Professional Documents
Culture Documents
COLLEEN MARTY
JULY 6, 2015
In clinic.
Patient presents for 4mo well child check.
Meeting milestones.
Additional History
Social History:
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:
Regular rate, regular rhythm, no murmur, no gallop or rub, normal S1 & S2 and
peripheral pulses
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
Table
Measurement of head
circumference
SEE UP-TO-DATE ARTICLE:
MACROCEPHALY IN INFANTS AND CHILDREN
Macrocephaly
Progressive enlargement
Figure
Weaver Curve
SEE UP-TO-DATE ARTICLE:
MACROCEPHALY IN INFANTS AND CHILDREN
Imaging Considerations
Plain radiographs:
Ultrasonography:
Increased ICP
Case Continued:
Imaging Studies
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
Lab Work-up
PT/INR 12.1/0.9
PTT 35
Factor IX - wnl
Follow up Head CT
(4/2015)
Behavior
Attention
Language
Cognition.
Ongoing Management
Rehab referral
Parental support
Social services