POMR Hydrocephalus

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Hydrocephalu Hydrocephalu s s Presented by : Presented by : Group II Group II Advisor : Advisor : Dr. Arie Ibrahim, Sp.BS Dr. Arie Ibrahim, Sp.BS

description

hidrosephalus

Transcript of POMR Hydrocephalus

  • 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