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 Cavitation in the spinal cord form of the spina bifida Most Common Not Most Severe

1.1.2. Hydrocephalus Increase in the volume of the volume of CSF

1.2. Cues

1.2.1. Nourah 26 year old Has epilepsy Takes Valporate and Carbamazepine Concerned about having seizures

1.2.2. Khaled 6 wk old Repiar of myelomeningocele at age of 3 days 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 Excitatory AMPA NMDA Disturbance with the inhibition

3.1.4. Epilepsy

3.1.5. WHY DID SHE HAVE THE SEIZURE? Not controlled with two agents!

3.2. Khaled

3.2.1. Spina Bifida

3.2.2. Hydrocepalus Due to Absorption of CSF Secretion of CSF Congenital Acqua duct absent Fibortic ventricle Following myelomeningocele Ventricles 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 Diagnosed at 10 first attack Tonic clonic seizure 6 months second generalized Diagnosed as JME Started on Sodium Valpoate No seizure Age of 15 level Didn't take medication Due to side effects Changed to carbamazepine Can't work as swimmig instructor A combination of two drugs Controlled epilepsy

6.1.2. Obestetrical At the end of pregnancy Decreased level of me no regular antenatal care Experienced another attack Back on Medications Stopped medication 3 wks Labour induced US done Decreased liqour Increase calcifcation 30 wk age gestational bleeding

6.1.3. Social BA degree Work in ministry Moved with her husband Moved to be close with family

6.1.4. Family History Parents alive Uncle had seizues

6.1.5. Examination ALL NORMAL

6.1.6. Investigation EEG confimed seizure

6.2. Khaled

6.2.1. History Vagnial delivery 38 week No complciation during delivery In10 minutes Rquired suction and needed breathing 3.5 kg

6.2.2. Physical Examination Problem with feeding Head circumferance 33 cm Upper limbs are normal Decreae tone in lower lims Urine passed and catherter inserted Anus was patchelous Oozing

6.2.3. Investigation CT in 2 days Dilated ventricles Repair 3 days 14 days Head cicumferance 27 cm Lethargic Increased ICP The Next day 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 1/1000 in Us Chances increase if the mother had another child with the defect

7.1.6. Causes Genetic Background Folic acid deficiency Medications Valproate Acid Carbamazinpe Antagonize folic acid Maternal hypethermia Maternal diarrhea Radiation Retinoic acid Smoking Sternous exercise

7.1.7. Other types of spina bifida Spina bifida Meinengocele Myeloschiasis

7.1.8. Pathogenesis\ Defect in closure

7.1.9. Signs & Symptoms Neurological Arnold Ciari Malfomation Episodes of apnea Non-neurological 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 2 seizure in 24 hours 1 siezure with neurological poblem

7.2.3. Classification Idiopathic Generalized Petit Mal EEG cannot detect this type of seizures Post ictal phase 15 minutes Partial Epileptic syndrome Monogenic Disorders Causes no Identifiable cause Genetic Problem In US 1/100 have unprovaced seizure Symptomtic

7.3. Hydrocephalus

7.3.1. Classification Acute Chronic

7.3.2. If there is no obstruction Communicating

7.3.3. If obstruction is present Non-communicating Due to tumors, ... Pressing on aqueduct Congenital problem

7.3.4. Arnold Chiari Malformation Four types

7.4. Relation to the case

7.4.1. the moter took her medication

7.4.2. As mentioned 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 Satrt with the safest Make sure of patient's complaince Increase dose to therapeutic level

11.1.2. MOA Blocking of Na+ chanels Valporate sodium Caramazepine Inhibition of upake Inhibition of NT e.g., glutamte Metabolis in the liver

11.1.3. Goals Eliminate seizure Reduce frequency Avoid long term side effects Reduced Vit. K

11.1.4. JME Valproate sodium Side effects Hair loss Weight gain Carbamazepine Conreversy of use?! Induce Myoclonic seizure Lamotrigine Phenytoin Second line agent Dangerou on child-bearing age NAow therapeutic index Osteopenia Ptoafenatol Safest on pregnant ladie

11.1.5. Lactation Two safe agents

11.1.6. Seizures, if fully controlled Patients can tapper the dose and eventually discontinue it completekly Nomal neurological examination Nomal EEG finding

11.1.7. Surgery Removal of lesion As long as it dose not intefere with vital function Depends on dominan hemisphere Side effects Cognetive abilities could be lost

11.1.8. Driving Recommended not to drive

11.1.9. Lifestyle Diet TV Video games

11.1.10. Acute management make in lateral duiticus position DO NO put any thing in their mouth Timing Seizing fo more than 5 mins rectal diazepam is administered In ER sitting ABC Central line History Phenytoin

11.1.11. Summary Recurrence of seizure Due to not compliance If doesn't want sodium valpoate acid Lamotrigine Education

11.2. Khaled

11.2.1. Hydrocephalus 72 hours Diuretics Acetozalamide SHUNT Introduced in te 50's One-valve way If there is any obstuction Opening etween 3rd & 4th ventricles If there is no obstruction Choroid cathateriztion Ventriculostomy Different fom the shunt Complication Infection Hemorrhage TOO MANY SIDE EFFECTS Measure size of venticles ICP Ventricular tap 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