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 RAPCC 15days back with• Chief complaints:• enlarged head , loss of vision , seizure since 2yrs4months
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.
• 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.
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.
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.
• 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.
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
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.
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
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 middle class family according to Modified Kuppuswamy scale.
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
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)
• BMI – 18 Kg/m2• Mid Arm Circumference – Actual 18 cm – Expected >13.5 cm• Head Circumference – Actual – 55 cm – Expected 48 cm – Inference Macrocephaly
Head to toe examination• Pallor present (palpebral conjunctiva)• No icterus Clubbing Cyanosis Lymphadenopathy Edema
• 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
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”
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 %
• Social – No social smile – Day time bed wetting present – DQ- 14%• Language – Monosyllables – DQ- 30 % – Global Developmental Delay
Systemic ExaminationCentral Nervous system examination- Conscious, disinterested in surrounding- Spastic response to sudden loud sound- Skull and Spine- no deformity
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
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 ?
Sensory system• Could not be assessed• Reflexes Superficial Right Left • Corneal Normal Normal • Abdominal Normal Normal • Plantar Upgoing Upgoing
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.
• Respiratory System- Trachea central, B/L symmetrical chest movements- Normal vesicular breath sound heard- No added sounds
• Cardiovascular system examination – PR- 90/min – Apex beat- 5th ICS medial to mid clavicular line – S1 S2 heard – No murmur
• Per abdomenAbdomen- soft, non tender no organomegaly
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
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).
• 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.