Patient List

No Identity Admission to ER Diagnosis Treatment

5. Ch. Iqbal/8y.o/32kg January, 21st 2019/ Decrease of consciousness Treatment from ER :

03.00 am due to Hydrocephalus non O2 4-8 lpm
communicant due to Susp IVFD D5 ½ NS 1540cc/24 hours
Meduloblastoma Inj. Paracetamol 3x350mg
Inj. H2 blocker 2x50mg
Inj. Corticosteroid 3x5mg
Inj. Anticonvulsan 3x50mg
Laboratory examination

Co. Neurosurgery
Advice:
 Ch. Iqbal/45 y.o/32kg

Chief Complain: Decrease of consciousness

History taking
Family complained about patient with decrease of consciousness since 12 hours before admission.
His father told the patients had history of seizure 1 day before with stiffness in whole body and this
happen without fever (-).
History of headache (+), vomit (+), but family denied about loss of weight loss (-) chemical contact
(-). Other complained:
- complained of blurred vision (+), dark vision (-), making it difficult to walk (+).
- complained weakness of both his legs and his right hand are weak, making it difficult to stand
up.
History of Past Illness : (-)
Patient was diagnosed with medulloblastoma and suggested to do operation, but family refused
History of Family Illness : (-)
Vital Sign
E2V2M5
BP: 130/80 mmHg
RR: 20 tpm
HR: 80 bpm
T: 36.6oC
SpO2 98% with O2 supply 4 lpm
Physical
Examination• Sclera icteric (-/-), pale conjungtiva (-/-), enlargement lymph node (-), equal pupil
Head (5mm/5mm)

• I : symetric respiratory movement, retraction (-), bruise (-)

Chest • P : Sonor at all lung fields
• A : symmetric VBS, rhonchi (-), wheezing (-)

• I : distension (-)
• A : Bowel sound (+) normal
Abdomen • P : defance muscular (-) tenderness (-) mass (-) ascites (-)
• P : Tymphani at all region

Extremities • warm extremities (+)

Mini Neurology
GCS E2V2M5, Meningeal sign :
Equal pupil 5mm/5mm Neck stiffness (-)
Direct light reflect (+/+) Patological reflex :
Indirect light reflect (+/+) Babinsky (-/-)
Lateralization : Chaddock (-/-)
(-/-) Physiological reflex :
BPR : +1/+1
KPR : +1/+1
CLINICAL PICTURE
 Examination Result Normal value
Hematology

Hemoglobin 15,1 14.00-18.00 g/dl

Leucocyte 14,7 4.00-10.5 103 /ul

Eritrocyte 5,40 4.10-6.00 million/ul

LABORATORY Hematocrit 44,2 37.0-47.0 Vol%

1/5/2018 Thrombocyte 226 150-450 103 /ul

RDW-CV 13,8 12.1-14.00 %

MCV, MCH, MCHC

MCV 81,9 75.0-96.0 fl

MCH 28,0 28.0-32.0 pg

MCHC 34,2 33.0-37.0 %

Diff Count
Gran % 82,6 50.0-70.0 %
Lymphocyte % 9,9 25.0-40.0 %
MID% 7,5 4.0-11.0 %
Random Blood Glucose 148 <200 mg/dl
Liver Function
SGOT 31 0-46 U/I
SGPT 118 0-45 U/I
Albumin 3.5-5.5 g/dl
Kidney Function
Ureum 20 10-50 mg/dL
Creatinin 0,48 0.6-1.2 mg/dL
Electrolyte
Sodium 143 136-145 Meq/L
Potassium 3,0 3.5-5.1 Meq/L
Chlorida 103 98-107 Meq/L
Head CT-Scan
Head CT-Scan
Conclusion :
• Medulloblastoma with
obstructive hydrocephalus
Working Diagnose
DOC due to Hydrocephalus non
communicans due to Susp Medulobalstoma
Management
Treatment from ER :
• O2 4-8 lpm
• IVFD D5 ½ NS 1540cc/24 hours
• Inj. Paracetamol 3x350mg
• Inj. H2 blocker 2x50mg
• Inj. Corticosteroid 3x5mg
• Inj. Anticonvulsan 3x50mg
• Laboratory examination

Co. Neurosurgery :