PARADE

NEUROSURGERY
WEDNESDAY, 19 JUNE 2019
Patient’s Identity
Name : Ny I
Gender : Female
Date of Birth : 01-07-1973 / 45 y.o
Medical Record : 85.97.97
Date of Admission : 17-06-2019
Room : Lontara 3 BD, Room 2 Bed 1
Specialist in Charge : Dr. dr. Djoko Widodo ,Sp.BS
History Taking
■ Chief complain: lump on the left head

■ Suffered since 3 year before admission

■ Initially the lump is small like marbles, then enlarged like a pingpong ball
■ Intermittent pain
■ There was history of trauma 3 year before
■ There was no history of decreased level of consciousness
■ There was no history of nausea and vomiting
■ There was no history of seizure
■ There was no history of weight loss
■ There was no history of hypertension and diabetes mellitus.
Physical Examination
■ General status : moderate illness/well-nourished/E4M6V5 (GCS 15)
■ Vital signs:
– BP : 110/70 mmHg
– HR : 92 x/min, regular beat
– RR : 20 x/min
–T : 36,5° C
■ Local status:
Head :
– Inspection: there are lump at left frontal with size 4 x 7 x 1,5 cm, fixated and hard solid
Physical Examination

■ Eye : Anemic (-), Icterus (-), isochoric pupil

■ Ear & Nose : Normal, Tonsils : normal, Pharynx : Normal, tongue : Normal, Lip : Normal
■ Leher: JVP: normal, Pembesaran kelenjar limfe (-)
■ Neck : JVP : Normal, Enlarged lymphonodes (-)
■ Thorax : symmetrical
■ Cor: S1/S2:regular, murmur(-)
■ Pulmo: vesiculer, rhonchi(-), wheezing(-)
Physical Examination

■ Abdomen : Distended (-), meteorismus (-)

■ Peristaltic: normal
■ Tenderness (-)
■ Extremity : warm, Edema (-)
Clinical picture
LABORATORY EXAMINATION

Item Hasil Nilai Rujukan Satuan Unit

Darah Rutin (18 juni 2019)
Leukosit 9.3 4.00 – 10.0 103 / uL
Eritrosit 5.28 4.00 – 6.00 106 / uL
Hb 15.1 12.0 – 16.0 g/dL
Hematokrit 43 37.0 – 48.0 %
MCV 82 80.0 – 97.0 fL
MCH 29 26.5 – 33.5 pg
MCHC 35 31.5 – 35.0 g/dL
Trombosit 307 150 – 400 103 / uL
Limfosit 39.6 20.0 – 40.0 %
Monosit 4.2 2.00 – 8.00 %
Neutrofil 52.6 52.0 – 75.0 %
BLOOD CHEMISTRY EXAMINATION ( 18 june
2019)
item Hasil Nilai Rujukan Satuan

AST/SGOT 47 <38 u/L

ALT/SGPT 67 <41 u/L

Ureum 26 10-50 mg/dL

Kreatinin 0.56 <1.1 mg/dL

Glukosa Sewaktu 173 <140 mg/dL

Natrium 141 136 - 145 mmol/L

Kalium 4.2 3.5-5.1 mmol/L

Clorida 108 97-111 mmol/L

Contrast Head CT Scan
• there is a homogeneous isodens lesion (29 HU) with post contrast
(70 HU), firm boundary, regular edge, non calcification extraaxial
impression in the left frontotemporoparietal region which constricts
the left lateral ventricle with hyperostosis in the left
frontotemporoparietal
• there is a homogeneous isodens lesion (23 HU) with post
contrast(70 HU) , firm boundary, regular edge, non calcification
extraaxial impression in the right temporal region that expand to
sella turcica with hyperostosis at greater wing of sphenoid dextra &
bilateral anterior clinoid processus
• Other sulci and gyri within normal limit
• Unshifted Midline
• Subarachnoid space within normal limit
• Ventricle within normal limit
• Pons and Cerebellum within normal limit
• Paranasalis sinus and aircell mastoid within normal limit
• Oculi Bulbus and retrobulber structure within normal limit
• Other bone within normal limit

• Conclusion :
• Multiple en plaque meningioma at left frontotemporoparietal
region & right temporal that expand to sella turcica
LABORATORY FINDINGS

No Laboratory Exam Result Normal Range Unit No Laboratory Exam Result Normal Range

HEMATOLOGY Blood Chemistry

Complete Blood Count Liver Functin
1 SGOT 47 <38 U/L
1 WBC 9.3 4,00-10,0 10^3/ul
2 SGPT 67 <41 U/L
2 RBC 5.28 4,00-6,00 10^6/ul Kidney Function
3 HGB 15.1 12,0-16,0 gr/dl 1 Kreatinin 0,56 0,6 – 1,3 mg/dl
2 Ureum 26 0 - 53 mg/dl
4 HCT 43 37,0-48,0 %
Electrolyte
5 PLT 307 150-400 10^3/ul 1 Sodium 141 136-145 mmol/l
2 Potassium 4,2 3,5-5,1 mmol/l
3 Chloryde 108 97-111 mmol/l
Working Diagnosis :
- Meningioma Frontotemporoparietal sinistra

Planning: Removal Tumor

Planning

■ Complete blood laboratory examination

■ Chest X-ray
■ removal tumor