Hydrocephal

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

Identity

Name
Sex
Age
Address
Tribe
Religion
Parents Name
Occupation
Education

: By. KY
: Male
: 1,9 years old
: Teluk Selimau RT.8 RW.3 Tj.Selor
: Dayak
: Protestan
: YP
: Private Employee
: Senior Highschool

Chief Complaint
Expulsion of the VP Shunt tube

Anamnese
(Need revisi)
History of Present Illness
Hospitalization : April 30th, 2007
Redness and swelling along the area of the
tubing pulled the tube out from the stomachs
skin upper the umbilical
Swelling appeared about 2 cm as long as the
wound
Difficulties of defecation since hospitalization
Fever since the last operation

Contd
Head 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.

Contd
More often got fever about twice a week,
after fever patient usually tend to vomite
which content of secret
Because of the head enlargement, patient
went to the docter, the diagnostic was
Hydrocephalus.

Contd
At seven month of ages, patient had been
advised to get surgical treatment
immediately in the RSUD AWS but the
parents refused it
At age 1 year and 6 months, patient got a
surgical therapy in RSUD AWS,
hospitalized a week and discharged
(Week third of February)

Contd
3 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 Illness

Diarrhea at four month
Seizure at nine months of age
History Family Illness
There is no history of hydrocephalus
History of Hospitalized
Hospitalization Tanjung Selor year 2006

Physical Examination
May 2nd, 2007 at 8.00 pm
General State
General Condition : moderate illness
Body weight
: 10 kg
Height
: 87 cm

Vital Sign
Mental Status
Pulse
Blood Pressure
Respiratory Rate
abdominal
Temperature

: Alert, Children Coma

Scale?
: 120 x/minutes, regular
:: 28 x/minutes, thoraco: 39oC, axial

Contd
Head
Abnormal with enlargement 54 cm,
venectasion of head veins
Eye: Pupil equal in size, 4mm
Left=Right
Light reflex R/L (-) Blinded
Eye Movement R/L=N/N
Sun set phenomenon of the eye

Contd
Thorax
Inspection

: Shape N

Chest Movement Symetris

VP shunt tube : Redness and swelling
Palpation
:Percussion
:Auscultation :
Cardio S1,S2 reguler
Pulmo Vesiculer R=L

right side

Contd
Abdomen
Intestine sound (+) N,
Extremity
Superior
: Normal
Dorsum pedis
: Spastic

Special Investigation :
Culture of LCS
Head CT Scan

Working Diagnose
Infections post VP Shunt et causa
Hydrocephalus

Therapy
Elaborate 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 Procedure
New, Expensive
Can see whole anatomicaly ventricel
Just to put endoscopy through the
parenchyme of the brain.

Prognose
Fungsionam Dubia ad malam
Vitam ad malam
Sanationam ad bonam

 Dr. Arie Ibrahim, Sp.BS

All C Group of Junior Clerk Ship
2007