Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of abnormal cranial shape noted by parents/pediatrician. Onset at [Age]. No history of trauma or metabolic bone disease. Developmental milestones are [Normal/Delayed]. No reported symptoms of increased intracranial pressure (ICP) such as emesis, lethargy, or irritability. Family history is [Positive/Negative] for syndromic craniosynostosis.
Clinical Examination Findings
Head circumference: [Value] cm (percentile). Cranial vault morphology reveals [Scaphocephaly/Brachycephaly/Plagiocephaly/Trigonocephaly]. Palpation of sutures: [Fused/Patent]. Presence of ridging at the [Sagittal/Coronal/Metopic/Lambdoid] suture. Facial symmetry: [Symmetric/Asymmetric]. Orbital findings: [Hypertelorism/Orbital dystopia/Proptosis]. Fontanelle: [Open/Closed/Tense].
Treatment Protocol
Recommended surgical intervention: [Endoscopic-assisted strip craniectomy / Open cranial vault remodeling]. Goal: Decompression of the cranial vault and aesthetic correction of skull morphology. Post-operative plan: [Helmet therapy / Observation]. Risks discussed: Bleeding, infection, dural tear, recurrence, and need for secondary procedures.