Identity (October 26th, 2023) RAN/LIS/ dr. AL, Sp.K.F.R., M.S.

(K)
Name : Mrs. Siti Aminah
Age : 53 years old
Sex : Female
Religion : Moslem
Marital Status : Married
RM : 12951654
HP : 082331505449
Address : Tuban
Occupation : Farmer
Reffered from Neuro Surgery OPC with Post Craniotomy Eksisi Tumor & Osteoplasty

Chief complaint: Kelemahan pada sisi wajah atas sebelah kiri

History of Present Illness
 2015  There was a gradual decrease in vision in the left eye
 2017  Her left eye was unable to see anything and can't differentiate between dark and light
 2020  Vision began to decrease in her right eye
 2022  The Patient seek treatment at Tuban Hospital, the vision in the right eye becomes
more blurry
 2023  The patient goes to Soetomo to the eye, from there she reffered to Neuro surgery to
do further examination
 2023, August  Patient underwent Post Craniotomy Tumor Excision & Osteoplasty. She
wasa hospitalized around 2 weeks in there and never went to rehabilitation therapy
 After surgery the vision in the right eye improved, but there was weakness above the left
eyebrow. The patient could not lift his left eyebrow
 The patient is able to fully smile and fully close both eyelids. No watery and dry in the eye.
Drooling (-). There is no mention of ear pain or a decrease in hearing. Moreover, no weakness
in chewing and no problems in swallowing. There is no history of slurred speech.

History of Functional Ability

The patient still could do all activities of daily living independently

History of Medication and Rehabilitation

DM : Metformin 3x500, Glimepiride 1x1, Insulin Novorapid 3x6 iu , Levemir 1x14 iu

History of Past Illness

No history of hypertension and Stroke before.
DM + Since 2 years ago

History of Work and Hobby

No spessific hobby, The patient work as a farmer near her house. Right now she is able to work again
but with limited activity

History of Psycho-Socio-Economic
The patient lives with her husband (56 yo). Lives in a one-story house, with a squatting toilet. The
patient Using BPJS for insurance

Family History
History of diabetes +,
No history of stroke, or hypertension in the family.

Patient’s Expectation
Facial muscles to be normal again.
III.1. General Status
GCS E4 V5 M6 BP: 120/80 mmHg, HR: 91x/min, RR: 18x/min, Temp: 36.5oC, SpO2: 99%
Height: 133 cm, Weight: 50 kg, BMI 31.09% (Obese Grade I)
Posture: Forward head, rounded shoulder, pelvic, ankle knee symetrical
Dominant extremity: Righthanded.
Gait: normal. Ambulation: independent without a walking aid

Head and neck : Anhidrosis (-) Ptosis (-|-) Enophthalmus (-|-) Miosis (-|-) Lagophthalmos (-|-)
Conjunctiva anemia (-|-), icterus (-|-), cyanosis (-), enlargement lymph node (-)
Cor : S1-S2 normal, regular, murmur (-), gallop (-)
Pulmo : Vesicular (+|+), wheezing (-|-), ronchi (-|-)
Abdomen : Soefl, peristaltic (+), tenderness (-)
Extremities : Warm acral (-|-), cyanosis (-), edema (-|-)

III.2. Head/Neck/Trunk,
Look : redness (-|-), swelling (-|-), skin lesion (-|-),
Feel : tender point (-|-), warmth (-|-), edema (-|-)
Move : pain when move (-)
Region Range of Motion MMT
Neck F|F 5|5
TMJ F|F 5|5
Trunk F|F 5|5

Neuromuscular :
Cranial Nerve Right
Cranial Nerve I Normal
Cranial Nerve II Visus 3/60
Cranial Nerve III Normal
Cranial Nerve IV Normal
Cranial Nerve V Sensory: normal
Motoric: Normal
Cranial Nerve VI Normal
Cranial Nerve VII Musc. Frontalis: 5
Musc. Corrugator: 5
Musc. Orbic. Oculi: 5
Musc. Nasalis: 5
Musc. Zygo. Mayor: 5
Musc. Orbic. Oris: 5
Musc. Bucinator: 5
Cranial Nerve VIII Rubbing Finger: Normal
Whisper Test Normal
Cranial Nerve IX Normal
Cranial Nerve X Normal
Cranial Nerve XI Normal
Cranial Nerve XII Normal
Left Reflex / Special Test
Normal
Visus - Direct Light Reflex (+|-)
Visual field: - Indirect Light Reflex (+|-)
Papil Atrofi
Normal
Normal
Sensory: normal Corneal Reflex (normal|normal)
Motoric: Normal
Normal
Musc. Frontalis: 1 Schirmer Test (+|+)
Musc. Corrugator: 1
Musc. Orbic. Oculi: 1 Taste 2/3 anterior third: normal|
Musc. Nasalis: 5 normal
Musc. Zygo. Mayor: 5
Musc. Orbic. Oris: 5 Stethoscope scratch: normal|normal
Musc. Bucinator: 5
Rubbing Finger: Normal Tinnitus (-|-)
Whisper Test Normal
Normal
Normal
Normal
Normal

III.3. Upper Extremities Region

Look : redness (-|-), swelling (-|-)
Feel : warmth (-|-), tender point (-|-), crepitation (-|-)
Move : pain (-|-)
Neuromuscular :
- Muscle tone : Normal
- Deep Tendon Reflex : BPR (+2|+2), TPR (+2|+2)
- Pathological reflex : Hoffmann (-|-), Tromner (-|-)
- Sensorics : normal
Region ROM MMT
Shoulder F/F 5/5
Elbow F/F 5/5
Wrist F/F 5/5
Fingers F/F 5/5

III.4. Lower Extremities Region.

Look : redness (-|-), swelling (-|-), deformity (-|-)
Feel : warmth (-|-), crepitation (-|-), tenderness (-|-)
Move : pain when move (-|-)
Neuromuscular :
- Tonus : normal
- Deep Tendon Reflex : KPR +2|+2; APR +2|+2
- Pathological reflex : Babinski (-|-)
- Sensorics : Normal

Region ROM MMT

Hip F/F 5/5
Knee F/F 5/5
Ankle F/F 5/5
Big Toes F/F 5/5
Toes F/F 5/5

III.5. Functional Status

Balance : Sitting balance (static and dynamic) is good, standing balance (static and
dynamic) is good
Transfer : lying to sitting independent, sitting to standing independent
Barthel Index : 90
Feeding 10/10 Bladder 10/10
Grooming 5/5 Toilet use 10/10
Bathing 5/5 Mobility 10/15
Dressing 10/10 Transfer 15/15
Bowel 10/10 Stairs 5/10

SUPPORTING EXAMINATION:

 Pemeriksaan Foto Thorax PA 20-07-2023

Cor : bentuk dan besar normal
Pulmo : tak tampak infiltrat / nodul
Trachea tampak di tengah
Sinus phrenicocostalis kanan kiri tajam
Hemidiafragma kanan kiri tampak baik
Tak tampak proses osteolitik / osteoblastik
Soft tissue tak tampak kelainan
Kesimpulan
- Tak tampak proses metastase pada paru dan tulang-tulang yang tervisualisasi
- Cor tak tampak kelainan
  TS Yth, Pemeriksaan MSCT 2023-08-02 Post Operasi
- Tampak defek calvaria regio fronto temporal kiri disertai densitas darah (65 HU) dan multiple foci
udara (-1112 HU) di frontal kanan kiri dan temporal kiri, tampak lesi disertai perifokal edema yang
mendesak dan menyempitkan ventrikle lateral kiri dan menyebabkan midline shift sejauh +/- 0,4 cm
ke sisi kanan
- Tak tampak gambaran abnormal contrast enhancement pada brain parenchyma
- Sulci tampak effacement
- Sistem ventrikel dan cysterna normal
- Pons dan cerebellum normal
- Tak tampak kalsifikasi abnormal
- Tampak penebalan mukosa (36 HU) di sinus sphenoid kanan
- Orbita, mastoid dan sinus paranasalis kanan kiri di luar lesi tak tampak kelainan

Kesimpulan
- Defek calvaria regio fronto temporal kiri disertai hemorrhage dan pneumocephaly di frontal
kanan kiri dan temporal kiri merupakan
gambaran post surgical disertai midline shift sejauh +/- 0,4 cm ke sisi kanan
- Brain edema
- Sinusitis sphenoid kanan

 MRI Kepala irisan axial, tanpa dan dengan kontras 20-10-2023

- Tak tampak lesi hipointense/hiperintense di brain parenchyme, yang dengan pemberian kontras tak
tampak abnormal contrast enhancement
- Tampak area di surgical bed di tuberculum sellae dengan hypointense signal pada T1WI,
hyperintense pada T2WI, hypointense pada T2FLAIR, unrestricted pada DWI, yang dengan
pemberian kontras tak tampak kontras enhancement
- Tampak small vessel ischemic di subcortical lobus frontalis kiri
- Sulci dan gyri di luar lesi tampak normal
- Sistem ventrikel dan cysterna tampak baik
- Tak tampak deviasi midline struktur
- Pons dan cerebellum tampak baik
- Mastoid, orbita kanan kiri tampak baik
- Tampak penebalan concha nasalis inferior kanan kiri yang tampak hypointense pada T1WI,
hyperintense pada T2WI; tampak deviasi septum nasi ke kanan
- MR Angiography : Circulus Willisi tampak patent, tak tampak aneurysma maupun vascular
malformation

Kesimpulan
- Tak tampak residual/resistive mass di surgical bed di tuberculum sellae
- Encephalomalaceal cyst di di surgical bed di tuberculum sellae
- Small vessel ischemic di subcortical lobus frontalis kiri
- Hypertrophy concha nasalis inferior kiri disertai deviasi septum nasi ke kanan

 Laporan Operasi 1 Augutus 2023

Flattening dari sphenoid ridge Insisi duramater C shape dengan pedicle ke arah Ridge dilakukan
Spliting sylvian untuk mempermudah retraksi hingga expose tumor Identifikasi Tumor dan batas-
batas tumor detachment tumor dari arah base (tuberculum sellae dan planum sellae) pisahkan tumor
sesuai arachnoid plane Debulking tumor dan kontrol perdarahan Evakuasi Tumor secara piece meal
Jahit duramater watertight Dilakukan osteoplasty Jahit kulit lapis demi lapis
Craniotomy Tumor Excision + Osteoplasty
Diagnosa: Tumor Supra sella ec Susp Tubercullum Sellae Meningioma + OS Optic Atrophy ec
Compressive Optic Neuropathy + DM Type 2 Hiperglikemia
PROGNOSIS
Ad vitam : Bonam
Ad sanactionam : Dubia
Ad functionam :
- Transfer : Independent
- Ambulation : Independent
- Other ADL : Independent

PROBLEM LIST
o Visual disturbance
o Left temporal parese
o Supra Sella Meningioma Post Osteoplasty et Craniotomy Excision (2 Months)
o DM type II
o Obese Grade I

ICF
Body Function :
b730 Muscle power function (left weakness on Musc. Frontalis, Corrugator, and Orbic. Oculi )
b749 Muscle functions, other specified and unspecified (Inability to frown)
b210 Seeing functions (Visual disturbance)
b530 Weight maintenance functions (Obese grade I)

Body Structure :
s198 Structure of nerve system (Parese of Left Temporal Branch)
s110 Structure of brain
(Supra Sella Meningioma Post Osteoplasty et Craniotomy Excision (2 Months))
s298 Eye, ear and related structures, other specified (Optic Atrophy)
s580 Structure of endocrine glands (DM type II)

Activities and Participation :

d475 Driving (afraid to ride a motorcycle)
d710 Basic interpersonal interactions (embarrassed with her facial condition)

Environmental Factors :
e580 Health Services, System and Policy (patient covered by BPJS)

ASSESSMENT
Visual Disturbance et Parese of Left Temporal Branch ec Supra Sella Meningioma Post Osteoplasty
et Craniotomy Excision (2 Months) + Diabetes Mellitus Type II (Controlled) + Obese Grade I

Goals:
Short Term :
1. Left facial muscle MMT improved by 1-2 point
2. Decrease body weight 0,5 kg/ week reach until normal BMI
3. Maintain other MMT of facial

Long Term :
1. Prevent complication
2. Achieved normal MMT of left facial muscle and symmetrical face
3. Improved quality of life
4. Achieved normal weight
PLAN
PDx: -

Therapeutic Plan
Modality:
• NMES Galvanic current motor point method at left frontalis muscle until visible muscle contraction

Thera Exc :
- Facial expression exercise (Especially frontalis muscle)
- Strengthening frontalis muscle
- Endurance exercise (F: 3-5x/weeks; I: 40-50% HRR; I: 30 minutes; T: static cycle)

PMx: Clinical, Vital signs, facial muscle, sensory, visual, other cranial nerve

Educational Plan

- Explain patient's condition, goals, and treatment plan

- Continue exercise at home
- Strengthening facial muscle in front of the mirror (3-5x/day 3 sets 10 repetitions)
- Facial expression exercise
- Warm compress
- Gentle massage of the facial muscles
- Strengthening facial muscle in front of the mirror
- Routinely control to Eye and Neuro Surgery OPC