POMR Hydrocephalus
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Transcript of POMR Hydrocephalus
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HydrocephalusPresented by :Group IIAdvisor :Dr. Arie Ibrahim, Sp.BS
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IdentityName: By. KYSex: MaleAge: 1,9 years oldAddress: Teluk Selimau RT.8 RW.3 Tj.SelorTribe: DayakReligion: ProtestanParents Name: YPOccupation: Private EmployeeEducation: Senior Highschool
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Chief ComplaintExpulsion of the VP Shunt tube
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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
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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.
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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.
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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)
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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)
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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
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Physical ExaminationMay 2nd, 2007 at 8.00 pmGeneral StateGeneral Condition: moderate illnessBody weight: 10 kgHeight: 87 cm
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Vital SignMental Status: Alert, Children Coma Scale?Pulse: 120 x/minutes, regularBlood Pressure: -Respiratory Rate: 28 x/minutes, thoraco-abdominalTemperature: 39oC, axial
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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
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ContdThorax Inspection : Shape NChest Movement SymetrisVP shunt tube: Redness and swelling right sidePalpation: -Percussion : -Auscultation: Cardio S1,S2 regulerPulmo Vesiculer R=L
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ContdAbdomenIntestine sound (+) N,ExtremitySuperior: Normal Dorsum pedis : Spastic
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Special Investigation :Culture of LCSHead CT Scan
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Working DiagnoseInfections post VP Shunt et causa Hydrocephalus
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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
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Neuroendoscopy ProcedureNew, ExpensiveCan see whole anatomicaly ventricelJust to put endoscopy through the parenchyme of the brain.
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PrognoseFungsionam Dubia ad malamVitam ad malamSanationam ad bonam
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Dr. Arie Ibrahim, Sp.BSAll C Group of Junior Clerk Ship 2007