Case Report

A 37 days preterm female newborn with head enlargement

Presented by :
Dimas Banurusman Lululangi
Gloria Permata Usodo
The IDENTITY of PATIENT
The Identity of
Patient

Name :S
DOB : Grobogan, March 18th 2017
Age : 37 days
Sex : Female
Address : Grobogan
Marital status : unmarried
Occupation :-
Educational status :-
Date of hospital admission : April 11th 2017
Identity of Parent

Father : Mr. H
Age : 33 years
Occupation : Trader
Educational status : Middle School
graduated

Mother : Mrs. S
Age : 27 years
Occupation : Trader
Educational status : Elementary School
History of Illness
History of Illness

Chief Complain

History of Illness
8 weeks before hospital admission

ANC The mother first noticed the increase of liquid in

patients head at the pregnancy age of 27 minggu in USG
examination
History of Illness

5 weeks before hospital admission

Repeated USG examination the liquid in patient head
gradually increased
Reffered to RSUD Grobogan elective termination of pregnancy

S was born by sectio caesaria, preterm at the pregnancy age of 30 weeks

Patient head circumstance = 34 cm enlargement of head
Patient spent 25 days in NICU
History of Illness

7 hours before hospital admission

Reffered to Emergency Unit in RSDK
Cito operation of VP-shunt implanting was suggested to the parent
CANCELLED decubitus ulcers were found at the incision site (region
temporoocipitalis dextra and sinistra)

Transffered to high risk baby care

Head circumstances (April 23rd 2017) : 43 cm

Normal bowel and bladder habits

VP-Shunt implating was held on April 24th 2017

History of Illness

Past Medical History

No history of fever, convulsion, vomitting

Family History
Not significant
History of Illness

Social-economy History

Parent occupation is trader in traditional market

Patient have two older siblings : 7 years and 2 years old, both of them are
normal in growth and developement

Medical bill are covered by National Insurance (JKN non PBI)

History of Illness

Perinatal History
Pre natal
Gestation status : G4P3A1, age 27 years old
ANC history = four times at midwife + twice at Obstetrics

The family have cat and chicken contacted before and during pregnancy
Fever and common cold at the pregnancy age of 2 months

There is no history of vaccination before pregnancy

Routine intake of Fe tab
History of Illness

Perinatal History

Natal
Preterm (30 minggu)
Sectio caesar
Newborn weight 2450 g
Head circumstances 34 cm
Spontaneous crying right after delivery
Active movement of hand and foot
Cynosis (-), jaundice (-).

Post natal
There is no vaccination history
Comsumption of pumped-breastmilk in every 3 hours since delivery
PHYSICAL EXAMINATION
 PHYSICAL
EXAMINATION

Vital Sign
General Status Body Length 72 cm
Blood pressure is not measured
Conciousness level Composmentis Body weight 2,6 kg
Pulse rate 130x/min
GPCS 14 E4M6V4 Arm circumstances 9
RR 35x/min
cm
Temperature 36 C
o

Skin normal turgor, pale

(-)
 PHYSICAL
EXAMINATION

GENERAL PHYSICAL GENERAL PHYSICAL

EXAMINATION EXAMINATION
GENERAL PHYSICAL
Head Nasal discharge -/-
EXAMINATION
Macrocephal (+) Oral cyanosis (-),
PULMO
hypersalivation (-) Inspection simetry in
Eye
Ear discharge -/- static and dynamic,
conjunctiva anemic (-/-) icterus (-/-)
intercostal retraction
sunset eye appearance (-/-) Neck trachea deviation (-), (-)
nystagmus horizontal (+/+) Palpation was
Stiff neck cant to be assessed difficult to be
Strabismus (+/+), lagoftalmus (-/-) evaluated
Vetebra dimple (-), deformity (-)
Percussion sonor
Auscultation
vesiculer, ronkhi (-/-),
wheezing (-/-)
PEMERIKSAAN
FISIK

GENERAL PHYSICAL
GENERAL PHYSICAL
GENERAL PHYSICAL EXAMINATION
EXAMINATION
EXAMINATION EXTREMITY SUPERIOR
ABDOMEN
Cor Inspection flat, redness Cyanosis (-/-)
Inspection ictus cordis Cold (-/-)
(-), venectation (-)
not vissible Capillary refill
Auscultation normal (<2/<2)
Palpation ictus cordis bowel sound Edema (-/-)
was palpated on SIC Atrophy (-/-)
IV linea midclavikula Percussion tymphani,
sinistra liver extends >2cm EXTREMITY INFERIOR
below the costal margin Sianosis (-/-)
Percussion normal cor
Palpation supel, liver can Cold (-/-)
configuration Capillary refill
sometimes be palpated
Auscultation S1-S2 (<2/<2)
Edema (-/-)
normal, murmur (-) , GENITALIA Atrophy (-/-)
 PHYSICAL
EXAMINATION

LOCAL STATUS of LOCAL STATUS of STATUS LOKALIS

HEAD HEAD KEPALA
INSPECTION PALPATION dull
PERCUSSION
Macrocephal(+), Fullness of the
venectation (-) anterior fontanele
Decubitus ulcer region Fluctuation (-)
temporoocipitalis Sutura merging (-)
sinistra 1,5cm (+) Headcircumstance 43 cm
dengan dasar tulang,
pus (+) Transilumination
was not examinated
Decubitus ulcer region
temporoocipitalis
dextra 2cm (+)
dengan dasar tulang,
 PHYSICAL
EXAMINATION

Extremity Superior
Right Lef
Movement + +
Power Difficult to be measure Difficult to be measure
(impression 3) (impression 3)
Tonus Normal Normal
Trophy Eutrophy Eutrophy
Extremity Inferior
Right Lef
Movement + +
Power Difficult to be measure Difficult to be measure
(impression 3) (impression 3)
Tonus Normal Normal
Trophy Eutrophy Eutrophy
 PHYSICAL
EXAMINATION

Reflex Examination

Physiologic Patologic Primitive

- Patella (+) - Babinsky snout :-
rooting :-
- Bicep (+) (-) grasping :+
- Chaddok palmomental : -
(-) glabela : no
assess
- Hoffman
(-)
- Tromer (-)
DIAGNOSIS, THERAPY
DIAGNOSIS

Clinical Diagnosis
- Hydrocephalus
- Decubitus ulcer region temporoocipitalis sinistra
grade IV
- Decubitus ulcer region temporoocipitalis dextra
Grade IV
DIAGNOSIS

Topical Diagnosis
- Intrakranial, cutis regio temporooccipitalis dextra and sinistra

Etiologic Diagnosis
- Abnormalities in CSF circulation or imbalance in production and
absorption of CSF
 INITIAL PLAN
Therapy
Diagnosis D10% infusion
Decubitus ulcer : inj cefotaxime 150 mg/8
Routine blood examination
hours
Head CT Scan without contrast Topical : ketoconazol cr 2%/12 hours, as.
Fusidat cr 2%/12 hours
Wound cleaning everyday
Change position every 2 hours
Hidrocephalus : reffer to neurosurgeon
Monitoring Pro VP-shunt implanting
Vital Sign Exclusive Breastmilk

Head circumstances
INITIAL PLAN

Education
- Explain to the parent that their daughter suffers from
congenital disease
- Explain to the parent that their daughter will be reffered to
neurosurgeon
- Explain to the parent about the aim, procedure, and
complication of VP-shunt implanting