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Morning Report

COLLEEN MARTY
JULY 6, 2015

In clinic.
Patient presents for 4mo well child check.

No specific parental concerns, except that he


had periods during which he was really fussy
around 3 months but these seem to be getting
better.

Formula fed and eating well.

Sleeping through the night 5-6 days/week.

Meeting milestones.

Additional History

Past Medical History:

Negative von Willebrands panel prior to circumcision

Family Medical History:

Mother with von Willebrands

Mother with depression

Social History:

Lives with Mom and Dad.

Dad is primary caregiver while Mom works during the


day, however Mom recently quit her job (about 2
weeks ago).

Finances are tight, but they have adequate food and


necessities.

Weight

Height

Head Circumference

Physical Exam
General: Alert, active infant boy, smiling and interactive. Cries with exam but easily
consolable
Skin:
Dry, rough maculopapular rash on bilateral arms and scalp with areas of
excoriation.
Head: Macrocephalic with prominent, large forehead. Anterior fontanelle full when
resting and bulging with crying.
Eyes:

Sclerae white, pupils equal and reactive, red reflex normal bilaterally

Ears:

Normal bilaterally

Nose:

Clear

Mouth:

No perioral or gingival cyanosis or lesions. Tongue is normal in appearance.

Lungs: Clear to auscultation bilaterally


Heart:
normal

Regular rate, regular rhythm, no murmur, no gallop or rub, normal S1 & S2 and
peripheral pulses

Abdomen: Soft, non-tender; bowel sounds normal; no masses, no organomegaly


GU:

Normal male - testes descended bilaterally and circumcised

Femoral pulses: present bilaterally


Extremities: extremities normal
Neuro: Alert, moves all extremities spontaneously, no head lag, sits with support, lower
extremities slightly hypertonic although exam limited due to patient agitation/crying

4 month old male


with new onset
macrocephaly

Table
Common causes of
macrocephaly in children
SEE UP-TO-DATE ARTICLE:
MACROCEPHALY IN INFANTS AND CHILDREN

Table
Clinical features of selected
syndromes associated with
macorcephaly
SEE UP-TO-DATE ARTICLE:
MACROCEPHALY IN INFANTS AND CHILDREN

Normal Head Growth


Head growthGeneral guidelines regarding head growth, a
reflection of brain growth, include the following:
The average head circumference at birth is 13.7 inches (35
cm)
Head circumference usually is 0.4 to 0.8 inches (1 to 2 cm)
larger than chest circumference at birth
Head circumference increases approximately 0.4
inches/month (1 cm/month) during the first year of life, with the
most rapid growth occurring during the first six months, with an
increase of 0.8 inches (2 cm) in the first month and 2.7 inches
(6 cm) in the first four months.
Brain weight doubles by four to six months of age and triples
by one year of age
The majority of head growth is complete by four years of age

Table
Measurement of head
circumference
SEE UP-TO-DATE ARTICLE:
MACROCEPHALY IN INFANTS AND CHILDREN

Macrocephaly

Macrocephaly: OFC greater than two SD above


the mean for given age, sex, and gestation (>
97% ile)

Evaluation should be initiated with:

Single abnormal measurement

Progressive enlargement

Increase in OFC > 2cm/month

Important History and


Exam Findings

Signs of elevated ICP, trauma, or infection


urgent evaluation

Syndromic features consider discussing with


genetics

Developmental delay neuroimaging

Normal development, reassuring exam


measure OFCs of 1st degree relatives (plot on
the weaver curve), ultrasonography

Figure
Weaver Curve
SEE UP-TO-DATE ARTICLE:
MACROCEPHALY IN INFANTS AND CHILDREN

Imaging Considerations

Plain radiographs:

Findings of skeletal dysplasia

Increased ICP (widening of sutures, prominent markings on the


inner table of the skull, erosion of the sella turcica)

Ultrasonography:

infants with normal neurodevelopmental examination

no evidence of increased ICP

open anterior fontanelle

MRI and CT:

Abnormal neuro exam

Progressively enlarging OFC

Increased ICP

Closed anterior fontanelle

Case Continued:
Imaging Studies

US Encephalography: Extra-axial space: Extraaxial spaces are enlarged. The


subarachnoid membrane appears to be pushed
down onto the surface of the brain. The fluid in
the extra-axial spaces have
some internal echoes.

Impression: Enlarged subdural spaces with


complex fluid in the
subdural spaces. This is worrisome for subdural
hemorrhage.

Initial Head CT (12/2014)

Imaging Contd

CT Brain WO Contrast

Impression:
1. Moderate enlargement of the extra-axial fluid spaces
by
fluid which is hyperdense to intraventricular CSF,
suggesting
subdural hygromas versus chronic subdural
hematomas, with bulging of the fontanelle and splaying
of the cranial sutures. No skull fracture noted. MRI with
contrast recommended for further evaluation if clinically
indicated.
2. Mild enlargement of the lateral and third ventricles.
No
brain parenchymal abnormality identified.

Imaging Contd

XR Osseous Survey: Normal

Ophthalmology exam: No retinal hemorrhages.


Normal visual acuity.

Lab Work-up

CBC WBC 17.6 (12.9% N, 75% L, 5.5% Eos),


Hct 35.6, Plt 556

CMP ALT 94, AST 77, Ca 10.4

PT/INR 12.1/0.9

PTT 35

Von Willebrand Panel wnl (Ag, VWF, and Factor


VIII Activity

Factor IX - wnl

Follow up Head CT
(4/2015)

Outcomes of Infants with


TBI

Outcomes for Infants


with TBI

Younger child age at injury predicts poorer post


injury outcomes and a more uncertain and
extended course of recovery

adverse long-term outcomes include greater


impairments in:

Behavior

Attention

Language

Cognition.

Ongoing Management

Close monitoring for neurodevelopmental


delays

Early Intervention referral

Rehab referral

Parental support

Social services