Case 5 History Physical Exam Diagnosis Poncio, Porlas, Quezon, Quichio, Ramos, Remonte, Reyes, Rivera A., Rivera K., Rivera M. Management

History History Physical Exam Diagnosis Management

Salient Points Premature ( 34 weeks AOG) 3 months old (neonate) Spontaneous vaginal delivery Gradual decrease of suck and activity 18 yo primigravid mom Slowly enlarging head History Physical Exam Diagnosis Management

Omitted Part of the History General Name and sex of patient HPI Bowel movement patterns and character Vomiting – character of vomitus, occurrence, frequency GI: Jaundice, abdominal enlargement, diarrhea, constipation, pain Neuro: Loss of consciousness, seizures, cry Hematologic: easy bruising, bleeding Infection or fever History Physical Exam Diagnosis Management

Omitted Part of the History HPI History of trauma Sleeping and breathing pattern Urine and urination Medication given Why was the patient in the hospital for 1 month? Why was the patient born premature? History Physical Exam Diagnosis Management

Omitted Part of the History Birth profile APGAR Dimensions(body weight, length, head circumference,) at birth Feeding/Nutritional History Breastfeed or formula milk History Physical Exam Diagnosis Management

Omitted Part of the History Maternal / Gestational history − Labor − Medications − Prenatal check up − Infections (UTI, STI) − HPN − DM − Alcohol intake − Drug use during pregnancy − Folic acid deficiency History Physical Exam Diagnosis Management

Omitted Part of the History Family History − Congenital abnormalities − Consanguinity Immunization Newborn screening History Physical Exam Diagnosis Management

Physical Exam History Physical Exam Diagnosis Management

Salient Findings Weight: 4.4kg : <2nd percentile, cut-off <5th percentile  underweight Length: 52 cm: <2nd percentile, cut-off <5th percentile  short stature Head Circumference: 44cm: >98th percentile, cut-off >95th percentile  increased head circumference History Physical Exam Diagnosis Management

Salient Findings Respiratory Rate: 24/min (NV= 35-50) bradypneic BP normal (Nelson’s - 65-85/45-55) History Physical Exam Diagnosis Management

Salient Findings Frontal bossing Prominent scalp veins Open posterior and sagittal fontanels Setting sun sign History Physical Exam Diagnosis Management

Needs to be Elicited HEAD AND NECK auscultation of the skull (Nelsons) bruises lymph nodes History Physical Exam Diagnosis Management

Needs to be Elicited ABDOMEN liver span or distance below the subcostal shape and size of the abdomen midline umbilicus percussion and auscultation of the abdomen ascites History Physical Exam Diagnosis Management

Needs to be Elicited SKIN complete dermatologic examination History Physical Exam Diagnosis Management

Needs to be Elicited NEURO EXAM Downward looking eyes w/ limitation Babinski – can still be normal Bilateral ankle clonus Cranial nerve assessment - I and V Muscle tone Withdraws to tactile stimulation? pain or tactile Reflexes (at 3 mo - typical Moro response has not persisted; makes defensive movements or selective withdrawal reactions) History Physical Exam Diagnosis Management

Diagnosis History Physical Exam Diagnosis Management

Is there a neurologic lesion? Yes, signs and symptoms of increased ICP. History Physical Exam Diagnosis Management

Primary Impression Hydrocephalus because of… Frontal bossing Prominent scalp veins Open posterior and sagittal fontanels Setting sun sign Vomiting History Physical Exam Diagnosis Management

Differentials for Increased ICP Increased CSF production Decreased CSF absorption History Physical Exam Diagnosis Increased ICP Management

Increased CSF Production History Differential diagnosis Rule in Rule out Choroid plexus papilloma Symptoms of increased ICP CPP usually affects young children about 5 years old. Physical Exam Diagnosis Management

Decreased CSF Absorption History Differential diagnosis Rule in Rule out Subarachnoid granulations secondary to infection or hemorrhage Symptoms of increased ICP Previously well Physical Exam Diagnosis Management

Decreased CSF Absorption History Differential diagnosis Rule in Rule out Aqueductal stenosis Symptoms of increased ICP May present at any time; must always be considered AS is associated with neural tube closure defects; none apparent in case Often associated with café-au-lait spots (none reported in case) Physical Exam Diagnosis Management

Decreased CSF Absorption History Differential diagnosis Rule in Rule out Dandy-Walker syndrome Symptoms of increased ICP Often diagnosed at 1 year old or later Non-CNS malformations in 20 to 33% of children Physical Exam Diagnosis Management

Decreased CSF Absorption History Differential diagnosis Rule in Rule out Chiari malformation type II Hydrocephalus Symptoms of increased ICP Weak cry Absence of nystagmus, dysphagia, stridor, apnea and myelomeningocoele Physical Exam Diagnosis Management

Decreased CSF Absorption History Differential diagnosis Rule in Rule out Intraventricular hemorrhage May be clinically not apparent. Common in premature babies. Severe forms are ruled out by absence of signs of space-occupying lesions eg. Focal deficit Physical Exam Diagnosis Management

Non-neurologic Differentials Chief complaint: vomiting Other possible causes: inborn errors of metabolism (i. e. galactosemia) gastroenteritis GERD Overfeeding GI obstruction History Physical Exam Diagnosis Management

Non-neurologic Differentials Hydrocephalus 20 to Intraventricular Hemorrhage History Physical Exam Diagnosis Management

Management History Physical Exam Diagnosis Management

Diagnostic Management Head Ultrasound Head CT scan MRI Newborn screening: Galactosemia History Physical Exam Diagnosis Management

Diagnostic Management IVH History Physical Exam Diagnosis Management

Diagnostic Management Aqueductal Stenosis History Physical Exam Diagnosis Management

Other Tests CBC with platelets PT/PTT Electrolytes ABG and pH EEG – if seizures occur CSF analysis History Physical Exam Diagnosis Management

Treatment Goal: Decrease ICP Shunting Lumbar puncture Medical treatment: Mannitol History Physical Exam Diagnosis Management