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Case 5 History Physical Exam Diagnosis Poncio, Porlas, Quezon, Quichio, Ramos, Remonte, Reyes, Rivera A., Rivera K., Rivera M. Management
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History History Physical Exam Diagnosis Management
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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
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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
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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
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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
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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
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Omitted Part of the History
Family History − Congenital abnormalities − Consanguinity Immunization Newborn screening History Physical Exam Diagnosis Management
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Physical Exam History Physical Exam Diagnosis Management
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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
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Salient Findings Respiratory Rate: 24/min (NV= 35-50)
bradypneic BP normal (Nelson’s /45-55) History Physical Exam Diagnosis Management
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Salient Findings Frontal bossing Prominent scalp veins
Open posterior and sagittal fontanels Setting sun sign History Physical Exam Diagnosis Management
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Needs to be Elicited HEAD AND NECK auscultation of the skull (Nelsons)
bruises lymph nodes History Physical Exam Diagnosis Management
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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
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Needs to be Elicited SKIN complete dermatologic examination History
Physical Exam Diagnosis Management
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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
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Diagnosis History Physical Exam Diagnosis Management
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Is there a neurologic lesion?
Yes, signs and symptoms of increased ICP. History Physical Exam Diagnosis Management
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Primary Impression Hydrocephalus because of… Frontal bossing
Prominent scalp veins Open posterior and sagittal fontanels Setting sun sign Vomiting History Physical Exam Diagnosis Management
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Differentials for Increased ICP
Increased CSF production Decreased CSF absorption History Physical Exam Diagnosis Increased ICP Management
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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
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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
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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
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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
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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
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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
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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
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Non-neurologic Differentials
Hydrocephalus 20 to Intraventricular Hemorrhage History Physical Exam Diagnosis Management
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Management History Physical Exam Diagnosis Management
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Diagnostic Management
Head Ultrasound Head CT scan MRI Newborn screening: Galactosemia History Physical Exam Diagnosis Management
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Diagnostic Management
IVH History Physical Exam Diagnosis Management
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Diagnostic Management
Aqueductal Stenosis History Physical Exam Diagnosis Management
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Other Tests CBC with platelets PT/PTT Electrolytes ABG and pH
EEG – if seizures occur CSF analysis History Physical Exam Diagnosis Management
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Treatment Goal: Decrease ICP Shunting Lumbar puncture
Medical treatment: Mannitol History Physical Exam Diagnosis Management
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