GRAND CASE

Supervisor:
dr. Yossi Maryanti, Sp.S

SPACE OCCUPYING LESION

CAVINA YASA (1608438241)

PATIENT’S IDENTITY
 Name : Mr. Z
 Age : 47 yo
 Gender : Male
 Addres : Mandau
 Religion : Islam
 Marital’s status : Married
 Occupation : Security
 Admitted to hospital : July 7th 2018
CHIEF COMPLAIN
Headache since 1 month before admitted to the hospital
Present illness history (1)
1 month before admitted to the hospital patient
complained about headache, he can’t point the
exact place of the headache and felt like the
head is going to explode, the intensity is severe,
not throbbing nor like have a band encircling the
head. There is no watery nose, lacrimation nor
red eye.
Present illness history (2)
The headache getting worse in the morning and
often wakes him up in the night. The pain last
more than 15 minutes. The patient tried to take
medicine but didn’t get any better symptoms. He
also complained about vomiting symptoms but
didn’t have nausea in the beginning.
Present illness history (3)
No history of neck pain, dental disorder,
blindness and overuse of analgesic. He also feels
the right extremities is weaker than another
since 2 weeks ago, the weakness goes slow and
getting worse day by day. He has a double vision
too and it begin at the same time where the
headache started. The double vision is gone
when he close one of his eye. He often crushes
something while walking, he told his family that
he can’t see to his left.
Present illness history (4)
Then He went to Bengkalis Hospital, got brain
CT- Scan and the result said that he had brain
tumor, he sent to Arifin Achmad Hospital to get
better treatment. He never gets seizure but has
story loss of body weight until 10 kilograms in 1
month.
Past illness history
 History of brain trauma unknown
 History of last fever, ear infections, teeth infections,
sinusitis unknown
 History of stroke unknown
 Hypertension unknown
 History of the tumor and malignancy unknown
 No history of long time of cough, hemoptoe or 6 month
of tuberculosis medicine consumption
Daily routine history

 Smoker (+),
 Alcoholism (-)
Physical examination
 Generalized Condition
 Blood Presure : 130/80 mmHg
 Heart Rate : 72 bpm
 Respiratory rate : 20 x/mnt
 Temperature : 36,9°C
 Weight : 60 kg
 Height : 165 cm
 BMI : 22 kg/m2 (normoweight)
 Physical examination
 Neck : No lymph node enlargement
 Thorax : Normal limit
 Abdomen : Normal limit
 Prostate : patient refuse to be examined
 Neurological status
 Consciousness : Compos mentis GCS : 15
(E4V5 M6)
 Noble Function : Normal
 Neck Rigidity : Negative
CRANIAL NERVES
 CN I (Olfactorius)
Right Left Interpretation

Sense of Smell Normal Normal Normal

 CN II (Opticus)
Right Left Interpretation

Visual Acuity Normal Normal

Visual Fields ? ? Color blindness

Colour
- +
Recognition
 CN III (Oculomotorius)
Interpreta
Right Left
tion
Ptosis
- -
Pupil
Shape
Round Round
Side
Φ2mm Φ2mm Normal
Extraoculer movement
+ +
Pupillary reaction to
light
+ +
Direct
+ +
Indirect
 CN IV ( Troklearis)
Right Left Interpretation
Extraocular
+ + Normal
movement
 CN V (Trigeminus)
Right Left Interpretation

Motoric Normal Normal

Normal
Sensory Normal Normal
Corneal reflex + +
 CN VI (Abduscens)
Right Left Interpretation
Eyes movement limited normal
Left deviation
Strabismus - -
conjugee
Deviation - -
 CN VII (Facialis)
Right Left Interpretation
Tic - -

Motoric N N
- corner of the More Deeper
mouth shallow
+ + VII nerve lesion
- nasolabialis folds + + central type
-frowning + +
-raise eyebrows + +
-closed eyes N N
Sense of taste - -
Chovstek sign
 CN VIII (Akustikus)
Right Left Interpretation
Hearing sense N N Normal
 CN IX (Glossofaringeus)
Right Left Interpretation

Pharyngeal Arch
Pharyngeal Arch Normal Normal
and gag reflex are
Flavour sense not not
normal but flavor
applicable applicable
sense not
Gag Reflex + +
applicable
 CN X (Vagus)
Right Left Interpretation
Pharyngeal Arch N N
Normal
Dysfonia - -

 CN XI (assesorius)
Right Left Interpretation
Motoric Normal Normal
Trofi Normal Normal Normal
 CN XII (Hypoglossus)

Right Left Interpretation

Motoric Normal Norma
Trofi Eutrophy Eutrophy Normal
Tremor - -
Disartria - -
 Motoric
Right Left Interpretation
Upper Extremity
Strength
Distal 4 5
Medial 4 5
Proksimal 4 5 Right
Tonus Hypertonus Normal hemiparesis
Trofi Eutrophy Eutrophy UMN type
Involunteer - -
movement
Clonus - -
Lower Extremity
Strenght
Distal 4 5
Medial 4 5
Proksimal 4 5
Tonus Hypertonus Normal
Trofi Eutrophy Eutrophy
Involunteer movement - -
Clonus - -
Sensory
Interpretatio
Right Left
n
Touch (+) (+) Normal
Pain (+) (+) Normal
Temperature Not applied Not applied -
Propioseptif
 Vibration Not applied Not applied -
 Position (+) (+) Normal
Proprioceptiv
 Two point discrimination (-) (+)
e disturbance
Proprioceptiv
 Stereognosis (-) (+)
e disturbance
Proprioceptiv
 Graphestesia (-) (+)
e disturbance
 Reflex
Right Left Interpretation
Physiologic
Biseps (++) (+)
Physiologic reflex is
Triseps (++) (+)
increase
Patella (++) (+)
Achilles (++) (+)
Patologic
(-) (-)
Babinski
(-) (-) Patologic reflex (-)
Chaddock
(-) (-)
Hoffman Tromer
(-) (-)
Openheim
(-) (-)
Schaefer

Primitive Reflex
(-) (-) No primitive reflex
Palmomental
(-) (-)
Snout
COORDINATION

Right Left Interpretation

Point to point (-) (-) Coordination
movement disturbance
Walk heel to toe Didn’t Didn’t ?
applied applied
Gait Didn’t Didn’t ?
applied applied
Tandem Didn’t Didn’t ?
applied applied
Romberg (-) (-) Normal
 Otonom
 Urinate : Normal
 Defecate : Normal
 IX. Others Examination
 Laseque : >70o
 Kernig : >130o
 Patrick : -/-
 Kontrapatrick : -/-
 Valsava test : -/-
 Brudzinski : -/-
WORKING DIAGNOSE
 Clinical Diagnose : Increased Intracranial Pressure
Syndrome
 Topical Diagnose : Cortex cerebri regio
frontooccypital lobe sinistra
 Etiological Diagnose : SOL ec suspect primary
brain tumor
 Differential Diagnose : SOL ec suspect tumor
metastase, SOL ec suspect cerebral abscess
SUGGESTION EXAMINATION:

Lab study :
 (Blood routine, blood chemistry)
 Imaging study :
 (Chest X-ray, Head MRI with contrast)
MANAGEMENT
Non pharmacologic therapy:
 Head up 30o
 IVFD NaCl 20 dpm

Pharmacologic therapy:
 Anti-edemas drugs:
 Dexametason 3 x 10 mg IV
LABORATORY FINDING
 Blood Routine (July, 7th)
WBC : 7.380 /ul
Hb : 16,0 g/dl
Ht : 46,6 %
PLT : 272.000/ul
 Blood Chemistry ( July 7th 2018 in Arifin Achmad Hospital)
Glucose : 103 mg/Dl
Ureum : 25 mg/dL
Creatinin : 0,95 mg/dL
 Head CT-Scan without Contrast ( June 26th 2018 in
Bengkalis Hospital)
Interpretation:
 Sulcus within normal limit
 Midline deviation
 Compression of left lateral
ventricle and third ventricle
 There is hypodens lesion with
local hypodens edema in
left occopito-parietal lobe

Impression: Left occipito-parietal

lobe mass with diameter ±5 cm
Rhontgen thorax (July 7th 2018)

Impression : within normal limit

FINAL DIAGNOSE

SOL ec suspect primary brain tumor

FOLLOW UP
Date Subject Object Assessment Plan
July The patient feels  Consciousness: CM SOL  IVFD NaCl 20
07th headache is getting  BP : 130/80 mmHg tpm
2018 worse  HR : 80 bpm  Inj. Dexa 3 x 1
 RR : 18 tpm amp
 T : 36,3˚C  Inj. Ceftriaxon
 NI : normal 2 x 1 gr
 NII : color blindness  Thorax
 NIV : normal rhontgen PA
 NV : normal  Head MRI with
 NVI : limited contrast
movement to dextra
 NVII : central type
sinistra NVII lesion
 NVIII-XII : normal
 Physiologic reflex (↑)
 Pathologic reflex (-)
 Sensoric :
proprioceptive lesion
 Motoric
UE : 444/555
LE : 444/555
FOLLOW UP
July 9th The headache  Consciousness: CM SOL  IVFD NaCl 20
2018 complain is  BP : 130/80 mmHg tpm
decrease  HR : 80 bpm  Inj. Dexa 3 x 1
 RR : 18 tpm amp
 T : 36,3˚C  Inj. Ceftriaxon
 NI : normal 2 x 1 gr
 NII : color blindness  Consul to
 NIV : normal neurosurgeon
 NV : normal
 NVI : limited
movement to dextra
 NVII : central type
sinistra NVII lesion
 NVIII-XII : normal
 Physiologic reflex (↑)
 Pathologic reflex (-)
 Sensoric :
proprioceptive lesion
 Motoric
UE : 444/555
LE : 444/555
 MRI result has
confirmed the brain
tumor suspect GBM
 MRI with contrast
IMPRESSION
There is mass in periventricular cornu
posterior of left ventricle lateral that
obliterate cauda of corpus callosum
with large perifocal edema that goes to
glioblastoma overview based on WHO
gr IV.
1,02 cm of subfalcin herniation to the
right side
Right sinusitis maxillaries.
July Patient still has  Consciousness: CM SOL Patient
10 headache  BP : 130/80 mmHg discharged
 HR : 80 bpm
 RR : 18 tpm
 T : 36,3˚C
 NI : normal
 NII : color blindness
 NIV : normal
 NV : normal
 NVI : limited
movement to
dextra
 NVII : central type
sinistra NVII lesion
 NVIII-XII : normal
 Physiologic reflex
(↑)
 Pathologic reflex (-)
 Sensoric :
proprioceptive
lesion
 Motoric
UE : 444/555
DISCUSSION
Space Occupying Lesion
 Extended lesion in brain

 Cranium is stiff with a fixed volume

 Kellie-Monroe hypothesis

 Sign and symptoms allows the doctor localize the lesion

 CT Scan and MRI are the best choices

Brain tumor
 Gives a symptoms that slowly emerging
 In vital position makes the symptoms appear
early
 Based on origination of the tumor the brain
tumor divided into primary tumor and
secondary tumor
 From the type of cell, brain tumor can divided
into glioma and non glioma
Clinical symptoms
 Change in mental status

 Headacehe

 Seizure

 Vomiting
Suporting exams
 CT Scan
 MRI

Management
 Anticonvulsion
 Cerebral edema
 Radiotherapy
 Chemotherapy
 Operation
BASIC DIAGNOSE
Basic clinical diagnose
 Severe headache
 Proyectile vomit
 Right hemiparese

Basic topical diagnose

 Color blindness
 Proprioceptive disturbance
 Right hemiparese
Basic etiological diagnose
 Headache
 Vomit
 No history of neoplasm early
 Prove it with CT Scan and MRI

Basic differential diagnose

 Another cause space occupying lesion
Basic of supportive examination
 Laboratory: knowing the general condition of the patient.
 Thoracic x-rays: to see the existence of a specific process,
to see metastasis or originate tumor
 Head CT-scan: to see a cross-sectional view of the brain
as whole, which related to patient’s complained.
 MRI : To know the specific location of tumor

Basic management
 IVFD RL 20 dpm : to maintain the state of euvolemic.
 Dexametason: to reduce the brain edema.
Thank you.