Case ReportHidrocephalus Communicans

Adri Permana UtamaNIM : 030.11.007

Kepaniteraan Klinik Ilmu Penyakit SarafPeriode 2015 – 1 agustus 2015

Fakultas Kedokteran Universitas Trisakti Jakarta

Pembimbing: dr. Ronny Yoes, Sp.S

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Identity • Mr. RName

• 29 y.oAge

• Elementary schoolEducation

• laborOccupation

• IslamReligion

• JawaEthnic

• MarriedSocial status

• 29/6/2015Admission date

Alloanamnesis & Autoanamnesis

• Main Complaint : Headache since + 3 weeks before went to the hospital

• History of Present Disease :Patient came to the hospital with headache about 3 weeks ago , headache was felt everyday mainly at night and occurred for 1 hour. Headache usually reduced by symptomatic drug but it felt worse by the day. Headache was felt all around head with nausea to vomiting. Sometimes the patient had disorientation but sometimes he could remembered. Complaints weren’t accompanied by convulsion, fever, double visions,dizzy and syncope.

Past Disease History

• Complaints of the patient occurred after he got motorcycle accident 3 weeks ago at night. He used a helmet but it off from his head. His head hit a tree and suddenly lost his consciousness about 2 hours. His nose and letf ear were bleeding.

Family History

SAME DISEASE( - )

HYPERTENSI( - )

DIABETES( - )

KIDNEY DISEASE( - )

ASTHMA( - )

HEART DISEASE (-)

Habits History

Alcohol consumption (-)

Smoking (+)

Tattoos (-)

Blood Transfusion (-)

Injected drugs (?)

Freesex (?)

General Condition

•severely ill General condition

•GCS •E:4 V:4 M:6

Consciousness

Vital Sign Blood

Pressure• 100/70

mmHg

Heart Rate• 82x/

mins

Respiration Rate• 16x/

mins

Temperature

• 36,5 ͦ C

Physical Examination Head

• Normocephalic

Eyes• Pupil Ishokor , direct light refleks (+/+) , indirect light refleks (+/+)• Icteric sclera -/-• Periorbital hematome (batle sign) (-)• Subkonjungtiva hematome (-)

Ears

• Bleeding (-)• LCS (-)

Nose

• Bleeding (-)• LCS (-)

Mouth

• Lip: cyanosis(-) dryness (+)

Neck

• Lymph gland & Thyroid gland is not palpable

Physical Examination(2)

Cor

• S1-S2 reguler , gallop (-) , murmur (-)

Pulmo

• VBS (+) , rh (-/-) , wh (-/-)

Abdomen

• Supel , Organomegaly (-) , Bowel Sound (+) N

Extremity

• Deformitas (-), Oedem (-/-)

psychology Status

• Can’t be checked

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Neurological Examination

Meningeal Sign

• Neck Stiffness : (-)• Brudzinski I : (-)• Brudzinski II : (-)• Kernig : (-)• Laseque : (-)

Speaking Ability

• Afasia Motorik : (-)• Afasia Sensorik : (-)• Disartria : (-)

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Cranial Nerves

N I (N. Olfaktorius)

• not checked

N II (N. Optikus)

• not checked

N III (N. Okulomotorius)

• Strabismus : -/-• Nistagmus : -/-• Eksoftalmus : -/-• Pupil : 2,5 mm / 2,5mm; ishokor• Direct light refleks : +/+• Indirect light refleks: +/+ 13

Cranial NervesN IV (N. Trokhlearis)

• Normal

N V (N. Trigeminus)

• Trismus (-), sensorik (+/+), cornea reflex (+/+)

N VI (N. Abducens)

• Normal

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N VII (N. Facialis)

• Central paresis (-), perifer paresis (-)

N VIII (N. Vestibulokoklearis)

• Not checked

Cranial NervesN IX (N. Glossofaringeus)

• not checked

N X (N. Vagus)

• Arkus faring : not checked• Speaking : normal• Swallowing : normal• Pulse : normal/normal• Refleks okulokardiak : not checked

N XI (N. Aksesorius)

• Not checked

N XII (N. Hipoglossus)

• Normal

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Extremity

Motorik

• Movement :• Upper :5555/5555• Lower : 5555/5555

Physiologic Reflex

• Biseps : +/+• Triseps : +/+• Patella : +/+• Achilles : +/+

Pathologic Reflex

• Hofman-Tromner : -/-• Babinski : -/-• Chaddok : -/-• Schaeffer : -/-• Oppenheim : -/-• Gordon : -/-

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Klonus

• Foot : -/-

Laboratory Examination29 june 2015 16.46

Hb *13,5 14 – 16 g%

Leukocyte *11.100 5 – 10 rb

Trombocyte 308.000 150 – 450rb

Ht *39 42 – 48 %

GDS 86 <140 mg/dl

Ureum 79 15-50 mg/dl

Creatinine *0,6 0,6-1,1 mg/dl

SGOT 47 < 37 u/L

SGPT 33 < 40 u/L

LED 5 <10

Bleeding time 2.00 1-3

Coating time 10.00 5-15

Natrium 140

Kalium 3,60

Chlorida 105

30 june 2015 10:23

Anti HIV Non Reaktive

HBsAg negative

CT SCAN KEPALA23/6/2015

Interpretasi : non obstructive hydrocephalusLeft zygomatic fracture

Ro. Thorax

• Kesan : Cor and Pulmo dalam batas normal

Assesment • Clinical : cephalgia• Etiology : trauma capitis• Pathology : non obstructive

hydrocephalus• Topis : ventrikel

RESUME

Treatment

• Inf RL 14 tpm/ 500cc/8hour• Acetozolamid 3 x 500mg• Glaucon 3x 500mg• Ksr 2x1tab• Pct 3 x 500mg• V-P shunt surgery

Prognosis

• Ad Vitam : Dubia ad Malam• Ad Functionam : Dubia ad Malam• Ad Sanactionam : Dubia ad Malam

Follow up Day-1 (30/6/2015)

Subyektif

• Cephalgia, nausea (-), vommit (-)

Obyektif

• KU : moderate ill• Consciousness : GCS E4V5M6• TD : 100/80 mmHg• Pupil : isokor, RCL +/+, RCTL +/+• TRM (-)• LNK (-)• R. Fisiologis up and low : +/+ • R. Patologis : Babinski : -/- • Motorik upper and lower: 5555/5555

Assesment 1

• Dx klinis : cephalgia• Dx etiologis : trauma capitis• Dx patologis : hydrocephalus• Dx topis : ventrikel

Plan

• IVFD RL 14 tpm• Acetozolamid 3x1

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Follow up Day-2 (1/7/2015)

Subyektif

• Cephalgia (<<), nausea (-), vomit (-)

Obyektif

• KU : moderate ill• Consciousness : GCS E4V5M6• TD : 90/60 mmHg• Pupil : isokor, RCL +/+, RCTL +/+• TRM (-)• LNK (-)• R. Fisiologis up and low : +/+ • R. Patologis : Babinski : -/- • Motorik upper and lower: 5555/5555

Assesment 1

• Dx klinis : cephalgia• Dx etiologis : trauma capitis• Dx patologis : hydrocephalus• Dx topis : ventrikel

Plan

• IVFD RL 14 tpm• Acetozolamid 3x500mg• Glaucon 3x500mg• Ksr 2x1• Pct 3x500mg• Vp shunt surgery (2july)

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Follow up Day-3 (2/7/2015)

Subyektif

• Cephalgia (<<), nausea (-), vomit (-)

Obyektif

• KU : moderate ill• Consciousness : GCS E4V5M6• TD : 100/80 mmHg• Pupil : isokor, RCL +/+, RCTL +/+• TRM (-)• LNK (-)• R. Fisiologis up and low : +/+ • R. Patologis : Babinski : -/- • Motorik upper and lower: 5555/5555

Assesment 1

• Dx klinis : cephalgia• Dx etiologis : trauma capitis• Dx patologis : hydrocephalus• Dx topis : ventrikel

Plan

• IVFD RL 14 tpm• Acetozolamid 3x500mg• Glaucon 3x500mg• Ksr 2x1• Pct 3x500mg• Vp shunt surgery

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Follow up Day-4 (3/7/2015)

Subyektif

• Cephalgia (<<), nausea (-), vomit (-), dizzy (+)

Obyektif

• KU : moderate ill• Consciousness : GCS E4V5M6• TD : 90/60 mmHg• Pupil : isokor, RCL +/+, RCTL +/+• TRM (-)• LNK (-)• R. Fisiologis up and low : +/+ • R. Patologis : Babinski : -/- • Motorik upper and lower: 5555/5555

Assesment 1

• Dx klinis : cephalgia• Dx etiologis : trauma capitis• Dx patologis : hydrocephalus• Dx topis : ventrikel

Assesment 2

• Post vp shunt

Plan

• IVFD Nacl 0,9% 2000cc/24jam• Ceftriaxon 2x2gr• Ketorolac 3x30mg• Omz 2x1• Citicolin 2x1gr• Transamin 3x1• Vit K 3x1

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Follow up Day-5 (4/7/2015)

Subyektif

• Cephalgia (<<), nausea (-), vomit (-), dizzy (+)

Obyektif

• KU : moderate ill• Consciousness : GCS E4V5M6• TD : 90/60 mmHg• Pupil : isokor, RCL +/+, RCTL +/+• TRM (-)• LNK (-)• R. Fisiologis up and low : +/+ • R. Patologis : Babinski : -/- • Motorik upper and lower: 5555/5555

Assesment 1

• Dx klinis : cephalgia• Dx etiologis : trauma capitis• Dx patologis : hydrocephalus• Dx topis : ventrikel

Assesment 2

• Post vp shunt

Plan

• Inj neulin 500mg

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Follow up Day-6 (5/7/2015)

Subyektif

• Cephalgia (<<), nausea (-), vomit (-), dizzy (+)

Obyektif

• KU : moderate ill• Consciousness : GCS E4V5M6• TD : 90/60 mmHg• Pupil : isokor, RCL +/+, RCTL +/+• TRM (-)• LNK (-)• R. Fisiologis up and low : +/+ • R. Patologis : Babinski : -/- • Motorik upper and lower: 5555/5555

Assesment 1

• Dx klinis : cephalgia• Dx etiologis : trauma capitis• Dx patologis : hydrocephalus• Dx topis : ventrikel

Assesment 2

• Post vp shunt

Plan

• Inj ceftriaxone 2x2gr• Inj neulin 2x500mg• Inj omz 2x40mg• Inj ondancentron bila mual• venflon

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Follow up Day-4 (3/7/2015)

Subyektif

• Cephalgia (<<), nausea (-), vomit (-), dizzy (+)

Obyektif

• KU : moderate ill• Consciousness : GCS E4V5M6• TD : 90/60 mmHg• Pupil : isokor, RCL +/+, RCTL +/+• TRM (-)• LNK (-)• R. Fisiologis up and low : +/+ • R. Patologis : Babinski : -/- • Motorik upper and lower: 5555/5555

Assesment 1

• Dx klinis : cephalgia• Dx etiologis : trauma capitis• Dx patologis : hydrocephalus• Dx topis : ventrikel

Assesment 2

• Post vp shunt

Plan

• Venflon• Cefadroxil 3x500mg• Pct 3x 500mg

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