Case Report

Hemiparese Dextra + Afasia Motoric ec

Intracranial tumor

Identitas Pasien
Name

Mrs. J

Age

77 years

Gender

female

Address

sagulung

Religion

Islam

Maritals Status

Married

Occupation

Entry Hospital

27 Oktober 2016

Medical Record

163636

I. Anamnese
Chief Complain
Severe Headache
Present illness history
2 weeks before admitted to hospital,
patient complained of headachebeing pressed
+dominantly on the left side of the head + continously +
did not disappear by taking medicines like bodrex migrain
getting worser day by day increased during activities
headache was not accompaniedby red eyes, tense
shoulder, neck stiffness, fever, blurred vision, speaking
difficulty, oblique mouth, faint, seizure. Patient complained
vomitting, projectile vomitting, reduced apptite and body
weight, and difficult to do daily activities.
2 months before admitted to hospital, patient complained
of right limbs weaknesses

Past Illness history

History of brain and spine trauma (-)
History of stroke (-)
Diabetes Mellitus (-)
Hypertensi(-)
Ear infections (-)
History of the disease malignancy (-)

The Family Disease History

No family complain that same complaint
A history of cancer or tumors (-)

RESUME ANAMNESIS

Patient Mrs. J, 77 years of age, entered to

RSUD Embung Fatimah main complaint with
headache, headache felt like being pressed
and felt dominantly on the right side of the
head, headche felt continously, the pain was
getting worser day by day, and increased
during activities. projectile vomitting,
reduced apptite and body weight, and
difficult to do daily activities. limbs
weaknesses, worser until the patient difficult
to stand.

Consciousness
15 (E4 V5 M6)

: Composmentis GCS :

Noble Function : afasia motorik

Neck Rigidity : Negatif

N. I (Olfactorius
)

Right

Left

Interpretation

Normal

Normal

Normal

Right

Left

Visual Acuity

Normal

Normal

Visual Fields

Normal

Normal

Colour Recognition

Normal

Normal

Sense of Smell

N. I (Olfactorius
)

N. I (Olfactorius
)
Ptosis
Pupil

Interpretation
Normal

Right

Left

(-)

(-)

Interpretation

Shape

Round

Round

Side

3mm

3mm

Normal

Normal

Normal

direct

Indirect

Extraocular movement
Pupillary reaction to light

N. IV
(Trokhlearis)

Right

Left

Interpretation

Normal

Normal

Normal

Right

Left

Interpretation

Motoric

Normal

Normal

Sensory

Normal

Normal

(+)

(+)

Right

Left

Normal

Normal

Strabismus

(-)

(-)

Deviation

(-)

(-)

Extraocular movement

N. V
(Trigeminus)

Corneal reflex

Normal

N. VI
(Abduscens)

Extraocular movement

Interpretation

Normal

N. VII (Facialis)
Tic

Right
(-)

Left
(-)

Motoric

Normal

Normal

Flavour Sense

Normal

Normal

Tanda chvostek

Interpretation

Normal

N. VIII
(Akustikus)

Right

Left

Interpretation

Hearing sense

Normal

Normal

Normal

N. IX (Glossofaringeus)

Right

Left

Arkus farings

Normal

Normal

Flavour sense

Normal

Normal

(+)

(+)

Gag Reflex

Interpretation

Normal

N. X (Vagus)

Right

Left

Interpretation

Normal (-)

Normal

Right

Left

Interpretation

Motoric

Normal

Normal

Trof

Eutrof

Eutrof

Right

Left

Interpretation

Motoric

Normal

Normal

Trof

Eutrof

Eutrof

Normal

Tremor

(-)

(-)

Disartria

(-)

(-)

Arcus farings
Dysfonia

N. XI
(Assesorius)

Normal
(-)

Normal

N. XII (Hipoglossus)

SENSORY
Interpretation

Touch
Pain
Temperatur
Propioseptif

Right

(+)

Left

(+)

(+)

(+)

(+)

(+)

Normal

(+)

(+)

REFLEX

Right

Interpretation

Left

Fisiologic

Biseps

Normal

Normal

Triseps

Normal

Normal

Patella

Hipereflex

Normal

Achilles

Hipereflex

Normal

Increas fsiologic reflex of

lower right extremity

Patologic

Babinski

(-)

(-)

Chaddock

(-)

(-)

Hoffman Tromer

(-)

(-)

No Patologic Reflex

Openheim

(-)

(-)

Schaefer

(-

(-)

VIII. Otonom
Urinate : Normal
Defecate : Normal
IX. Others Examination

Laseque : Negatif
Kernig : Negatif
Patrick : Negatif
Valsava test : Negatif

Brudzinski

: Negatif

EXAMINATION RESUME
Generalized Condition
Blood Presure : 120/80 mmHg
Heart Rate : 96 bpm
Respiratory : Respiratory rate : 20 x/mnt Type : abdominotorakal
Temperature : 37C
Weight : 50 kg
Height : 160 cm
Noble Function :afasia motoric
Meningeal Sign :(-)
Cranial Nerve : Normal
Motoric : Hemiparese dextra UMN
Sensory : Normal
Coordination : Normal
Otonom : Norrmal
Reflex
Fisiologis : Increase fsiologic reflex of right extremity
Patologic : Negative

WORKING DIAGNOSA
Clinic Diagnosa: Hemiparese Dextra
Topic Diagnosa: Intracranial
Etiologic Diagnosa: Brain tumor
SUGGESTION EXAMINATION :
Blood Routine
Blood Chemistry
Electrolit
Head CT-Scan without contras

Interpretation: inhomegen solid mass at cortical subcortical of left

temporooccipitalis lobe with perifocal edema., suggestive astrocitoma

FINAL DIAGNOSA
Clinic Diagnosa: hemiparese dextra
Topic Diagnosa: Intracranial
Etiologic Diagnosa: intracranial tumor

clinical symptoms associated with brain

tumors
mental status changes
Headaches
vomiting,
seizures

Support examination
A brain tumor can be detected with a CT-scan
or MRI
CT-scan cheaper than an MRI
More specialized MRI to detect tumors with
small size, tumors at the base of the skull