HydrocephalusPresented by :Group IIAdvisor :Dr. Arie Ibrahim, Sp.BS
IdentityName: By. KYSex: MaleAge: 1,9 years oldAddress: Teluk Selimau RT.8 RW.3 Tj.SelorTribe: DayakReligion: ProtestanParents Name: YPOccupation: Private EmployeeEducation: Senior Highschool
Chief ComplaintExpulsion of the VP Shunt tube
Anamnese(Need revisi)History of Present Illness Hospitalization : April 30th, 2007Redness and swelling along the area of the tubing pulled the tube out from the stomachs skin upper the umbilicalSwelling appeared about 2 cm as long as the woundDifficulties of defecation since hospitalizationFever since the last operation
ContdHead enlargement was realized since five month of ages about 47 cm circumference of head, its accompanied by increased irritability and high pitch cry. No limitation of apetite & sucking baby bottle. The parents thougt that the body weight was normal. Developmental delayed and lethargy.
ContdMore often got fever about twice a week, after fever patient usually tend to vomite which content of secretBecause of the head enlargement, patient went to the docter, the diagnostic was Hydrocephalus.
ContdAt seven month of ages, patient had been advised to get surgical treatment immediately in the RSUD AWS but the parents refused itAt age 1 year and 6 months, patient got a surgical therapy in RSUD AWS, hospitalized a week and discharged (Week third of February)
Contd3 weeks post hospitalization, patient hospitalization again for 2 weeks with fever as a chief complaint (In Tj. Selor Hospital)3 days post hospitalized, patient came back to RSUD AWS becouse of the swelling (chief complaint)
History of Past IllnessDiarrhea at four monthSeizure at nine months of age
History Family IllnessThere is no history of hydrocephalus
History of HospitalizedHospitalization Tanjung Selor year 2006
Physical ExaminationMay 2nd, 2007 at 8.00 pmGeneral StateGeneral Condition: moderate illnessBody weight: 10 kgHeight: 87 cm
Vital SignMental Status: Alert, Children Coma Scale?Pulse: 120 x/minutes, regularBlood Pressure: -Respiratory Rate: 28 x/minutes, thoraco-abdominalTemperature: 39oC, axial
ContdHeadAbnormal with enlargement 54 cm, venectasion of head veinsEye: Pupil equal in size, 4mmLeft=RightLight reflex R/L (-) BlindedEye Movement R/L=N/NSun set phenomenon of the eye
ContdThorax Inspection : Shape NChest Movement SymetrisVP shunt tube: Redness and swelling right sidePalpation: -Percussion : -Auscultation: Cardio S1,S2 regulerPulmo Vesiculer R=L
ContdAbdomenIntestine sound (+) N,ExtremitySuperior: Normal Dorsum pedis : Spastic
Special Investigation :Culture of LCSHead CT Scan
Working DiagnoseInfections post VP Shunt et causa Hydrocephalus
TherapyElaborate the source of infection Treat seizure due to febris state : Benzodiazepam (short acting)Goal of treatment is also to reduce the pressure in the patient's head and to properly drain the cerebral spinal fluid (CSF) Neuroendoscopy procedure Liquid & electrolyte mantainance
Neuroendoscopy ProcedureNew, ExpensiveCan see whole anatomicaly ventricelJust to put endoscopy through the parenchyme of the brain.
PrognoseFungsionam Dubia ad malamVitam ad malamSanationam ad bonam
Dr. Arie Ibrahim, Sp.BSAll C Group of Junior Clerk Ship 2007