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By:
Gilang Pradigdo
1408465702
Supervisor:
dr.Riki Sukiandra, Sp.S
DEPARTMENT OF NEUROLOGY
MEDICAL SCHOOL RIAU UNIVERSITY
RSUD ARIFIN ACHMAD
PEKANBARU
2016
1
I.
Patients Identity
Name
Mr. TB
Age
53 years
Gender
Male
Address
Religion
Kristen Protestan
Maritals Status
Married
Occupation
Unemployment
Admitted to Hospital
Medical Record
926xxx
II ANAMNESIS :
Alloanamnesis (June, 12th 2016)
Chief Complain
Loss of consciousness since one day before admitted to the hospital
Present illness history
One days before admitted to hospital, patient had a loss of consciouness.
At the time patient was lying in bed. His family invited him for dinner. But when
called, patients difficult to wake. Patient only respond by moved his hand when
his arm was pinched. Then, the family brought patient to the Petala Bumi Hospital
and the patient treated for half day, and she get refered to Arifin Ahmad Hospital
because the limitation of facility. Patient didnt complained about seizure, fever,
cough and breathless.
Hypertension(+)
Patient knew that he suffered with hypertension since 2011, but he didnt
controlled it routinely.
History of the disease malignancy (-)
a. Lung cancer (-): He didnt complained about the presence of cough, chest
pain, shortness of breath, hoarseness, difficult swallowing, pain/fever lost
arising.
b. Colon Cancer (-): He didnt complained there was bowel disorders
(constipation, bloody and slimy, diarea or slimy), such as goat droppings.
c. Prostat cancer (-): He didnt complained there was micturition problem.
There is no history of micturition pain, micturition drip or discontentment on
peeing.
d. Kidney cancer (-): He didnt complained of pain in the waist, the presence
of a lump in the abdomen, and bloody urine.
Daily routine history
a.
Smoker (+)
Patient smoked since 1972 until 1983 with 10 cigerettes per day
Long Drug Consumption (+)
Patient took amlodipine to control his hypertension, but he didnt consumpted it
routinely.
Alkoholism (-)
History Jobs
Construction workers (1990-2002)
Mechanic (2005-2014)
The Family Disease History
No family complain that same complaint
A history of cancer or tumors (-)
Summary
Patient Mrs. M, 53 years old, admitted to RSUD Arifin Achmad with
chief complaint loss of consciousness. Patient didnt complained about seizure,
fever, cough and breathless. Patient complained about severe headache and
progressive about one year. Patient also complained weakness of entire body,
difficult to talk, difficult to eat, vomitting and blurred vision.
III. Physical Examination
A. Generalized Condition
Blood Presure : Right: 180/110 mmHg
Heart Rate
: 83 bpm
Respiratory
Type : Abdominothoracal
Temperature : 37,1C
Weight
BMI
: 63 kg
: 24,6 kg/m2 (overweight)
Height : 160 cm
B. Physical examination
Thorax
: Normal limit
Abdomen
Opthalmoscopy
: Normal limit
:
C. Neurological status
1)
Consciousness
: Stupor
2)
Noble Function
: Difficult to asses
3)
Neck Rigidity
: Negative
Cranial Nerves
1. N. I (Olfactorius )
Sense of Smell
Right
Difficult
to asses
Left
Difficult
to asses
Interpretation
Right
Left
Interpretation
Difficult
to asses
Difficult
to asses
Difficult to asses
Difficult to asses
2. N.II (Opticus)
Visual Acuity
Visual Fields
Colour Recognition
3. N.III (Oculomotorius)
Right
Left
(-)
(-)
Round
Round
4mm
2mm
Difficult
to asses
Difficult
to asses
Ptosis
Interpretation
Pupil
Shape
Side
Extraokuler movement
Pupil
anisokor,
Pupillary
Reflex (+/+)
Right
Difficult
to asses
Left
Difficult
to asses
Right
Left
Interpretation
Difficult to asses
5. N. V (Trigeminus)
Motoric
Sensory
Corneal reflex
Difficult Difficult
to asses to asses
+
+
Interpretation
Difficult to asses,
Corneal reflex (+/+)
6. N. VI (Abduscens)
Extraocular movement
Strabismus
Deviation
Right
Left
Difficult Difficult
to asses to asses
(-)
(-)
(-)
(-)
Interpretation
Difficult to asses
7. N. VII (Facialis)
Tic
Right
(-)
Left
(-)
Difficult
to asses
Difficult
to asses
Motoric
Flavour Sense
Interpretation
Difficult to asses
Tanda chvostek
8. N. VIII (Akustikus)
Hearing sense
Right
Difficult
to asses
Left
Difficult
to asses
Interpretation
Right
Left
Interpretation
Difficult
to asses
Difficult
to asses
Difficult to asses
Right
Difficult
to asses
Left
Difficult
to asses
Right
Difficult
to asses
Eutrofi
Left
Difficult
to asses
Eutrofi
Right
Difficult
to asses
Eutrofi
Left
Difficult
to asses
Eutrofi
-
Difficult to asses
9. N. IX (Glossofaringeus)
Arkus farings
Flavour sense
Gag Reflex
10. N. X (Vagus)
Arcus farings
Dysfonia
Interpretation
Difficult to asses
11.N. XI (Assesorius)
Motoric
Trofi
Interpretation
Difficult to asses
Interpretation
Difficult to asses
IV. Motoric
Right
Left
Interpretation
Upper Extremity
Strength
Distal
Difficult to
Proksimal
asses
Difficult to
asses
Tonus
Normotonus Normotonus
Trofi
Eutrophy
Eutrophy
Involunteer movement
(-)
(-)
Clonus
Lower Extremity
(-)
(-)
test, there is no
Strenght
Distal
Proksimal
Tonus
Trofi
Involunteer movement
Clonus
lateralization
Difficult to
Difficult to
asses
asses
Normotonus Normotonus
Eutrophy
Eutrophy
(-)
(-)
(-)
(-)
Eutrofi
Eutrofi
(-)
(-)
Body
Trofi
Involunteer movement
Abdominal Reflex
Normal
V. SENSORY
Right
Left
Interpretation
Touch
Pain
Temperatur
Difficult to
asses
Propioseptif
VI. REFLEX
8
Difficult
to asses
Difficult to
asses
Right
Left
Biseps
(+)
(+)
Triseps
(+)
(+)
Patella
(+)
(+)
Achilles
(+)
(+)
Babinski
(-)
(-)
Chaddock
(-)
(-)
Hoffman Tromer
(-)
(-)
Openheim
(-)
(-)
Schaefer
(-)
(-)
Interpretation
Physiologic
Physiologic Reflex
(+/+)
Patologic
VII. Coordination
Right
Left
Difficult
Difficult
to asses
to asses
Interpretation
: Urine cathetherized
Defecate
: No defecate
: Unlimited
b. Kernig
: Unlimited
c. Patrick
: -/-
d. Kontrapatrick
: -/-
e. Valsava test
: -/-
f. Brudzinski
: 9
Difficult to asses
IV. Summary
General Status
Blood Presure : 180/110 mmHg
Heart Rate
: 83 bpm
Respiratory
Temperature
: 37,1C
Weight
BMI
: 63 kg
: 24,6 kg/m2 (overweight)
Thorax
Height : 160 cm
: Normal
Abdomen : Normal
Noble Function : Difficult to asses
Meningeal Sign : (-)
Cranial Nerve : Pupil anisokor
Motoric
: Difficult to asses
Sensory
: Difficult to asses
Coordination : Difficult to asses
Otonom
: Abnormal urination and defecation
Reflex Fisiologis: Positive
Refleks Patologic: Negatif
WORKING DIAGNOSA
Clinic Diagnosis: Increased Intracranial Pressure Syndrome
Topic Diagnosis: The right side hemisphere of the cerebri
Etiologic Diagnosis: SOL ec Primary Brain Tumor
Differential Diagnosis: Brain abscess
Secondary diagnosis: Hypertension Grade II
SUGGESTION EXAMINATION :
1. Blood Routine
4. Electrolyte test
2. Blood Chemistry
10
NGT
DC
Dexametason inj 3 x 10 mg
Amlodipine 1 x 10 mg
LABORATORY FINDING :
1. Blood Routine (June, 12th 2016)
WBC
: 9,100 /ul
Hb
: 13,5 g/dl
Ht
: 39,4 %
PLT
: 173.000/ul
: 0,71 mg/dl
K+
11
12
CT-Scan Reading :
Show images of isodens perifokal mass with round shape with edema, size 6x5cm
in fronto-parietal region dextra convexity.
Ventrikel lateral dextra is pressed by mass
Midline shift to the left
Interpretation :
SOL appearance at fronto-parietal region dextra convexity.
ec : suspect Meningioma
13
: GCS 14 (E3M6V5)
Blood Pressure
:170/100 mmHg
Heart Rate
: 78 bpm
Respiratory Rate
Temperature
: 20 x/i
: 36,9 C
Physical Examination
Thorax
: Normal limit
: Normal
Meningeal Sign
: Normal
Cranial Nerves
Motoric
: Normal
Sensory
: Normal
Coordination
: Normal
Autonomy
: Normal
Reflex
Pathologic : Negative
Physiology : Positive
A
NGT
DC
Dexametason inj 3 x 10 mg
Amlodipine 1 x 10 mg
14
: GCS 14 (E3M6V5)
Blood Pressure
:160/90 mmHg
Heart Rate
: 81 bpm
Respiratory Rate
Temperature
: 18 x/i
: 36,5 C
Physical Examination
Thorax
: Normal limit
: Normal
Meningeal Sign
: Normal
Cranial Nerves
Motoric
: Normal
Sensory
: Normal
Coordination
: Normal
Autonomy
: Normal
Reflex
Pathologic : Negative
Physiology : Positive
A
NGT
DC
Dexametason inj 3 x 10 mg
Amlodipine 1 x 10 mg
15
: GCS 14 (E3M6V5)
Blood Pressure
:160/90 mmHg
Heart Rate
: 76 bpm
Respiratory Rate
Temperature
: 19 x/i
: 36,8 C
Physical Examination
Thorax
: Normal limit
: Normal
Meningeal Sign
: Normal
Cranial Nerves
Motoric
: Normal
Sensory
: Normal
Coordination
: Normal
Autonomy
: Normal
Reflex
Pathologic : Negative
Physiology : Positive
A
NGT
DC
Dexametason inj 3 x 10 mg
Amlodipine 1 x 10 mg
16
Definition
Headache is pain or discomfort on whole area of the head. headache is
Migraine
Periodic disorder with unilateral or bilateral headache and can be
following with vomiting and visual disturbances. This condition occurs
frequently, more than 10% of the population are experiencing at least one
migraine attack in her life. Migraine can occur at all of ages, but generally
the onset occurs on teenage or twenties and female more often than male.
17
cranial or cervical
vascular disorder
Headache attributed to non-vascular intracranial disorder
Headache attributed to a substance or its withdrawal and infection
Headache attributed to disorder of homeoeostasis
Headache or facial pain attributed to disorder of cranium, neck, eyes, ears,
allows tissue to be sampled from the lesion in a relatively safe way. This deploys a
coordinate system based on scans, which allows the surgeon to access the tumour
for biopsy in a minimally invasive approach. The other alternative is that a biopsy
is performed as part of the debulking or excision of a tumour.
Broadly speaking, brain tumours can be classified as either gliomas or
nongliomas. These are either tumours of the glial cells of the brain or tumours of
the other intracranial cells. The vast majority of lesions in adults tend to be
supratentorial (above the tentorium cerebelli) and 86% of these falls into the
category of gliomas.This includes astrocytomas, oligodendrogliomas and
ependymomas.
1. Gliomas
Astrocytomas are the most common type of glioma and are graded
according to the WHO scale of grades one to four. Grade 1 astrocytomas include
pilocytic astrocytomas which are benign. Grade 2 astrocytomas are low grade
infiltrating tumours. Grade 3 anaplastic astrocytomas exhibit mitoses. Finally, the
grade 4 glioblastoma multiforme (GBM)6 is the most aggressive primary brain
tumour in humans and has a median survival of 14 months following diagnosis
even if given optimal therapy.4,5 GBM can arise as a first presentation or a
secondary presentation to a lower grade astrocytoma. The gliomas most
commonly encountered in adults are neoplasms of astrocytic or oligodenrocytic
lineage. Mixed tumours also occur, the most common of which is termed
anaplastic oligoastrocytoma.10 In US studies, glioblastomas formed around 50%
of these tumours. This was followed by oligodendrogliomas (9.2%), other
astrocytomas (9.1%) and ependymomas (5.6%).7
2. NonGliomas
Nongliomas form the remainder of brain tumours. This includes
meningiomas, which arise from the meninges and compress the brain thereby
creating a mass effect. With an incidence of around 2 per 100,000,8 over 90% of
these tumours are benign and are therefore potentially curable through resection.
Loss of chromosome 22 is a characteristic genetic feature of these tumours. 7
20
Pituitary adenomas also fall into the category of nongliomas and are
eitherfunctioning or nonfunctioning. If functioning, they may secrete hormones
causing endocrine disturbance.
The clinical manifestation of the tumour depends on the hormone
secretion. Sexual dysfunction and galactorrhoea occur in prolactinoma. A buffalo
hump, moon face, acne, weight gain, hypertension and diabetes mellitus occur
in Cushings disease (ACTH hypersecretion). Acromegaly can result from an
oversecretion of growth hormone with the typical changes that occurs with soft
tissue growth in adult sufferers. Rarely, other secreting pituitary tumours such as
TSHomas occur. Nonfunctioning pituitary tumours may exert a mass effect due
to their proximity to the optic chiasm and can cause visual disturbance such as
bitemporal hemianopia.9
Medulloblastomas are primitive neuroectodermal tumours which are rare
in adulthood but much more common in children, accounting for 20% of
childhood brain tumours.10These tumours are generally located in the cerebellum
and therefore present with signs of cerebellar dysfunction. They can involve the
4th ventricle and lead to the development of hydrocephalus.11
With the correct initial treatment of medulloblastoma, longterm survival
may be achieved in around 4060% of all patients.12These tumours can however
spread in the subarachnoid space to involve other parts of the CNS. Primary CNS
lymphoma is another tumour within the grouping of nongliomas. These
constitute 23% of total brain tumours in people of normal immunity. Patients
with immunodeficiency are at an increased risk of developing this form of cancer.
21
secondary tumors. Most brain metastases have occurred in the cerebrum, the
cerebellum 80% 16%, and 4% of the brainstem, the incidence of occurrence of
metastases to the brain is 20%-40% of all cancer patients, as much as 70% had
multiple lesions.12
Cancer cells that develop in the brain can suppress, irritating and or
destroy normal brain tissue, so that it will give rise to a progressive headache,
vomiting, seizures, impaired verbal symptoms, weakness of the limbs, paralysis,
unconsciousness, and even death.This occurs if the size of the tumor already
causing damage in the brain. But not everyone complained about it, even a third
of sufferers are tumor metastases have no symptoms at all. 12
Generally ypes of cancer can spread to the brain, so it's important for the
doctor to determine the cause of the primary sources of the metastases tumor of
brain. So that it can determine and implement for the effective option treatment.
Early diagnosis and treatment of brain metastases tumor can cause remission or
recovery of symptoms of disorders of the brain and may improve the patient's
quality of life and prolonging survival. 12
3.3 Clinical Symptoms
There are 4 common clinical symptoms associated with brain tumors, like
mental status changes, headaches, vomiting, and seizures. 11
a. Changes in mental status
Early symptoms can be vague. The inability of the execution of daily
tasks, irritability, labile emotions, mental inertia, impaired concentration, even
psychosis.2 Cognitive function is a complaint often made by cancer patients with a
variety of forms, ranging from mild memory dysfunction and difficulties
concentrating until disorientation, hallucinations, or lethargy. 13
b. Headaches
Headaches is an early symptom of intracranial tumors on 20% of sufferers.
The character of the headache felt like being pressedor full flavor on the head as if
willing to explode 2 Initially pain can be mild, episodic and dull, and then gain
weight, blunt or sharp and also intermittent. Pain can also be caused by the side
effects of chemotherapy drugs. This pain is more excellent in the morning and can
be diperberat by coughing, tilt your head or physical activity.3 The location of the
22
pain that can be unilaterally in accordance with location of tumor. Tumors in the
posterior fossa kranii head pain usually leads to ipsilateral retroaurikuler.
Supratentorial tumors in pain cause head on the side of the tumor, in a frontal or
parietal, temporal orbita.13
c. Vomiting
Vomiting is also often arise in the morning and not food-related. Where
vomiting is typical projectiles and not preceded by nausea. This situation is often
found in the posterior fossa of tumor.13
d. Seizures
Focal seizure is another manifestation that is commonly found in the 1415% of sufferers of brain tumor, 20-50% of patients brain tumor showed
symptoms of seizures. Seizures arising first on age of consent indicating the
presence of a tumor in the brain. Seizure related brain tumor was originally a form
of focal seizures (focal damage indicative of serebri) as in meningiomas, can then
become a public seizure is mainly a manifestation of glioblastoma multiforme. 13
Seizures usually paroxysmal, a result of the cortex in neurological serebri. Partial
seizures due to focal areas of emphasis on the brain and menifestasi on the
secondary, while local seizures occurring if the tumor is widespread on both
hemisphere serebri. 14
3.4 Support examination
A brain tumor can be detected with a CT-scan or MRI. The choice depends
on the availability of facilities at each hospital. CT-scan cheaper than an MRI,
commonly available in hospital and when you use the contrast can detect the
majority of brain tumors. More specialized MRI to detect tumors with small size,
tumors at the base of the skull and bones in the posterior fossa. In addition, MRI
can also help the surgeon to plan the surgery because it showed tumors in a
number of areas.14
3.5 Management
Treatment of patients with SOL include: 13.14
Symptomatic.
a. Antikonvulsi
23
mental
retardation,
psychiatric
disorders
and
other
neuropsychiatric effects.
d. Chemotherapy
Chemotherapy is rarely used for the treatment of brain metastases,
as chemotherapeutic agents penetrate the blood-brain barrier very
badly. However, some types of cancer such as lymphoma,
carcinoma small cell lung and breast cancer is a very
chemosensitive and chemotherapy can be used to treat extracranial
to metastatic disease cancer. Experimental treatment for brain
metastases is intrathecal chemotherapy, a technique in which
chemotherapy drugs delivered through intralumbar injection into
the cerebrospinal fluid. However, it was not approved by the u.s.
Food and Drug Administration (FDA) for the treatment of brain
metastases. 14
e. Operation
Brain metastasis frequently managed surgically, with a maximum
of surgical resection followed by stereotactic radiosurgery or whole
24
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DAFTAR PUSTAKA
Price SA, Wilson ML. Patofiologi konsep klinis proses-proses penyakit. Ed 6.
Jakarta : EGC 2005. h. 1021-2024
Sherwood L. Fisiologi manusia dari sel ke sistem. Ed 6. Jakarta : EGC 2011. h.
151-154
Shams, Shahzad. 2011.SOL . Omar Hospital, Jail Road, Lahore: Pakistan.
Kumar, Ravindra. 1996. Diagnosis SOL. Lucknow: Department of Neurology
King George Medical College.
Yanardag, H. S Uygun, V Yumuk, M Caner, B Canbaz. 2005. Cerebral Intracranial
Tumour. Singapore Med J 2005; 46(12): 731.
Adamson, C, et al. "Glioblastoma multiforme: a review of where we have been
and where we are going." Expert opinion on investigational drugs 18.8
(2009): 10611083.
Packer, R J, and Vezina, G. "Management of and prognosis with
medulloblastoma: therapy at a crossroads." Archives of neurology 65.11
(2008): 14191424.
Suslu, Hikmet Turan, Mustafa Bozbuga, Cicek Bayindir. 2010. SOL . JTN: 21(3):
427-429.
Buckner, J C, et al. "Central nervous system tumors." Mayo Clinic proceedings
82.10 (2007): 12711286.
Wahjoepramono EJ. Tumor Otak. Jakarta: FK Pelita Harapan. 2006
Ropper AH, Brown RH. Intracranial Neoplasms and Paraneoplastic Disorders in
Adams and Victors Principles of Neurology. 8th edition. USA: Mc Graw Hill,
2005. 546-88
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