Case Presentation

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Case Presentation

  1. 1. CASE PRESENTATION ALI A. AL-BALUSHI OMSB, EM R-5
  2. 2. OBJECTIVES <ul><li>CASE </li></ul><ul><li>LETRETURE REVIEW </li></ul>
  3. 3. Case <ul><li>ON 16/2/2010 @ 08:30 hrs </li></ul><ul><li>S. A , 2 y.o boy </li></ul><ul><li>H/O Vomiting </li></ul>
  4. 4. 24/11/2009 HX PRIMARY SURVEY <ul><li>VOMITING </li></ul><ul><li>A </li></ul><ul><li>B </li></ul><ul><li>C </li></ul><ul><li>D </li></ul><ul><li>E </li></ul><ul><li>VITAL SIGNS </li></ul><ul><li>HR 64 /min </li></ul><ul><li>BP 110/60 </li></ul><ul><li>RR 24 /min </li></ul><ul><li>Temp 37.2 </li></ul><ul><li>SPO2 100% </li></ul><ul><li>RBS 5.8 </li></ul>MONITER,O2, IV LINES, ECG MORE HX HPC AMPLE
  5. 5. Hx <ul><li>Intermittent , started 2 wks ago </li></ul><ul><li>Dx = AGE </li></ul><ul><li>This time: started middle of night </li></ul><ul><li>10 hrs ago </li></ul><ul><li>This is the 3 rd episode </li></ul><ul><li>h/o low appitite </li></ul><ul><li>h/o loss of wt </li></ul>
  6. 6. Hx <ul><li>NORMAL BOWEL MOVEMENT , NO BLOOD OR MALENA </li></ul><ul><li>NO URINARY SYMPTOMS </li></ul><ul><li>NO H/O FEVER </li></ul><ul><li>NO COUGH OR SOB </li></ul><ul><li>NO H/O FITS </li></ul>
  7. 7. Hx <ul><li>PMHx: </li></ul><ul><li>3/12 ago, had similar episode lasted for a wk </li></ul><ul><li>Unremarkable antenatal Hx </li></ul><ul><li>Immunization = upto date </li></ul>
  8. 8. Hx <ul><li>Not on any drugs </li></ul><ul><li>No h/o allergy </li></ul><ul><li>No h/o travel </li></ul><ul><li>No similar Hx in family </li></ul>
  9. 9. 24/11/2009 HX PRIMARY SURVEY SECONDARY SURVEY <ul><li>VOMITING </li></ul><ul><li>A </li></ul><ul><li>B </li></ul><ul><li>C </li></ul><ul><li>D </li></ul><ul><li>E </li></ul>MONITER,O2, IV LINES, ECG MORE HX HPC AMPLE <ul><li>HEAD & NECK </li></ul><ul><li>RESP </li></ul><ul><li>CVS </li></ul><ul><li>ABD </li></ul><ul><li>CNS </li></ul><ul><li>MSKS </li></ul><ul><li>SKIN </li></ul><ul><li>VITAL SIGNS </li></ul><ul><li>HR 64 /min </li></ul><ul><li>BP 110/60 </li></ul><ul><li>RR 24 /min </li></ul><ul><li>Temp 37.2 </li></ul><ul><li>SPO2 100% </li></ul><ul><li>RBS 5.8 </li></ul>
  10. 10. SECONDRY SURVEY <ul><li>H&N </li></ul><ul><li>NO ABNORMAL FEATURES </li></ul><ul><li>MODERATELY DEHYDRATED </li></ul><ul><li>NO PALLOR </li></ul><ul><li>NO JAUNDICE </li></ul><ul><li>NO L.N </li></ul><ul><li>SUPPLE NECK </li></ul><ul><li>NO MENINGEAL SIGNS </li></ul>
  11. 11. SECONDRY SURVEY <ul><li>R.S </li></ul><ul><li>GOOD A.E, CLEAR </li></ul><ul><li>CVS </li></ul><ul><li>PULSES= REGULAR RATE & RHYTHM </li></ul><ul><li>S1 S2 NORMAL, NO MURMERS </li></ul>
  12. 12. SECONDRY SURVEY <ul><li>P/A </li></ul><ul><li>SOFT, NON TENDER </li></ul><ul><li>NO ORGANOMEGALY </li></ul><ul><li>NORMAL B.S </li></ul><ul><li>HERNIAL ORIFICES = INTACT </li></ul><ul><li>PR = NOT DONE </li></ul><ul><li>GENETALIA = NORMAL </li></ul>
  13. 13. SECONDRY SURVEY <ul><li>CNS : </li></ul><ul><li>AWAKE </li></ul><ul><li>FOLLOWING COMMANDS </li></ul><ul><li>MOVING ALL EXTREMITIES </li></ul><ul><li>CN INTACT </li></ul>
  14. 14. SECONDRY SURVEY <ul><li>EXTREMITIES: </li></ul><ul><li>WELL PERFUSED, NO CLUBBING OR CYANOSIS OR EDEMA </li></ul><ul><li>CAP REFIL = 3 SEC </li></ul>
  15. 15. 24/11/2009 HX PRIMARY SURVEY SECONDARY SURVEY DDX <ul><li>VOMITING </li></ul><ul><li>A </li></ul><ul><li>B </li></ul><ul><li>C </li></ul><ul><li>D </li></ul><ul><li>E </li></ul>MONITER,O2, IV LINES, ECG MORE HX HPC AMPLE <ul><li>HEAD & NECK </li></ul><ul><li>RESP </li></ul><ul><li>CVS </li></ul><ul><li>ABD </li></ul><ul><li>CNS </li></ul><ul><li>MSKS </li></ul><ul><li>SKIN </li></ul>? <ul><li>VITAL SIGNS </li></ul><ul><li>HR 64 /min </li></ul><ul><li>BP 110/60 </li></ul><ul><li>RR 24 /min </li></ul><ul><li>Temp 37.2 </li></ul><ul><li>SPO2 100% </li></ul><ul><li>RBS 5.8 </li></ul>
  16. 16. 24/11/2009 HX PRIMARY SURVEY SECONDARY SURVEY DDX LAB RX DISPOSTION <ul><li>VOMITING </li></ul><ul><li>A </li></ul><ul><li>B </li></ul><ul><li>C </li></ul><ul><li>D </li></ul><ul><li>E </li></ul>MONITER,O2, IV LINES, ECG MORE HX HPC AMPLE <ul><li>HEAD & NECK </li></ul><ul><li>RESP </li></ul><ul><li>CVS </li></ul><ul><li>ABD </li></ul><ul><li>CNS </li></ul><ul><li>MSKS </li></ul><ul><li>SKIN </li></ul>RADIOLOGY ? <ul><li>VITAL SIGNS </li></ul><ul><li>HR 64 /min </li></ul><ul><li>BP 110/60 </li></ul><ul><li>RR 24 /min </li></ul><ul><li>Temp 37.2 </li></ul><ul><li>SPO2 100% </li></ul><ul><li>RBS 5.8 </li></ul>
  17. 17. INVESTIGATIONS <ul><li>CBC ,, Hb= 11.0 (LOW MCV & MCH) </li></ul><ul><li>Plt= 388 </li></ul><ul><li>WBC= 6.6 </li></ul><ul><li>LFT ,, WNR </li></ul><ul><li>U/E ,, WNR </li></ul><ul><li>URINE ,, NAD </li></ul><ul><li>AMYLASE ,, WNR </li></ul>
  18. 18. INVESTIGATIONS <ul><li>CHEST/ ABDOMEN X-RAY: </li></ul><ul><li>NORMAL MEDIASTINUM </li></ul><ul><li>NO CARDIOMEGALY </li></ul><ul><li>CLEAR CHEST </li></ul><ul><li>NO SIGNS OF BOWEL OBSTRUCTION </li></ul><ul><li>NO A.U.D </li></ul><ul><li>ECG: </li></ul><ul><li>SINUS BRADY. </li></ul>
  19. 19. 24/11/2009 HX PRIMARY SURVEY SECONDARY SURVEY DDX <ul><li>VOMITING </li></ul><ul><li>A </li></ul><ul><li>B </li></ul><ul><li>C </li></ul><ul><li>D </li></ul><ul><li>E </li></ul>MONITER,O2, IV LINES, ECG MORE HX HPC AMPLE <ul><li>HEAD & NECK </li></ul><ul><li>RESP </li></ul><ul><li>CVS </li></ul><ul><li>ABD </li></ul><ul><li>CNS </li></ul><ul><li>MSKS </li></ul><ul><li>SKIN </li></ul>? LAB RADIOLOGY <ul><li>VITAL SIGNS </li></ul><ul><li>HR 64 /min </li></ul><ul><li>BP 110/60 </li></ul><ul><li>RR 24 /min </li></ul><ul><li>Temp 37.2 </li></ul><ul><li>SPO2 100% </li></ul><ul><li>RBS 5.8 </li></ul>
  20. 20. OBSERVATION <ul><li>DURING OBSERVATION, CHILD HAD TCS </li></ul><ul><li>TREATED WITH IV. LORAZEPAM </li></ul>
  21. 21. NEXT ?? <ul><li>CT BRAIN ( NON CONTRAST) : </li></ul><ul><li>OBSTRUCTIVE HYDROCEPHALUS </li></ul><ul><li>POSTERIOR FOSSA MASS ? TUMOR </li></ul>
  22. 22. 24/11/2009 HX PRIMARY SURVEY SECONDARY SURVEY DDX LAB RX DISPOSTION <ul><li>VOMITING </li></ul><ul><li>A&C </li></ul><ul><li>B </li></ul><ul><li>C </li></ul><ul><li>D </li></ul><ul><li>E </li></ul>MONITER,O2, IV LINES, ECG MORE HX HPC AMPLE <ul><li>HEAD & NECK </li></ul><ul><li>RESP </li></ul><ul><li>CVS </li></ul><ul><li>ABD </li></ul><ul><li>CNS </li></ul><ul><li>MSKS </li></ul><ul><li>SKIN </li></ul>RADIOLOGY ? ? <ul><li>VITAL SIGNS </li></ul><ul><li>HR 64 /min </li></ul><ul><li>BP 110/60 </li></ul><ul><li>RR 24 /min </li></ul><ul><li>Temp 37.2 </li></ul><ul><li>SPO2 100% </li></ul><ul><li>RBS 5.8 </li></ul>
  23. 23. Rx & DISPOSITION <ul><li>CONTINUED TO HAVE SEIZURES ,, Rx WITH LORAZEPAM </li></ul><ul><li>INTUBATED </li></ul><ul><li>REFERED TO NEUROSURGERY </li></ul><ul><li>PT HAD MRI BRAIN,, CONFIRMED TUMOR </li></ul><ul><li>TUMOR RESECTED </li></ul>
  24. 24. POSTERIOR FOSSA BRAIN TUMORS
  25. 25. INTRODUCTION <ul><li>Tumors in posterior fossa are considered critical brain lesions. This is, primarily, because of the limited space within the posterior fossa and the potential involvement of vital brain stem nuclei. </li></ul><ul><li>Some pts should undergo emergency operation, especially if they present with acute symptoms of brain stem involvement or herniation. </li></ul>
  26. 26. INTRODUCTION <ul><li>Posterior fossa tumors are more common in children than the adults. </li></ul><ul><li>Between 54% and 70% of all childhood brain tumors originate in the posterior fossa. </li></ul><ul><li>About 15-20% of brain tumors in adults occur in the posterior fossa. </li></ul>
  27. 27. INTRODUCTION <ul><li>Certain types of posterior fossa tumors, such as medulloblastoma, pineoblastoma, ependymomas, primitive neuroectodermal tumors (PNETs), and astrocytomas of the cerebellum and brain stem, occur more frequently in children. </li></ul><ul><li>Some glial tumors, such as mixed gliomas, are unique to children. They are located more frequently in the cerebellum (67%) and are usually benign. </li></ul>
  28. 28. PRESENTATION <ul><li>BRAIN TUMOURS IN PAEDs CHARACTERISTICALY PRESENT WITH SYMPTOMS OF INCREAED ICP CAUSED BY HYDROCEPHALUS </li></ul><ul><li>90% OF PTs WITH MEDULLOBLASTOMA OR CEREBELLAR ASTROCYTOMA & 65% WITH EPENDYMOMAS PRSENT WITH HYDROCEPHALUS SYMPTOMS </li></ul>
  29. 29. PRESENTATION <ul><li>SYMPTOMS; HEADACHE, VOMITING, IRRITABILITY , LETHERGY </li></ul><ul><li>MORE COMMON IN THE MORNING BECAUSE OF RECUMBENCY & RELATIVELY ELEVATED PaCO2 INCREASES ICP </li></ul><ul><li>BRADYCARDIA IS OMINOUS BECAUSE IT SIGNIFIES VENTILATORY ARREST IS IMMINENT </li></ul>
  30. 30. Investigations <ul><li>CT is the first to be done </li></ul><ul><li>Detect 95% of brain tumors </li></ul><ul><li>CT scan of the posterior fossa is inferior to MRI in diagnostic value because of the artifact produced from the surrounding thick bone. However, CT scan is helpful for postoperative follow-up </li></ul>
  31. 31. Management <ul><li>INDICATIONS FOR SURGERY; </li></ul><ul><li>To decompress the post. fossa for the purpose of relieving pressure on the brain stem and/or to release ICP & avert the risk of herniation </li></ul><ul><li>To diagnose the tumor based on histopathology </li></ul><ul><li>To determine further plan of management depending on the nature of the tumor </li></ul>
  32. 32. Management <ul><li>When indicated, to treat hydrocephalus by shunting cerebrospinal fluid (CSF) to the peritoneal cavity </li></ul>
  33. 33. THANKS

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