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Mentor :
Dr. Ronny Yoes Sp.S
Identity
Name
: Mr. A
Gender : Male
Age : 31 years old
Address : Ciamis
Date of hospital admission : Feb 29th,
2016
Marital Status
:Education
: Senior High School
Room
: Numfor Island
Main complaint
Unconscious since 2 weeks ago
Other complaints
convulsion since 5 days ago and high
fever since 3 days ago
Objectives
General condition : comatous
Level of consciousness : E1, M2, V1
(GCS = 4)
Vital sign
General examination
: normal
Neurological examination
Meningeal sign
Nuchal rigidity : Can not be examined
Brudzinsky I
: Can not be
examined
Brudzinsky II
: Laseque
: Kernig
:-
Head
2 post operation wounds on both side of
the temporal region. Stitches condition are
good, dry, blood (-), pus (-), drainage (-)
Eyes
Pupils isocoria 2mm/2mm
Direct/indirect light reflexes -/-
Neck
Can not be examined
Motoric aphasia
Can not be examined
Cranial nerves
Can not be examined
Sensibilities
: no response
Motoric
: Can not be examined
Reflexes
Physiological
: bisep +2/+2
: Trisep +2/+2
: Patella +2/+2
: Achilles +2/+2
Pathological
: Babinsky -/: Chaddock -/: Hofman-tromner -/-
Laboratory Findings
10/3/2016
WBC
:
RBC
:
Hb
:
Ht
Platelets :
ESR
:
Diff count
Basophils
17.700/L
Eosinophils :
Neutrophils
4.8 mil/dL
rod
:
13.5
segment
:
: 41
605.000/L Lymphocytes :
Monocyte
65mm/hr
:0
2
0
81
12
:5
Glucose : 142
Electrolytes
Natrium
: 137
Kalium : 3.22
Cloride : 96
15/3/2016
Renal function
Ureum : 62
creatinine : 1.0
Radiology Findings
CT scan (contrast) 1/3/2016
Diagnose
Dx 1
Clinical : Unconsiousness, febris, tonic
convulsion, hydrocephalus post
VP
shunt
Ethiological : tumor
Topical : 3rd ventricle
Pathological : Suspect
glioblastome/plexus coroideus papiloma
Dx 2
Hypokalemia
Treatment
IVFD NaCl 0,9% 14 dpm
Manitol 4 x 125cc
Meropenem 3 x 1gr
OMZ
1 x 40mg
Head 30 elevation
Dexamethasone 3 x 1 amp
NGT
Citicholine 2 x 500mg
Urine catheter
Phenytoin inj
3 x 500mg
Sanmol 3 x 1
KSR
3 x 1 tab
Depakote 3 x 500mg
Resume
Patient named Mr.A being unconscious since 2 weeks
ago. convulsion since 5 days ago, and fever since 3
days ago. General condition comatous, GCS 4, Vital
sign BP 130/80, HR 116x/min, RR 24x/min, temp
39.9C. There are 2 operation wounds on the both
side of temporal region, in good condition. Meningeal
sign can not be examined, cranial nerves can not be
examined, pupils isocoria 2mm/2mm, direct-indirect
light reflexes -/-. Physiological reflexes +2/+2 upper
and lower extremities. Pathological reflexes -/-. Lab
findings leukocytosis, thrombocytosis, hypokalemia.
CT scan with contrast mass in the 3 rd ventricle,
volume 58.3 mm3 suspect glioblastome
Prognosis
Ad vitam
: ad malam
Ad functionam
: ad malam
Ad sanationam : ad malam
Poor prognosis
Thank you