1. Step [1]: Identifying Difficult Word & Cues
1.1. Difficult Word
1.1.1. Myelomeningeocele
1.1.1.1. Cavitation in the spinal cord form of the spina bifida
1.1.1.2. Most Common
1.1.1.3. Not Most Severe
1.1.2. Hydrocephalus
1.1.2.1. Increase in the volume of the volume of CSF
1.2. Cues
1.2.1. Nourah
1.2.1.1. 26 year old
1.2.1.2. Has epilepsy
1.2.1.3. Takes Valporate and Carbamazepine
1.2.1.4. Concerned about having seizures
1.2.2. Khaled
1.2.2.1. 6 wk old
1.2.2.2. Repiar of myelomeningocele at age of 3 days
1.2.2.3. Requires monitoring for hydrocepalus
2. Step [2]: Problem Formulation
2.1. Nourah
2.1.1. 26 year-old epileptic mother, came to the clinic because she is concerned of having epileptic attack Though she is taking anti-epileptic drugs
2.2. Khaled
2.2.1. 6 wk old boy requiring monitoring for hydrocephalus a repair of myelomeninocele at age of 3 days.
3. Step [3]: Hypotheses Generation
3.1. Nourah
3.1.1. Folic acid deficiency
3.1.2. Intrauterine exposure of anti-convulsants cause NTD in te fetus
3.1.3. Seizures
3.1.3.1. Excitatory
3.1.3.1.1. AMPA
3.1.3.1.2. NMDA
3.1.3.2. Disturbance with the inhibition
3.1.4. Epilepsy
3.1.5. WHY DID SHE HAVE THE SEIZURE?
3.1.5.1. Not controlled with two agents!
3.2. Khaled
3.2.1. Spina Bifida
3.2.2. Hydrocepalus
3.2.2.1. Due to
3.2.2.1.1. Absorption of CSF
3.2.2.1.2. Secretion of CSF
3.2.2.2. Congenital
3.2.2.2.1. Acqua duct absent
3.2.2.2.2. Fibortic ventricle
3.2.2.3. Following myelomeningocele
3.2.2.4. Ventricles
3.2.2.5. Normal pressure hydrocephalus
4. Step [4]: Hypotheses Organization
4.1. Nourah
4.1.1. Epilepsy
4.2. Khaled
4.2.1. Congenital
4.2.2. Genetic
4.2.3. Acquired
5. Step [5]: Learning Objectives
5.1. 1. To learn Myelomeningocele
5.1.1. Causes
5.1.2. Pathophysiology
5.1.3. Complications of Surgery
5.2. 2. To define epilepsy
5.2.1. Pathophysiology
5.2.2. Symptoms & Signs
5.2.3. What Investigation should be done
5.3. 3. Side effects of Medication during pregnancy
5.3.1. Of both mother and fetus
5.4. 4. To define hydrocephalus
5.4.1. Causes
5.4.2. Types
6. Step [7] Inquary Plan & Gathering Infomation
6.1. Nourah
6.1.1. History
6.1.1.1. Diagnosed at 10
6.1.1.2. first attack Tonic clonic seizure
6.1.1.3. 6 months second generalized
6.1.1.4. Diagnosed as JME
6.1.1.5. Started on Sodium Valpoate
6.1.1.6. No seizure
6.1.1.7. Age of 15 level
6.1.1.8. Didn't take medication
6.1.1.8.1. Due to side effects
6.1.1.9. Changed to carbamazepine
6.1.1.10. Can't work as swimmig instructor
6.1.1.11. A combination of two drugs
6.1.1.11.1. Controlled epilepsy
6.1.2. Obestetrical
6.1.2.1. At the end of pregnancy
6.1.2.1.1. Decreased level of me
6.1.2.2. no regular antenatal care
6.1.2.3. Experienced another attack
6.1.2.3.1. Back on Medications
6.1.2.4. Stopped medication 3 wks
6.1.2.5. Labour induced
6.1.2.6. US done
6.1.2.6.1. Decreased liqour
6.1.2.6.2. Increase calcifcation
6.1.2.7. 30 wk age gestational bleeding
6.1.3. Social
6.1.3.1. BA degree
6.1.3.2. Work in ministry
6.1.3.3. Moved with her husband
6.1.3.4. Moved to be close with family
6.1.4. Family History
6.1.4.1. Parents alive
6.1.4.2. Uncle had seizues
6.1.5. Examination
6.1.5.1. ALL NORMAL
6.1.6. Investigation
6.1.6.1. EEG confimed seizure
6.2. Khaled
6.2.1. History
6.2.1.1. Vagnial delivery
6.2.1.2. 38 week
6.2.1.3. No complciation during delivery
6.2.1.4. In10 minutes
6.2.1.5. Rquired suction and needed breathing
6.2.1.5.1. 3.5 kg
6.2.2. Physical Examination
6.2.2.1. Problem with feeding
6.2.2.2. Head circumferance 33 cm
6.2.2.3. Upper limbs are normal
6.2.2.4. Decreae tone in lower lims
6.2.2.5. Urine passed and catherter inserted
6.2.2.6. Anus was
6.2.2.6.1. patchelous
6.2.2.6.2. Oozing
6.2.3. Investigation
6.2.3.1. CT in 2 days
6.2.3.1.1. Dilated ventricles
6.2.3.2. Repair
6.2.3.2.1. 3 days
6.2.3.3. 14 days
6.2.3.3.1. Head cicumferance 27 cm
6.2.3.3.2. Lethargic
6.2.3.3.3. Increased ICP
6.2.3.4. The Next day
6.2.3.4.1. Ventriculoperitoneal shunt
6.2.4. Summary
7. Step [6] Review of last session
7.1. Myelomeningocele
7.1.1. NTD
7.1.2. Failure of neural tube closure
7.1.3. Protrusion of of meninges & spainl cord
7.1.4. 90 % of population with myelomeningocele have ydrocephalus
7.1.5. Prevalence
7.1.5.1. 1/1000 in Us
7.1.5.2. Chances increase if the mother had another child with the defect
7.1.6. Causes
7.1.6.1. Genetic Background
7.1.6.2. Folic acid deficiency
7.1.6.3. Medications
7.1.6.3.1. Valproate Acid
7.1.6.3.2. Carbamazinpe
7.1.6.3.3. Antagonize folic acid
7.1.6.4. Maternal hypethermia
7.1.6.5. Maternal diarrhea
7.1.6.6. Radiation
7.1.6.7. Retinoic acid
7.1.6.8. Smoking
7.1.6.9. Sternous exercise
7.1.7. Other types of spina bifida
7.1.7.1. Spina bifida
7.1.7.2. Meinengocele
7.1.7.3. Myeloschiasis
7.1.8. Pathogenesis\
7.1.8.1. Defect in closure
7.1.9. Signs & Symptoms
7.1.9.1. Neurological
7.1.9.1.1. Arnold Ciari Malfomation
7.1.9.1.2. Episodes of apnea
7.1.9.2. Non-neurological
7.1.9.2.1. Esophaseal malformation
7.1.10. Mot common in the lumbosacral region
7.2. Epilepsy
7.2.1. Sudden synchrouns discharge of cereberal cortex
7.2.2. Criteria for diagnosis
7.2.2.1. 2 seizure in 24 hours
7.2.2.2. 1 siezure with neurological poblem
7.2.3. Classification
7.2.3.1. Idiopathic
7.2.3.1.1. Generalized
7.2.3.1.2. Petit Mal
7.2.3.1.3. EEG cannot detect this type of seizures
7.2.3.1.4. Post ictal phase 15 minutes
7.2.3.1.5. Partial
7.2.3.1.6. Epileptic syndrome
7.2.3.1.7. Monogenic Disorders
7.2.3.2. Causes
7.2.3.2.1. no Identifiable cause
7.2.3.2.2. Genetic Problem
7.2.3.3. In US 1/100 have unprovaced seizure
7.2.3.4. Symptomtic
7.3. Hydrocephalus
7.3.1. Classification
7.3.1.1. Acute
7.3.1.2. Chronic
7.3.2. If there is no obstruction
7.3.2.1. Communicating
7.3.3. If obstruction is present
7.3.3.1. Non-communicating
7.3.3.2. Due to tumors, ...
7.3.3.3. Pressing on aqueduct
7.3.3.4. Congenital problem
7.3.4. Arnold Chiari Malformation
7.3.4.1. Four types
7.4. Relation to the case
7.4.1. the moter took her medication
7.4.2. As mentioned
7.4.2.1. They are teratogens
8. Step [8] Diagnostic Decision
8.1. Nourah
8.1.1. Juvemile myoclonic epilepsy
8.2. Khaled
8.2.1. Myelomeningocele
8.2.2. Hydoicephalus
9. Leaning Ojectives
9.1. Nourah
9.1.1. [1] Medications of epilepsy
9.1.2. [2] Compliance
9.2. Khaled
9.2.1. Treatment of hydrocephalus
10. Step [9] Review of Last Session
10.1. Nourah
10.2. Khaled
11. Step [10] Management
11.1. Nourah
11.1.1. General Consideratio
11.1.1.1. Satrt with the safest
11.1.1.2. Make sure of patient's complaince
11.1.1.3. Increase dose to therapeutic level
11.1.2. MOA
11.1.2.1. Blocking of Na+ chanels
11.1.2.1.1. Valporate sodium
11.1.2.1.2. Caramazepine
11.1.2.2. Inhibition of upake
11.1.2.3. Inhibition of NT
11.1.2.3.1. e.g., glutamte
11.1.2.4. Metabolis in the liver
11.1.3. Goals
11.1.3.1. Eliminate seizure
11.1.3.2. Reduce frequency
11.1.3.3. Avoid long term side effects
11.1.3.4. Reduced Vit. K
11.1.4. JME
11.1.4.1. Valproate sodium
11.1.4.1.1. Side effects
11.1.4.1.2. Hair loss
11.1.4.1.3. Weight gain
11.1.4.2. Carbamazepine
11.1.4.2.1. Conreversy of use?!
11.1.4.2.2. Induce Myoclonic seizure
11.1.4.3. Lamotrigine
11.1.4.4. Phenytoin
11.1.4.4.1. Second line agent
11.1.4.4.2. Dangerou on child-bearing age
11.1.4.4.3. NAow therapeutic index
11.1.4.4.4. Osteopenia
11.1.4.5. Ptoafenatol
11.1.4.5.1. Safest on pregnant ladie
11.1.5. Lactation
11.1.5.1. Two safe agents
11.1.6. Seizures, if fully controlled
11.1.6.1. Patients can tapper the dose and eventually discontinue it completekly
11.1.6.2. Nomal neurological examination
11.1.6.3. Nomal EEG finding
11.1.7. Surgery
11.1.7.1. Removal of lesion
11.1.7.1.1. As long as it dose not intefere with vital function
11.1.7.1.2. Depends on dominan hemisphere
11.1.7.2. Side effects
11.1.7.2.1. Cognetive abilities could be lost
11.1.8. Driving
11.1.8.1. Recommended not to drive
11.1.9. Lifestyle
11.1.9.1. Diet
11.1.9.2. TV
11.1.9.3. Video games
11.1.10. Acute management
11.1.10.1. make in lateral duiticus position
11.1.10.2. DO NO put any thing in their mouth
11.1.10.3. Timing
11.1.10.4. Seizing fo more than 5 mins
11.1.10.4.1. rectal diazepam is administered
11.1.10.5. In ER sitting
11.1.10.5.1. ABC
11.1.10.5.2. Central line
11.1.10.5.3. History
11.1.10.5.4. Phenytoin
11.1.11. Summary
11.1.11.1. Recurrence of seizure
11.1.11.1.1. Due to not compliance
11.1.11.1.2. If doesn't want sodium valpoate acid
11.1.11.1.3. Lamotrigine
11.1.11.1.4. Education
11.2. Khaled
11.2.1. Hydrocephalus
11.2.1.1. 72 hours
11.2.1.2. Diuretics
11.2.1.3. Acetozalamide
11.2.1.4. SHUNT
11.2.1.4.1. Introduced in te 50's
11.2.1.4.2. One-valve way
11.2.1.5. If there is any obstuction
11.2.1.5.1. Opening etween 3rd & 4th ventricles
11.2.1.6. If there is no obstruction
11.2.1.6.1. Choroid cathateriztion
11.2.1.7. Ventriculostomy
11.2.1.7.1. Different fom the shunt
11.2.1.8. Complication
11.2.1.8.1. Infection
11.2.1.8.2. Hemorrhage
11.2.1.8.3. TOO MANY SIDE EFFECTS
11.2.1.9. Measure size of venticles
11.2.1.10. ICP
11.2.1.10.1. Ventricular tap
11.2.1.11. NOT to do LP if there is ICP
12. Step [11] Evaluation
12.1. Resourses
12.1.1. Merit' Neuology
12.1.2. Davidson
12.1.3. Harrison
12.1.4. Medscape