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    Congenital Hydrocephalus: Case Presentation

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    Ian Mizzel A. Dulfina
    This document describes congenital hydrocephalus, which is an excess buildup of cerebrospinal fluid in the brain at birth that can cause increased pressure and brain damage. It provides statistics on hydrocephalus, including that over 10,000 babies are affected each year in the United States. The case presentation then gives biographic and assessment details for a 1 year old Filipino patient admitted with congenital hydrocephalus, noting large head circumference, decreased consciousness, and other findings.

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    Congenital Hydrocephalus: Case Presentation

    Uploaded by

    Ian Mizzel A. Dulfina
    66 views35 pages
    This document describes congenital hydrocephalus, which is an excess buildup of cerebrospinal fluid in the brain at birth that can cause increased pressure and brain damage. It provides statistics on hydrocephalus, including that over 10,000 babies are affected each year in the United States. The case presentation then gives biographic and assessment details for a 1 year old Filipino patient admitted with congenital hydrocephalus, noting large head circumference, decreased consciousness, and other findings.

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    This document describes congenital hydrocephalus, which is an excess buildup of cerebrospinal fluid in the brain at birth that can cause increased pressure and brain damage. It provides statistics on hydrocephalus, including that over 10,000 babies are affected each year in the United States. The case presentation then gives biographic and assessment details for a 1 year old Filipino patient admitted with congenital hydrocephalus, noting large head circumference, decreased consciousness, and other findings.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    66 views35 pages

    Congenital Hydrocephalus: Case Presentation

    Uploaded by

    Ian Mizzel A. Dulfina
    This document describes congenital hydrocephalus, which is an excess buildup of cerebrospinal fluid in the brain at birth that can cause increased pressure and brain damage. It provides statistics on hydrocephalus, including that over 10,000 babies are affected each year in the United States. The case presentation then gives biographic and assessment details for a 1 year old Filipino patient admitted with congenital hydrocephalus, noting large head circumference, decreased consciousness, and other findings.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 35

    Congenital Hydrocephalus

    CASE PRESENTATION
    INTRODUCTION
    Congenital hydrocephalus is a
    buildup of excess cerebrospinal
    fluid (CSF) in the brain at birth.
    The extra fluid can increase
    pressure in the babys, causing
    brain damage and mental and
    physical problems.

    INTRODUCTION GLOBAL
    SETTING
    In the United States, a little over 1 in
    1000 births are affected by
    hydrocephalus. Hydrocephalus is one
    of the most common birth defects
    and afflicts in excess of 10,000 babies
    each year. Studies by the World
    Health Organization show that one
    birth in every 2,000 result in
    hydrocephalus.
    INTRODUCTION GLOBAL
    SETTING
    There are 70,000 discharges a year
    from hospitals in the United States
    with a diagnosis of hydrocephalus.
    More than 50% of hydrocephalus
    cases are congenital. As many as
    75% of children with hydrocephalus
    will have some form of motor
    disability.
    INTRODUCTION GLOBAL
    SETTING
    Over the past 25 years, death rates
    associated with hydrocephalus have
    decreased from 54% to 5%;
    intellectual disability has decreased
    from 62% to 30%.

    INTRODUCTION NATIONAL
    SETTING
    In the Philippines, congenital anomalies
    rank among the top 20 causes of death
    across the life span and are already
    the third leading cause of death in the
    infancy period (Philippine Department
    of Health, 1996). Despite the
    magnitude of the problem, no formal
    systematic registration of birth defects
    INTRODUCTION NATIONAL
    SETTING
    has been done in the country up until
    1999. Various attempts have been
    made by different study groups to
    gather data but there was never a
    formal effort to consolidate the
    information and establish a centralized
    registry.
    INTRODUCTION LOCAL
    SETTING
    In Davao City congenital
    hydrocephalus is at number nine in ten
    leading causes of neonatal deaths (0-
    28 days), Rate/1,000 Live Births as of
    2000, 5 year average (1995-1999).
    BIOGRAPHIC DATA
    NAME: X
    AGE: 1 year
    BIRTHDATE: 03-28-13
    ADDRESS:Pangibiran, Mabini, Comval
    NATIONALITY: Filipino
    RELIGION: Catholic
    BIOGRAPHIC DATA
    HEALTH CARE FINANCING:
    PhilHealth and personal savings
    AGENCY: DRH, Pedia Ward
    ATTENDING PHYSICIAN: Dr. Rea
    Mae C. Isip, M.D.
    ADMITTING DIAGNOSIS: Congenital
    Hydrocephalus
    BIOGRAPHIC DATA
    ADMISSION DATE AND TIME: 06-30-
    14 / 7:30am
    Chief complaint
    Increase Head Circumference
    History of present illness


    BIOGRAPHIC DATA
    Patient was delivered at a lying in at 7
    months AOG. noted with large head
    circumference consult done at Regan
    Hospital patient was admitted for CT-
    Scan EEG hence this admission

    BIOGRAPHIC DATA
    Past medical history
    Prenatal (Yes)
    Developmental Milestone in 8 months
    can roll over
    Immunization: BCG DPT OPG
    Measles Hepatitis B


    PATIENT NEED ASSESSMENT
    Name: X
    Admitting Medical Diagnosis:
    Congenital Hydrocephalus
    Arrive on unit by: Public
    transportation vehicle
    Accompanied by: Her Mother
    Admitting weight/VS: WT. 8.8kg
    Temp. 36.3, RR-41 cpm HR-138


    PATIENT NEED ASSESSMENT
    Clients Perception of Reason for
    Admission: Increasing Head
    circumference
    How has the problem been managed
    at home: None
    Allergies: None

    PATIENT NEED ASSESSMENT
    PHYSIOLOGICAL NEEDS
    I- Oxygenation
    CR: 138BPM *RR:41CPM
    Lungs (per auscultation: character;
    lung sound; symmetry of chest
    expansion; breathing character
    pattern) Bronchial breath sound,
    symmetrical chest expansion, fremitus

    PATIENT NEED ASSESSMENT
    Cardiac status (per auscultation-
    (sound, character, chest pain)S1 and
    S2 heard upon auscultation, chest pain
    not noted
    Capillary refill:4 seconds (poor).
    Skin character and color:
    warm skin with poor skin turgor
    II- Temperature Maintenance

    PATIENT NEED ASSESSMENT
    Temperature: 36.3c
    o

    Skin Character: dry skin and poor skin
    tugor
    III- Nutritional Fluids
    Height/Weight: 79cm/8.8kg
    Eating Pattern: Breakfast, lunch,
    Dinner

    PATIENT NEED ASSESSMENT
    IV- Elimination
    Normal Pattern: 3 times a day
    Urination (frequency, amount,
    character, sensation)
    Intermittent, scanty, yellowish,
    sensation not noted
    Other observation: Vomiting noted

    PATIENT NEED ASSESSMENT
    V- Rest-Sleep
    Bedtime: varies 6-8 pm
    Waking Up: 4-5 am
    Sleep (Pattern, amount, of sleep): 2-4
    hours of sleep
    Problems: sleepless
    Other Observations (related): looks
    tired.

    PATIENT NEED ASSESSMENT
    VI- Pain Avoidance
    Rate Pain:4 Time Started: anytime
    Bedtime: anytime
    Location: head
    Frequency: intermittent
    Behavior (Restless, Facial expression,
    Irritable, Diaphoretic)irritable
    Character: Cracking

    PATIENT NEED ASSESSMENT
    SAFETY-SECURITY NEED
    Neuro V/S: Pupil size 2L&R, reaction
    B(brisk) L&R,Handgrip M(moderate)
    L&R, Leg movement M(moderate)
    Mental Status
    Decreased consciousness
    Emotional problem: none.

    PHYSICAL ASSESSMENT
    General Survey
    Received patient awake in bed in a
    side lying position sleeping with diaper,
    and with a capillary refill of 4 sec.

    PHYSICAL ASSESSMENT
    Skin
    Brown skin generally uniform in color
    except in areas exposed to the sun
    No jaundice
    Prompt capillary refill time (4 seconds)

    PHYSICAL ASSESSMENT
    Head
    56cm Head circumference
    widening and bulging fontanels
    distended scalp veins
    thin, shiny and fragile-looking scalp
    skin

    PHYSICAL ASSESSMENT
    Eyes
    roof of orbit is depressed
    eyes displaced downward
    prominent sclera
    setting-sun sign (sclera)

    PHYSICAL ASSESSMENT
    Ears
    Color same as facial skin
    Symmetrically aligned
    Pinna immediately recoils after it is
    folded
    Pinna is not tender
    No lesions or discoloration

    PHYSICAL ASSESSMENT
    Nose
    Symmetric and straight
    Nasal septum intact and in the midline

    PHYSICAL ASSESSMENT
    Mouth and Throat
    Outer lips uniform slightly pale in color,
    dry with symmetric contour,
    Buccal mucosa is of uniform slightly in
    pale in color

    PHYSICAL ASSESSMENT
    Gums are slightly in pale
    Tongue slightly pale, not so moist, at
    central position
    Neck

    PHYSICAL ASSESSMENT
    Breast
    Firm
    Generally symmetric in size

    PHYSICAL ASSESSMENT
    Cardiovascular
    HR 138
    Respiratory/Chest
    Chest symmetric
    Chest wall intact, no tenderness, no
    masses
    Symmetric chest expansion and
    excursion

    PHYSICAL ASSESSMENT
    Respiratory rate 41
    Gastrointestinal/Abdomen
    Globular
    Musculoskeletal/Extremities

    PHYSICAL ASSESSMENT
    poor muscle tone in legs
    Neurologic
    decrease level of consciousness

    PHYSICAL ASSESSMENT
    poor muscle tone in legs
    Neurologic
    decrease level of consciousness

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