0900: A 12-week-old full-term male infant, born via spontaneous vaginal delivery without complications and with no known genetic disorders, presents with concerns related to head size and development. The mother reports that his head appears larger than other babies his age. She states, “He begins that shrill-like cry every time we lay him in the crib or try to change his diaper,” and the infant is found crying with a high-pitched cry that improves only when held by his father. The infant breastfed for 20 minutes prior to being laid in the crib but vomited within a few minutes of lying down. On observation, the infant does not smile and is unable to lift or control his head when picked up, requiring full support. Fontanel assessment revealed a large, bulging, non-pulsatile anterior fontanel, while the posterior fontanel was closed. The mother also reports that the infant’s head appears larger than other babies in the nursery, suggesting abnormal head growth and the need for further evaluation.

0915: 24-gauge PIV placed in the right forearm, infant tolerated it well. Labs collected. Infant transported to radiology for ultrasound.

0900

• NPO
• Insert peripheral IV
• Complete Blood Count
• Basic Metabolic Panel
• Cranial ultrasound
• Neuro checks Q2 hours

0915: 24-gauge PIV placed in the right forearm, infant tolerated it well. Labs collected. Infant transported to radiology for ultrasound.

1200: Infant able to move all extremities spontaneously, but delayed responses noted when stimulated. Opens eyes to nailbed pressure only, and produces a mild, weak cry. Pupils are unequal, right pupil 3 mm, round, sluggish reaction to light, left pupil 2 mm, round, sluggish reaction to light. Anterior fontanel assessment unchanged, remains bulging, firm, and non-pulsatile.

1100

Cranial Ultrasound

Clinical Indication: Macrocephaly, bulging anterior fontanelle, high-pitched cry, vomiting, poor head control.

Impression:

• Findings consistent with hydrocephalus, characterized by significant lateral and third ventricular enlargement.
• No evidence of hemorrhage or mass effect.
• Clinical correlation recommended to evaluate for possible causes, such as aqueductal stenosis or other obstructive processes.

1215

• 0.9% NS infusion 2 mL/kg/hr
• NPO

1500

Procedure Note

Ventriculoperitoneal (VP) shunt placed without difficulty. Incision to scalp closed with 2 staples. Small puncture incision to umbilical area closed with surgical glue. Pre-procedure ICP 40 mmHg, post-procedure ICP 8 mmHg.

0915

24-gauge PIV placed in the right forearm, infant tolerated it well. Labs collected. Infant transported to radiology for ultrasound.

1200

Infant able to move all extremities spontaneously, but delayed responses noted when stimulated. Opens eyes to nailbed pressure only, and produces a mild, weak cry. Pupils are unequal, right pupil 3 mm, round, sluggish reaction to light, left pupil 2 mm round, sluggish reaction to light. Anterior fontanel assessment unchanged, remains bulging, firm, and non-pulsatile.

1300

Provider at bedside discussing radiology findings with the infant’s parents and providing information about placement of a ventriculoperitoneal shunt. Parents provided verbal consent to the provider to allow for the procedure. Informed consent document signed by both parents.

1520

Infant returned post-procedure. Parents present. All four extremities move spontaneously. Infant appears drowsy, eyes open spontaneously. Pupils 2mm bilaterally, round, equal, and reactive to light. Strong cry noted when stimulated. Anterior fontanel is flat, soft.

1300

• VP Shunt placement

1500

• Acetaminophen 10 mg/kg/dose oral suspension every 6 hour for pain
• Continue 0.9% NS infusion 2 mL/kg/hr until infant completes 2 feedings
• Neuro assessment q1h for 24 hours then q2h
• Keep the infant's head flat on the non-operative side until reevaluated by the surgical team.
• Cefotaxime 50 mg/kg/dose IV infusion over 1 hour bid
• Nutrition consultation for evaluation of nutritional status and needs.