History of Present Illness Diagnosed case of Severe communicating hydrocephalus, post-meningitic (2010, NCH). Advised to underwent shunting but deferred several times due to growth on CSF. Last CSF analysis done was on Sept 2010 at NCH. Maintained on phenobarbital at 4mkd; Regular follow-up with NCH. 2 days PTA (+) nonproductive cough and colds (+) fever (tmax 37.9C), given paracetamol Good appetite 1 day PTA (+) cough and colds, (-) fever Noted decreased activity; hence, consult at NCH. Prescribed with cefuroxime. Day of admission Difficulty of breathing: alar flkaring; Circumoral cyanosis consult at private clinic PCMC
Birth and Maternal History Born to a 27 y/o G4P5 (3205), nonsmoker, non-alcoholic beverage drinker; 2 prenatal checkups starting 5mos AOG at LHC. (+) SVI at 2mos AOG, took paracetamol. No other illnesses. No exposure to viral exanthems, radiation. Delivered preterm (32 weeks), twin pregnancy, via NSD at EAMC Admitted at EAMC NICU as neonatal sepsis, pneumonia x 3 months. Work-up included CUTZ which revealed hydrocephalus.
Feeding History Prenan 2-3oz q3hours Complementary feeding at age 6 months Soft diet, milk per orem
Immunization History HepB, DPT x 2 doses OPV x 3 doses
Past Medical History Severe communicating hydrocephalus secondary to post-meningitic changes; Cerebral palsy, quadrispastic At age 3-4 months at NCH. Regular follow-up at NCH s/p Vent tap x 2; Last CSF analysis (Sept 2010): (+) growth (Staphylococcus, Streptococcus), treated with Vancomycin, Oxacillin, PipTazo Oct 2010: seizures (upward gaze, jerking of upper extremities); last seizure: September 2012 Maintained on Phenobarbital (4mkd) For shunting Pneumonia October 2012 at NCH