General case Juhi Dhanawat  Pratik Kumar   Ashar LodiRidhima Sakhuja   Richa Singh
history•   Name: Shreya•   Age : 2.5yrs , sex: female•   From: Shimoga•   Informant: mother, Reliability : good•   Came to...
History of presenting illness• Child was apparently normal 2yrs4months back when she  developed fever for which the mother...
• No other episodes of fever. No history of vomiting.• No history of difficulty in feeding .• When the child did not impro...
Birth history• Antenatal history: primigravidaIst trmester:Concieved spontaneously.No history of fever with rash, burning ...
2nd trimester: quickening felt at 6th month.No history of fever with rash.No history of GDM, PIH.One USG scan done-nnormal...
• Full term delivery.• Elective caesarian section due to decrease in  fetal movements.• Baby cried immediately after birth...
Developmental history• Gross motor- head control not achieved•                baby cannot sit with support• Fine motor- gr...
Immunization history• Immunized for age• Last vaccine taken: 1.5 yrs- DPT booster and  OPV.• Dietary history:• Exclusive b...
calories        protiens8am                     5buiscuits+ I cup   100+ 130= 230   0+7=7                        milk(200m...
Family history• Child born out of consanguinous marriage
Socio economic history•   5 members in the family•   3rooms, no over crowding•    income rs 4000/month•   Belongs to lower...
Examination
General Condition• A well nourished, conscious and confortable child• Decreased alertness to surrounding• VITALS     - Afe...
Anthropometry• Weight  – Actual-       12.5 kg  – Expected-     13 kg  – Inference –    96 % Normal (IAP)• Height  – Actua...
• BMI – 18 Kg/m2• Mid Arm Circumference  – Actual      18 cm  – Expected    >13.5 cm• Head Circumference  – Actual –    55...
Head to toe examination• Pallor present (palpebral conjunctiva)• No icterus      Clubbing      Cyanosis      Lymphadenopat...
• Head Circumference of 55 cm (macrocephaly)• Prominent forhead• No dilated scalp veins• Anterior Fontanelle – Open, non p...
•   Normal facial feature•   Limbs- Increased tone•   Chest – normal•   Spine – normal•   Abdomen – normal•   Genitals – n...
Developmental Assesment• Expected for age (2.5 yr)Gross Motor       - Runs well, Climb stairsFine Motor       - Turns Page...
Developmental          assessment(obsereved)• Gross Motor  – No head control  – Cant sit with support  – DQ- 14%• Fine mot...
• Social  – No social smile  – Day time bed wetting present  – DQ- 14%• Language  – Monosyllables  – DQ- 30 %  – Global De...
Systemic ExaminationCentral Nervous system examination- Conscious, disinterested in surrounding- Spastic response to sudde...
Cranial nerve examinationI.              Not doneII.             Pupils reactive                Menace reflex- AbsentIII, ...
Motor System Examination               Right              Left               Upper/Lower        Upper/LowerNutrition      ...
Sensory system• Could not be assessed• Reflexes     Superficial     Right     Left     • Corneal       Normal    Normal   ...
Deep refelexes                        Right       Left•   Triceps             Grade 2            Grade 2•   Biceps        ...
• Respiratory System- Trachea central, B/L symmetrical chest  movements- Normal vesicular breath sound heard- No added sou...
• Cardiovascular system examination  – PR- 90/min  – Apex beat- 5th ICS medial to mid clavicular line  – S1 S2 heard  – No...
• Per abdomenAbdomen- soft, non tender       no organomegaly
Summary•   Decreased alertness to surrounding•   Grade II Stunting•   Macrocephaly with open ant fontanelle•   Setting sun...
DIFFERENTIAL DIAGNOSIS OF       LARGE HEAD
• MEGALENCEPHALY :  - No signs of increased intracranial pressure.  - Ventricles are not large, nor under increased   pres...
• Chronic Subdural hematoma : - Causes large head,mostly located in the parietal   region without prominent scalp veins or...
INVESTIGATIONS
Haematological investigations• Haemoglobin• Total count and differential count• ESR• Platelets
In our patient• Haemoglobin- 12.2g%• Total count-11,800/cc• Differential count  N-32% L-59% M-6% E-3%• Platelets-2.3 lakh/...
Biochemical investigations• Electrolytes• Serum urea and creatinine• Liver function tests
In our patient• Electrolytes Na⁺ 143meq/L (136-149meq/L) K⁺ 4.4meq/L (3.5-5.3meq/L) Cl⁻ 107.3meq/L (98-111meq/L) HCO₃⁻ 23....
Radiological investigations• CT scan of brain• Ultrasound• MRI
In our patient• CT scan brain   grossly distended lateral,3rd ,4th ventricles   communicating hydrocephalus
Other investigations•   CSF analysis•   Urine screening tests•   Visual assessment•   Hearing assessment•   EEG•   EMG•   ...
In our patient• Hearing assessment BERA OAE IntermittanceImpression-bilateral adequate hearing for  speech and language...
TREATMENT
TREATMENTMENT OF          HYDROCEPHALUS MEDICAL TREATMENT-It provides temporary relief & includes the use of drugs which a...
• Since, the increase in head size is associated with   progressive symptoms, therefore it is necessary to   intervene sur...
Gc  hydrocephalus
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Gc hydrocephalus

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Gc hydrocephalus

  1. 1. General case Juhi Dhanawat Pratik Kumar Ashar LodiRidhima Sakhuja Richa Singh
  2. 2. history• Name: Shreya• Age : 2.5yrs , sex: female• From: Shimoga• Informant: mother, Reliability : good• Came to RAPCC 15days back with• Chief complaints:• enlarged head , loss of vision , seizure since 2yrs4months
  3. 3. History of presenting illness• Child was apparently normal 2yrs4months back when she developed fever for which the mother gave paracetamol tablet. Fever decreased but spiked up again on the 8th day with one episode of seizure. There was no frothing of saliva or biting of tongue. The hands and legs became stiff which normalized within 2-3 minutes. Baby was admitted in the ICU at a local hospital ,treated and was discharged on medications for seizure, a tablet and syrup.• Every time the mother gives the child head bath, she develops seizure.• History of loss of vision since 2yrs 4 months.• The child does not recognize the mother and no social smile present.
  4. 4. • No other episodes of fever. No history of vomiting.• No history of difficulty in feeding .• When the child did not improve, mother took her to manipal hospital 2months back where scans were done and mother was told an operation would be required. She was referred to RAPCC.• No history of difficulty in chewing.• No history of lateral gaze palsy.• No history of hearing deficit, drooling of saliva, nasal regurgitation .• History of difficulty in wearing napkins.
  5. 5. Birth history• Antenatal history: primigravidaIst trmester:Concieved spontaneously.No history of fever with rash, burning micturition.No history of exposure to radiation or intake of drugs.Ultrasound scan not done.
  6. 6. 2nd trimester: quickening felt at 6th month.No history of fever with rash.No history of GDM, PIH.One USG scan done-nnormal3rd trimester:No history of GDM, PIH.USG scan done-normal.
  7. 7. • Full term delivery.• Elective caesarian section due to decrease in fetal movements.• Baby cried immediately after birth.• Birth weight:2.75 kg• Meconium and urine passed within 24hrs.• Breast feeding initiated after 4hrs of delivery.• No postoperative complications.
  8. 8. Developmental history• Gross motor- head control not achieved• baby cannot sit with support• Fine motor- grasp reflex present.• Language and communication: bysyllables (amma) only word spoken.• Social: no social smile• does not recognise the mother• Inference: global deveopmental delay
  9. 9. Immunization history• Immunized for age• Last vaccine taken: 1.5 yrs- DPT booster and OPV.• Dietary history:• Exclusive breast feeding till the age of 5months.• Weaning : 5th month, cerelac given.• Presently eats from the family pot.
  10. 10. calories protiens8am 5buiscuits+ I cup 100+ 130= 230 0+7=7 milk(200ml)10am ½ dosa 60 1.51pm 1 cup rice+I cup 175+50=225 4+ 2=6 curry3pm 1 fruit 50 0.55pm 5buicuits +1cup 100+130=230 0+7=7 milk7pm I cup rice+ 1 cup 175+50=225 4+2=6 curry9pm 1cup milk 130 7total 1150 35required 1150 19.5Inference: no deficit
  11. 11. Family history• Child born out of consanguinous marriage
  12. 12. Socio economic history• 5 members in the family• 3rooms, no over crowding• income rs 4000/month• Belongs to lower middle class family according to Modified Kuppuswamy scale.
  13. 13. Examination
  14. 14. General Condition• A well nourished, conscious and confortable child• Decreased alertness to surrounding• VITALS - Afebrile - Pulse rate – 96/min - Respiratory Rate – 16/min - Blood Pressure- 110/ 80 mm hg
  15. 15. Anthropometry• Weight – Actual- 12.5 kg – Expected- 13 kg – Inference – 96 % Normal (IAP)• Height – Actual - 83 cm – Expected - 93 cm – Inference - 89 % Grade II stunting (Waterlow)
  16. 16. • BMI – 18 Kg/m2• Mid Arm Circumference – Actual 18 cm – Expected >13.5 cm• Head Circumference – Actual – 55 cm – Expected 48 cm – Inference Macrocephaly
  17. 17. Head to toe examination• Pallor present (palpebral conjunctiva)• No icterus Clubbing Cyanosis Lymphadenopathy Edema
  18. 18. • Head Circumference of 55 cm (macrocephaly)• Prominent forhead• No dilated scalp veins• Anterior Fontanelle – Open, non pulsatile, in level, 4x4 cm• Normal hair distribution and growth• Eyes- Setting sun sign present - Unresponsive to light
  19. 19. • Normal facial feature• Limbs- Increased tone• Chest – normal• Spine – normal• Abdomen – normal• Genitals – normal• No skin abnormalities
  20. 20. Developmental Assesment• Expected for age (2.5 yr)Gross Motor - Runs well, Climb stairsFine Motor - Turns Pages, Dress her/himselfSocial - Dry by day, listen to storiesLanguage - 3 word simple sentences, refer to self as “I”
  21. 21. Developmental assessment(obsereved)• Gross Motor – No head control – Cant sit with support – DQ- 14%• Fine motor – Grasps finger – Can hold objects in one hand DQ- 17 %
  22. 22. • Social – No social smile – Day time bed wetting present – DQ- 14%• Language – Monosyllables – DQ- 30 % – Global Developmental Delay
  23. 23. Systemic ExaminationCentral Nervous system examination- Conscious, disinterested in surrounding- Spastic response to sudden loud sound- Skull and Spine- no deformity
  24. 24. Cranial nerve examinationI. Not doneII. Pupils reactive Menace reflex- AbsentIII, IV, VI. Could not be assessedV. Normal B/LVII. No facial palsyVIII. Could not be assessedIX, X, XI, XII. Not assessed
  25. 25. Motor System Examination Right Left Upper/Lower Upper/LowerNutrition Normal/ Normal Normal/NormalTone Increased/Increase Increased/Increase d dPower Grade 3/ Grade 3 ? Grade 3/ Grade 3 ?
  26. 26. Sensory system• Could not be assessed• Reflexes Superficial Right Left • Corneal Normal Normal • Abdominal Normal Normal • Plantar Upgoing Upgoing
  27. 27. Deep refelexes Right Left• Triceps Grade 2 Grade 2• Biceps Grade 2 Grade 2• Knee Grade 3 Grade 3• Ankle Grade 3 Grade 3Visceral- No bladder controlGait- could not be assessed, scissoring of lowerlimbs present.
  28. 28. • Respiratory System- Trachea central, B/L symmetrical chest movements- Normal vesicular breath sound heard- No added sounds
  29. 29. • Cardiovascular system examination – PR- 90/min – Apex beat- 5th ICS medial to mid clavicular line – S1 S2 heard – No murmur
  30. 30. • Per abdomenAbdomen- soft, non tender no organomegaly
  31. 31. Summary• Decreased alertness to surrounding• Grade II Stunting• Macrocephaly with open ant fontanelle• Setting sun sign, loss of vision, Pallor• Hypertonia• Severe Global developmental delay• Grade 3 lower limb reflexes
  32. 32. DIFFERENTIAL DIAGNOSIS OF LARGE HEAD
  33. 33. • MEGALENCEPHALY : - No signs of increased intracranial pressure. - Ventricles are not large, nor under increased pressure Causes : 1. Hurler’s syndrome 2. Metachromatic leukodystrophy 3. Tay Sach’s disease
  34. 34. • Chronic Subdural hematoma : - Causes large head,mostly located in the parietal region without prominent scalp veins or sunset sign.• Others : 1. Hydranencephaly 2. Rickets 3. Achondroplasia 4. Hemolytic anemias 5. Familial macrocephalies
  35. 35. INVESTIGATIONS
  36. 36. Haematological investigations• Haemoglobin• Total count and differential count• ESR• Platelets
  37. 37. In our patient• Haemoglobin- 12.2g%• Total count-11,800/cc• Differential count N-32% L-59% M-6% E-3%• Platelets-2.3 lakh/cumm
  38. 38. Biochemical investigations• Electrolytes• Serum urea and creatinine• Liver function tests
  39. 39. In our patient• Electrolytes Na⁺ 143meq/L (136-149meq/L) K⁺ 4.4meq/L (3.5-5.3meq/L) Cl⁻ 107.3meq/L (98-111meq/L) HCO₃⁻ 23.3meq/L (23-27meq/L)• Serum urea-26mg/dl (5-18mg/dl)INCREASED• Serum creatinine-0.4mg/dl (0.3-0.7mg/dl)• Liver function tests total bilirubin-0.1mg/dl (0.2-1.2mg/dl) direct bilirubin-0.0mg/dl (upto 0.3mg/dl)
  40. 40. Radiological investigations• CT scan of brain• Ultrasound• MRI
  41. 41. In our patient• CT scan brain grossly distended lateral,3rd ,4th ventricles communicating hydrocephalus
  42. 42. Other investigations• CSF analysis• Urine screening tests• Visual assessment• Hearing assessment• EEG• EMG• Metabolic work-up
  43. 43. In our patient• Hearing assessment BERA OAE IntermittanceImpression-bilateral adequate hearing for speech and language development
  44. 44. TREATMENT
  45. 45. TREATMENTMENT OF HYDROCEPHALUS MEDICAL TREATMENT-It provides temporary relief & includes the use of drugs which act either by decreasing CSF secretion by choroid plexus (Acetazolamide & loop diuretics ) , or by increasing CSF resorption (isosorbide).
  46. 46. • Since, the increase in head size is associated with progressive symptoms, therefore it is necessary to intervene surgically.1. VENTRICULO-PERITONEAL SHUNT -CSF directly drained into circulation or peritoneal cavity. -Advantage- shunt need not be lengthened as the child grows.2. VENTRICULO ATRIAL SHUNT ( VASCULAR SHUNT )3. VENTRICULOSTOMY -by endoscopic approach.
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