Khaled & Nourah

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Khaled & Nourah by Mind Map: Khaled & Nourah

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

12.2. What to improve