Received Jan 1, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| UNK | VACCINE NOT SPECIFIED (OTHER) | UNKNOWN MANUFACTURER | 1 | — | IM |
Healthy normal newborn born XXXX with no abnormal prenatal findings on 3 Maternal Fetal Medicine ultrasounds. Last ultrasound completed on 9/15/23 with no abnormal findings. Newborn completed all recommended pediatrician follow-up appointments and received all 10 vaccines as recommended from XXXX through XXXX. On XXXX at 4 month check up, bump on top of head was stressed to pediatrician and fast MRI ordered and completed same day to show 8.6cm arachnoid cyst compressing brain. Further follow-up with Neurosurgery and sedated MRI on 2/7/24 showed growing cyst to be 9.3cm and surgery for Cystoperitoneal Shunt placement completed on 2/13/24 at hospital at 4 months old. Infant recovered and cyst drained with complete re-expansion of brain by June 2023. CP shunt to stay in with neurosurgery follow-up and monitoring for life.
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Transabdominal ultrasound examination. View: Good view Pregnancy ========= Singleton pregnancy. Number of fetuses: 1 Dating ====== Date Details Gest. age EDD LMP 1/6/2023 36 w + 0 d U/S based upon AC, BPD, Femur, HC 35 w + 6 d Assigned dating Dating performed on 05/25/2023 Based on the LMP 36 w + 0 d General Evaluation ============== Cardiac activity present. FHR 133 bpm. Fetal movements visualized. Presentation cephalic. Placenta anterior. Umbilical cord Cord vessels: 3 vessel cord. Amniotic fluid Amount of AF: normal amount. MVP 4.8 cm. AFI 15.1 cm. Q1 4.2 cm, Q2 4.8 cm, Q3 2.2 cm, Q4 3.9 cm. Fetal Biometry ============ Main Fetal Biometry: BPD 86.8 mm 35w 0d 30% Hadlock OFD 117.3 mm -/- 97% Jeanty HC 330.2 mm 37w 4d 59% Hadlock AC 323.4 mm 36w 2d 68% Hadlock Femur 66.7 mm 34w 2d 10% Hadlock Fetal Weight Calculation: EFW 2,763 g 35w 5d 45% Hadlock EFW (lb,oz) 6 lb 1 oz EFW by Hadlock (BPD-HC-AC-FL) Head / Face / Neck Biometry: Cephalic index 0.74 2% Nicolaides Extremities / Bony Struc Biometry: FL / BPD 0.77 FL / HC 0.20 FL / AC 0.21 Fetal Anatomy =========== The following structures appear normal: Head / Neck Lateral ventricles. Choroid plexus. Midline falx. Cavum septi pellucidi. Cerebellum. Cisterna magna. Heart / Thorax 4-chamber view. Diaphragm. Abdomen Stomach: size and position. Kidneys: bilateral kidneys. Bladder: size and shape. Gender: male. Biophysical Profile ============== 2: Fetal breathing movements 2: Gross body movements 2: Fetal tone 2: Amniotic fluid volume 8/8 Biophysical profile score Fetal Doppler =========== Umbilical Artery: normal. EDF: positive MD 17.70 cm/s S / D 2.41 51% Acharya VTI 14.16 cm HR 128 bpm Impression ========= A single, viable IUP is visualized with normal heart tones. Interval growth is appropriate. BPP = 8/8. Normal AFI. Normal cervix and adnexa. Follow-up ======== Follow-up as clinically indicated. DOCUMENT NAME: Operative Report DOCUMENT STATUS: Auth (Verified) RESULT DATE: 2/13/2024 08:52 EST DATE OF SURGERY: 02/13/2024 ANESTHESIA: General endotracheal. Prior to the procedure, I had a detailed conversation with the family regarding the risks, benefits and alternatives to the procedure. Specifically, I described what we were going to do and how it would likely benefit the patient. We talked about the surgical team and the fact that I would be assisted during the procedure by other physicians and nurses. We discussed my specific experience with this sort of procedure. I further informed the family about alternatives to surgery and the risks associated with not treating surgically or waiting to treat surgically. I was clear that there are risks with any procedure - including this one, and that it was possible that the procedure would not work. We talked about the potential need for additional surgery. I described some of the possible complications and the relative likelihood of those complications. We specifically discussed the risks of infection, bleeding, postoperative pain, and even major complications such as paralysis, loss of major body function or death. Finally, I offered to the family the opportunity to repeat back their understanding and ask questions. SERVICE: Pediatric Neurosurgery. PREOPERATIVE DIAGNOSIS: Left parietal arachnoid cyst. POSTOPERATIVE DIAGNOSIS: Left parietal arachnoid cyst. PROCEDURE PERFORMED: 1. Insertion of left arachnoid cyst - peritoneal shunt (CPT: 62192). 2. Neuroendoscopic placement of cyst catheter (CPT: 62160). SPECIMENS REMOVED: Several spinal fluids. IMPLANTS: 1. One Bactiseal ventricular catheter. 2. One Bactiseal peritoneal catheter. 3. One Medtronic ultrasmall low-pressure valve. BRIEF CLINICAL HISTORY: The patient is a baby with head growth acceleration, bony defect in the left parietal area with asymmetric left parietal bossing, and an MRI that shows a very large arachnoid cyst over the convexity compressing the brain. He has come to the operating room for shunting, understanding the other options for his parents including fenestration or observation. They understand the relative risks of surgery including but not limited to infection, bleeding, stroke, paralysis, numbness, weakness, injury to the visceral organs, need for further surgery, even death. They understand, questions have been answered, and they wished to proceed. No guarantees as to outcome were made or implied. PROCEDURE IN DETAIL: The patient was taken to the operating room, and after induction, successfully intubated. He was placed in the supine position with his head turned to the right side on a well-padded donut and a roll underneath the left shoulder. The right parietal area was shaved, and the head, neck, and abdomen were prepped and draped in the usual sterile fashion. A curvilinear incision was made over the left parietal boss with the top of the incision essentially at the bony defect. A small flap was turned. We opened and lifted the periosteum over the bone at the inferior aspect of the incision. We placed a burr hole here such that our catheter would have some steadiness to it and hopefully decreased the risk of spinal fluid leakage. A small 2 cm incision was made to the left of the umbilicus and taken down through all layers to the peritoneum, which was isolated and opened. We could pass a blunt instrument in the peritoneal cavity under direct vision. A shunt passer was passed from the abdominal incision to the scalp incision and a Bactiseal catheter was brought through. We connected an ultrasmall low pressure shunt to the proximal end of the catheter and secured it using a 2-0 silk tie. The system was flushed using antibiotic solution. We made a pocket underneath the galea to accommodate the valve. At this point, we used the electrocautery to open the dura and spinal fluid from the arachnoid cyst came out under fairly high pressure. We introduced a ventricular catheter into the cyst and took off some spinal fluid for routine studies. We placed the NeuroPEN endoscope down the barrel of the catheter. We came through the tip of the catheter and visualized the inside of the cyst. We could see the parietal cortex. We advanced the catheter and could see the arachnoid on the distal end of the cyst where fenestration would have been possible. The catheter was cut to approximately a 4-5 cm, connected to the valve and secured using a 2-0 silk tie. We pulled the peritoneal catheter to allow for the valve to sit nicely underneath the galea and placed a 4-0 Nurolon suture over the proximal arm of the shunt to keep it from toggling back and forth, tying it to the pericranium. Spinal fluid flowed nicely and spontaneously from the peritoneal catheter, which was shortened, wiped with bacitracin solution, and placed in the peritoneal cavity under direct vision. Both incisions were closed in anatomic layers with absorbable sutures and Dermabond was placed on the incisions. The patient was awakened, extubated, and taken to the recovery room in stable condition. Sponge and needle were counts at the end of the case correct.