Imairment o- 8A and M' thro!gh 'I allo"s the
recognition o- microstr!ct!ral changes in eri*entric!lar "hite matter region that may +e
too s!+tle on con*entional M>I(5
Ot(e Te#t#
A-ter sh!nt insertion con-irm correct ositioning o- installed hard"are "ith a lain
radiograh(
EE i- sei3!re occ!rs
BOO9S PATIENTS RES-,TS
History No fami!" (i#to"H/? enlarged head -or ast 1
month
Meas!rement o- ?8$ 4= cm
)erc!ssion o- the in-antNs sk!ll may rod!ce a
tyical cracked ot so!nd :Mace"enNs signI
;lood analysis
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+ANAE+ENT
oa!:
o achie*e eD!ili+ri!m +et"een rod!ction and a+sortion
Aceta3olamide decreases the rod!ction o- $S8
>eeated #)/*entric!lar ta to maintain normal ress!re
TREAT+ENT
+EDICA, TREAT+ENT:
Aceta2o!amide >Diamox?
&oncometiti*e re*ersi+le inhi+itor o- en3yme car+onic anhydrase "hich cataly3es the reaction+et"een "ater and car+on dioide res!lting in rotons and car+onate( his contri+!tes to
decreasing $S8 secretion +y choroid le!s(
'oses% 52 mg/kg/d )? tidG not to eceed 100 mg/kg/d
,oo* di'etic#
hese agents increase ecretion o- "ater +y inter-ering "ith the chloride=+inding cotransort
system "hich res!lts -rom inhi+ition o- rea+sortion o- sodi!m and chloride in the ascendingloo o- Henle and distal renal t!+!le(
F'o#emide >,a#ix?
Mechanisms roosed -or lo"ering I$) incl!de lo"ering cere+ral sodi!m !take a--ecting"ater transort into astroglial cells +y inhi+iting cell!lar mem+rane cation=chloride !m and
decreasing $S8 rod!ction +y inhi+iting car+onic anhydrase( sed as ad!ncti*e theray "ith
A$P in temorary treatment o- osthemorrhagic hydrocehal!s in neonates(
'oses% 1 mg/kg/d I
+EDiCINES: ecei1ed 5" *atient
S.R.No. +EDICINE DOSE RO-TE FRE@ENC RATIONA,E
1( Syr( )$M( 60 mg ?ral Q6H A&I)O>EI$
A&A#ESI$
5( In aim 200mg I/ ;' Anti+iotic 8or re*ent
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the secondary in-ection(
( In( Amikacin 152mg I/ ;' Anti+iotic 8or re*ent
the secondary in-ection(
S-RICA, TREAT+ENT:
Hydrocehal!s can +e treated thro!gh a *ariety o- s!rgical roced!res incl!ding direct oeration
on the lesion ca!sing the o+str!ction s!ch as a t!morG *entric!lostomy intracranial sh!nts -or
selected cases o- noncomm!nicating hydrocehal!s to di*ert -l!id -rom the o+str!cted segmento- the *entric!lar system to the s!+arachnoid saceG and etracranial sh!nts :most common< to
di*ert -l!id -rom the *entric!lar system to an etracranial comartment -reD!ently the
eritone!m or right atri!m(Etracranial Sh!nt )roced!res
7entic'!o*eitonea! >7P? #('nt
A *entric!loeritoneal sh!nt remo*es ecessi*e cere+rosinal -l!id -rom the *entricles
and sh!nts it to the eritone!m( A one="ay *al*e is resent in the t!+ing +ehind the ear(
o 'i*erts $S8 -rom a lateral *entricle or the sinal s!+arachnoid sace to the
eritoneal ca*ity(
o A t!+e is assed -rom the lateral *entricle thro!gh an occiital +!rr hole
s!+c!taneo!sly thro!gh the osterior asect o- neck and arasinal region to the
eritoneal ca*ity thro!gh a small incision in the right lo"er D!adrant(
o A *entric!lar access de*ice is an imlanted reser*oir and catheter !sed -orremat!re neonates less than 5000 g in lie! o- a sh!nt( he catheter drains -l!id
-rom the *entricles into the reser*oir "hich can then +e emtied !sing asetic
techniD!e( When "eight eceeds 5000 g a sh!nt !s!ally can +e laced(
7entic'!oatia! >7A? #('nt%
o A t!+e is assed -rom the dilated lateral *entricle thro!gh a +!rr hole in the
arietal region o- the sk!ll(
o It then is assed !nder the skin +ehind the ear and into a *ein do"n to a oint
"here it discharges into the right atri!m or s!erior *ena ca*a(
o A one="ay ress!re=sensiti*e *al*e "ill close to re*ent re-l! o- +lood into the
*entricle and oen as *entric!lar ress!re rises allo"ing -l!id to ass -rom the
*entricle into the +loodstream(
7entic'!o*!e'a! #('nt%
o 'i*erts $S8 to the le!ral ca*ity(
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o Indicated "hen the ) or A ro!te cannot +e !sed(
7entic!e0ga!! 5!adde #('nt%
o 'i*erts $S8 to the common +ile d!ct(
o sed "hen all other ro!tes are !na*aila+le(
+o#t #('nt# (a1e t(e fo!!o3ing com*onent#:
o entric!lar t!+ing(
o A one="ay or !nidirectional ress!re=sensiti*e -lo" *al*e(
o A !ming cham+er(
o 'istal t!+ing(
Pogamma5!e #('nt# ae a1ai!a5!e( hese can +e rogrammed to a certain -lo"
ress!re and ress!re settings can +e read!sted +ased !on atient resonse( A magnetic
de*ice is !sed to ad!st the ress!re setting o- the sh!nt *al*e( he !se o- a
rogramma+le sh!nt eliminates the need -or m!ltile s!rgeries or hosital *isits to ad!stsh!nt ress!re(
S('nt Com*!ication#
Altho!gh a sh!nt may -!nction "ell immediately a-ter insertion comlications mayarise in the -orm o- kinking searation or l!gging o- the sh!nt t!+ing( )ost oerati*e
artially sh!nt +lockage may occ!r +y +loced tiss!e dislodge d!ring s!rgical roced!re( he
most serio!s comlication is in-ection o- the sh!nt leading to *entric!litis seticemia(
When the sh!nt +ecomes in-ected it is !s!ally remo*ed massi*e anti+iotic theray isgi*en( ;eca!se o- gro"th d!ring early childhood sh!nts m!st +e re*ised eriodically(
&eed -or sh!nt re*ision -reD!ently occ!rs +eca!se o- occl!sion in-ection or mal-!nction
esecially in the -irst year o- li-e(
Sh!nt re*ision may +e necessary +eca!se o- gro"th o- the child( &e"er models ho"e*er
incl!de coiled t!+ing to allo" the sh!nt to gro" "ith the child(
Sh!nt deendency -reD!ently occ!rs( he child raidly mani-ests symtoms o- increased
I$) i- the sh!nt does not -!nction otimally( ?nset may +e s!dden or insidio!s(
$hildren "ith A sh!nts may eerience endocardial cont!sions and clotting leading to
+acterial endocarditis +acteremia and *entric!litis or throm+oem+olism and cor!lmonale(
$hildren "ith A sh!nts reD!ire +iann!al or ann!al chest L=ray to check length o- t!+ing(
$hest L=ray is also done d!ring gro"th s!rts esecially d!ring !+erty( When t!+ing is
short or close to +eing o!t o- the right atri!m sh!nt relacement needs to +e sched!led(
TESTIN SH-NT FOR PATENC:0
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$omressing o- the cham+er or reser*oir
)!m is comressed -irmly and D!ickly "ith -ore-ingers
Pogno#i#
)rognosis deends on early diagnosis and romt theray(
With imro*ed diagnostic and management techniD!es the rognosis is +ecomingconsidera+ly +etter(
o Many children eerience normal motor and intellect!al de*eloment(
o he se*erity o- ne!rologic de-icits is directly roortional to the inter*al +et"een
onset o- hydrocehal!s and the time o- diagnosis(
Hydrocehal!s d!e to meningitis might sontaneo!sly resol*e d!e to grad!al
disaearance o- adhesions(
Aroimately t"o=thirds o- atients "ill die at an early age i- they do not recei*e
s!rgical treatment(
Com*!ication#
Sei3!res(
Herniation o- the +rain(
Sontaneo!s arrest d!e to nat!ral comensatory mechanisms ersistent increased I$)
and +rain herniation(
'e*elomental delays(
'eression in adolescents is common(
PATIENT: #'ge" not done "et 5't accoding to docto t(e" 3i!! *!an fo 10* #('nt afte
#(ifting to t(e 3ad
N-RSIN +ANAE+ENT
&!rsing AssessmentIn-ants
Assess head circ!m-erence(
o Meas!re at the occiito-rontal circ!m-erence oint o- largest meas!rement(
o Meas!re the head at aroimately the same time each day(
o se a centimeter meas!re -or greatest acc!racy(
)alate -ontanelle -or tenseness +!lging(
Assess !illary resonse(
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Assess le*el o- conscio!sness :#?$eort changes in *ital signs Maintain n!trition% -eed +a+y -reD!ently
$hanges osition -reD!ently to lesser chances o- de*eloment o- ress!re on scal
s!ort +a+yRs head care-!lly "hile li-ting to re*ent tra!ma
)reare +a+y -or diagnostic roced!res
Ens!re In-ormed consent +y the arents
POST OPERATI7E
>ecord *ital signs e*ery 12 to 0 mins a-ter s!rgery
Monitor -or sign o- I$$) % "idened !lse ress!re slo" !lse change in +odytemerat!re
Assess !illary resonse(
Assess le*el o- conscio!sness :#?$
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.ee the in-ant in the non oerati*e side to re*ent ress!re on sh!nt *al*e
.ee atient -lat a-ter 54 ho!rs o- s!rgery
I- -ontanelle is deressed in-ormed doctor
)ro*ide the medication as ordered
Ed!cate the arents on the -!nction o- the sh!nt and diagnostic roced!re care o- the
child a-ter dischargeN'#ing Diagno#e#
Ine--ecti*e $ere+ral iss!e )er-!sion related to increased I$) +e-ore s!rgery
Im+alanced &!trition% #ess han ;ody >eD!irements related to red!ced oral intake and
*omiting
>isk -or Imaired Skin Integrity related to alterations in #?$ and enlarged head
Aniety o- arents related to child !ndergoing s!rgery
>isk -or In!ry related to mal-!nctioning sh!nt
>isk -or 'e-icient 8l!id ol!me related to $S8 drainage decreased intakeostoerati*ely
>isk -or In-ection related to +acterial in-iltration o- the sh!nt
Ine--ecti*e 8amily $oing related to diagnosis and s!rgery
N-RSIN DIANOSES IN THE PATIENT
8e*er related to disease condition(
High risk -or in-ection related to s!rgical "o!nd in*asi*e line
&!trition alteration in less than +ody reD!irement(
.no"ledge de-icit regarding disease condition health ro+lem
SHORT TER+ OA,S
o maintain +ody temerat!re and monitoring o- *ital signs
o re*ent in-ection
o maintain n!tritional le*el
o ed!cate arents a+o!t the disease conditions
,ON TER+ OA,S
o reha+ilitate the client
o teach atient a+o!t the treatment regimen and -ollo" ! m o romote health
REFERENCES:
.liengman and et alG &elson et+ook o- )ediatricsG 1,thedition : E=;ook
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?) hai and et alG hai Essential )ediatricsG 7thEditionG ages 250=254
Issel+acher et alG HarrisonRs )rinciles o- Internal Medicine7th Edition :E=;ook