Professional Documents
Culture Documents
Name : Ms. S
Age : 42 yo
Gender : Female
Address : Mandau
Religion : Islam
Marital’s Status : Married
Occupation : Housewife
Admitted to Hospital : January, 24th 2018
Medical Record : 9771**
Chief Complain
1 day 5 Month
Other complaints
were unknown.
History of
last fever,
Tumor and
ear
malignancy
infection,
sinusitis
UNKNOWN
Hyperte Diabetic
nsion Mellitus
Daily Routine Family Disease
History Jobs
History History
• Smoker (-) • Housewife • Unknown
• Alcoholism (-
)
Summary
N.II (Opticus)
Right Left Interpretation
Not
Not
Visual Acuity applicable
applicable
Not Not
Visual Fields applicable applicable
Not applicable
Not Not
applicable applicable
Colour Recognition
Cranial Nerves
N.III (Oculomotorius)
Right Left Interpretation
Ptosis - -
Pupil
Shape Round Round
Doll eyes
Side Φ2mm Φ2mm
movement (+)
Extraoculer movement normal normal
Pupillary reaction to light
Direct + +
Indirect + +
Cranial Nerves
4. Cranial nerve IV (Trochlear)
Right Left Interpretation
Extraokuler Doll eyes
movement + + movement (+)
Motoric N N
- corner of the mouth N N
- nasolabialis folds + + Normal except sense
-frowning + + of taste not applicable
-raise eyebrows + +
-closed eyes + +
Sense of taste Not Not
applicable applicable
Chovstek sign
- -
Body
Trofi Eutrophy Eutrophy
Involunteer movement - - Normal
Abdominal Reflex (+) (+)
Interpretati
Right Left
on
Touch
Sensory System Pain
Temperature Not applicable Not applicable
Not
applicable
Proprioceptive
Gait No No No appreciate
appreciate appreciate
Tandem
Romberg
Autonomy System Others Examination
Laseque : Limited in
Urinate : Normal
dextra <70o
Patrick : (-)
Kontrapatrick : (-)
Brudzinsky : (-)
• Increase Intracranial Pressure Syndrome
Clinical diagnose
DIAGNOSE
• SOL ec suspect primary brain tumor
Etiological diagnose
Image
Lab Study
study
M
A • Head up 30o
Non
N pharmacologic • IVFD RL 20 dpm
A therapy
G
E
M • Anti-edemas drugs:
Pharmacologic Dexametason 4 x 4
E therapy mg IV
N
T
Head CT-Scan without Contrast
Interpretation: (Mandau General Hospital)
Lab
There isn’t soft tissue swelling at extracranial
( January, 24th 2018 in Mandau General Hospital)
Study
Intact visualized bone structure
gray matter matter and white matter are not
firm
the lateral ventricle
Blood WBC narrowed
: 11.270 /ul
Routine
Midline shift to dextra
Jan, , 24
Visible
th Hb
inhomogen
: 11,6 g/dl hipodens –
lession
2018 in
Permata Hati’s
hiperdens, Ht
amorf : 33 %
shaped, borderless, irregular
Hospital
edge, size 40-60 PLT at the left frontal lobes.
: 174.000/ul
Blood
Impression: Mass apperance at lobus
Chemis
frontalis sinistra dd astrocytoma high grade
try Glucose : 121 mg/dL
dd/ (Oligodendroglioma
January, 24th Ureum : 25 :mg/dL
2018 in Suggested MRI
Permata Hati’s
Hospital Creatinin : 0,8 mg/dL
Brain Tumor
Classification
Primary Secondary
tumor tumor
Case Report DISCUSSION
Case Report DISCUSSION
Metastase
Tumor
Cerebral metastases have spread to the brain from
cancer cells in other organs in the body.
Changes in mental
Clinical status
Symptoms Headaches
Vomiting
Seizures
Support
CT scan MRI
examination
Management
Radiotherapy Chemotherapy
Operation
BASIC DIAGNOSE
Basic clinical Basic
diagnoseclinical diagnose
Anamnesis
Lost of chronic Status mental
consciousness seizure change
Progressive Headache
Physical examination
Reflex Patologis (+)
Lateralization to dextra
babinsky
Lost of consciousness
Increased intracranial pressure syndrome
Seizure
Progressive Headache
Status mental change
- Deficit neurology
(+) Its proven by
radiology imagine
that there are MRI
- in physical multiple lession at Tumor Marker
examination there intracranial suspect
wasn’t find metastase
abnormalities
Basic differential diagnose
Labor • knowing risk factors whether infection exists, and knowing the general condition of the
atory patient.
Chest
X-ray to see the existence of a specific process, the primary tumor in the lung.