Case Report

HANA KASHIRA CHERINA

030.11.120

Mentor :
Dr. Ronny Yoes Sp.S

KEPANITERAAN KLINIK ILMU SARAF

RS AL DR MINTOHARDJO
PERIODE 7 MARET 9 APRIL 2016
FAKULTAS KEDOKTERAN UNIVERSITAS
TRISAKTI
JAKARTA

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

History of present illness

This patient was being unconscious, and remain in
unconscious state since 2 weeks ago. Several times he
got generalized convulsion, rigid. The duration was
less than 30 minutes, and stopped after given
medication. No response after that.
Since Dec 2015 he complained of having a very severe
headache on his back of his head, and also double
vision. He went to the doctor for it but there are no
abnormalities found. On Jan 2016 he got his head
scanned and found a mass inside his brain. He was
transferred to Dr.Mintohardjo navy hospital and the
doctor planted a shunt. He recovered, feeling better
after the operation, the headache lessen, he can eat,
walk, talk, no nausea, no vomit, no fever, no weakness.
5 days after the operation his consciousness
decreased, sleepy all the time and then become
unconscious.

Past medical history

This was his first time. Hypertension (-),
diabetes (-), lung problems (-),
tumor/cancer (-)
Family history
Cancer (-), hypertension (-), diabetes (-),
tb (+) brother got recovered
Social-economy and personal history
Good

Objectives
General condition : comatous
Level of consciousness : E1, M2, V1
(GCS = 4)
Vital sign

Blood pressure : 130/80

Heart rate: 116x/min
Respiration rate
: 24x/min
Temperature : 39.9C

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

Head Ct Scan with

contrast
Brain window, axial
Hyperdensitic Lesion in
the 3rd ventricle
Size : 36.9 x 39.5 mm
Results :
Suspect Glioblastome

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