A 45 Y.

O WOMAN WITH
SECONDARY CEPHALGIA,
HEMIPARESIS SINISTRA AND
INTRACRANIAL SOL
Aristya Nur Fitasari
030.12.033
Counsellor: dr. Ronny Y, Sp.S
Patients Identity
Name : Mrs, R
Age : 45 y.o
Sex : Female
Addres : St. Mangga Besar no. 13
Marital Status : Married
Occupation : Housewife
Educational Background : Elementary
Religion : Moslem
Admission date : May 12th 2017
Chief Complaint
The patient complained about headache that she has
been experienced since 6 months before but getting more
sever in the past two months.
History of Present Illness
Autoanamnesis and alloanamnesis on May 15 th 2017
The patient complained about the headache she has been
experiencing for the past 6 months and its getting more
severe for the last two months. She complained that she felt
the headache as a kind of pressure-like pain that she felt on
the front side of her head, that sometimes she felt like her
head are going to explode. She felt it more severe on the right
side of her head. She also said that she felt the pain more
severe in the morning that sometimes she is woken up from
her sleep because of the headache. She tried to take some
pain over the counter medicine to treat her headache but it will
only alleviate the pain for a short moment and then the pain
will come back.
History of Present Illness
Autoanamnesis and alloanamnesis on May 15 th 2017
She also said that she felt a lump on the right side of her head.
She only noticed since 2 months ago, and since then it has
grown bigger. She said that there is no pain when she touched
it.
She also said that she felt her left sides are weaker than her
right sides. She said she has felt it since one and a half months
before.
She denied any double visions complained, blurred vision,
impairment of smell function, nausea, vomits, loss of
conciousness or seizures.
Her husband denied any changes in her personalities for the
past months.
Past Medical History
Hypertension (-)
Diabetes Mellitus (-)
Heart Disease (-)
Lung disease (-)
The occurrence of similar complaints (-)
There is a history of when she fell on an escalator about a year ago.
Her family said that theyre not there to watch how she fell and the
patient said that she didnt remember how it happened just that she
lost consciousness and when she wake up she is in a recovery room at
a train station. She denied any weakness on one sides, headache, or
dysarthria after the accident. The patient said that there is no head
injury visibe after the incident and that she denied ever going to the
hospital or clinic after that.
Family Medical History
Hypertension (-)
Diabetes Mellitus (-)
Heart Disease (-)
Lung disease (-)
The occurrence of similar complaints (-)
Malignancies (-)
Physical Examination
Consciousness : Compos Mentis, E4M6V5
Blood Pressure : 130/80 mmHg
Pulse : 92 x/min, regular
Respiratory rate : 20 x/min
Temperature : 36,8 oC
Physical Examination
Head
Normocephal, asymmetrical, a lump on the frontal
right side, hyperemia (-), tenderness (-), mobile
(-), 4 cm
Eyes
Conjunctival pallor (-), scleral icterus (-), pupil
isocoria 4 mm DLR +/+ IDLR +/+
Mouth
Cyanosis (-), dryness (-)
Neck
Lymph nodes & thyroid gland not palpable
Neck stiffness (-)
Physical Examination
Heart
S1 & S2 regular, gallop (-), murmur (-)
Lungs
Vesicular breathing sounds +/+, ronchi -/-, wheezing
-/-
Abdomen
Supple, bowel sounds (+), organ enlargement (-),
Upper and lower extremities
Warm extremities
Edema
Neurological Examination
Meningeal Signs
Neck stiffness (-)
Brudzinsky I (-)
Brudzinsky II (-)
Laseque (-)
Kernig (-)
Speech
Motor aphasia (-)
Sensory aphasia (-)
Dysarthria (+)
Cranial Nerves Examination
N.I (Olfactory nerve)
Not performed
N. II (Optic nerve)
Not performed
N. III (Oculomotor nerve)
Strabismus (-)
Nystagmus (-)
Exophtalmos (-)
Pupils : 4 mm / 4 mm; isochoric
Direct light reflex +/+
Indirect light reflex +/+
Cranial Nerves Examination
N. IV (Throchlear nerve)
Eye movement (downward-inside) +/+
Diplopia (-)
N. V (Trigeminal nerve)
Mouth opening: Normal
Chewing: Not examined
Biting: Not examined
Cornea reflex (+/+)
Face sensibility: Normal
N. VI (Abducens nerve)
Eye movement (lateral) +/+
Diplopia (-)
Cranial Nerves Examination
N. VII (Facial nerve)
Furrowing forehead: (+); Symmetrical
Closing eyes: Normal
Puffing cheeks: Not examined
Showing teeth: asymmetrical, left sides paresis
Taste sensibility: Not examined
N. VIII (Vestibulocochlear nerve)
Swabach: Not examined
Rinne: Not examined
Weber: Not examined
N. IX (Glossopharyngeal nerve)
Taste sensibility: Not examined
Pharynx sensibility: Not examined
Cranial Nerves
N. X (Vagus nerve)
Examination
Pharyngeal arch: Normal, symmetrical
Speaking: Normal
Swallowing: Not examined
Oculocardiac reflex: Not examined
N. XI (Accessory nerve)
Uplifting shoulders: Assymetrical, more
downward towards left side
Turning head aside: Not examined
N. XII (Hypoglossal nerve)
Tongue out: deviation to the left
Articulation: Has a difficulty with pronouncing
words that has r in it
Upper Extremities
Sensory
Pain : Normal/Hipesthesia
Temperature : Not examined
Light Touch : Normal/Hipesthesia
Motor
Strength: 5555/4444
Trophy: Normal
Tone: Normal
Upper Extremities
Physiological reflexes
Biceps ++ / ++
Triceps ++ / ++
Pathological reflexes
Hofman Tromner - / -
Lower Extremities
Sensory
Pain : Normal/Hipesthesia
Temperature : Not examined
Light Touch : Normal/Hipesthesia
Motor
Strength: 5555/4444
Trophy: Normal
Tone: Normal
Lower Extremities
Physiological reflexes
Patella ++ / ++
Achilles ++ / ++
Pathological reflexes
Babinsky - /-
Chaddock - / -
Schaeffer - / -
Oppenheim - / -
Gordon - / -
Neurological Examination
Coordination, gait, & balance
Gait : Not examined
Romberg test : Not examined
Disdiadokinetic : Not examined
Finger to Nose : Not examined
Dix-Hallpike : Not examined
Autonomic reflexes
Micturition: Not examined
Defecation : Not examined
Anal Reflex : Not examined
Abnormal movements
Tremor: -/-
Athetose : -/-
Myoclonic : -/-
Chorea : -/-
Summary
A 45 y.o female came to neurologic center of dr. Mintohardjo Marine Hospital
with a chief complain of headache. She has been experiencing headache for
the past 6 months and its getting more severe for the last two months. She
complained that she felt the headache as a kind of pressure-like pain that
she felt on the front side of her head, that sometimes she felt like her head
are going to explode. She felt it more severe on the right side of her head.
She also said that she felt the pain more severe in the morning. she felt a
lump on the right side of her head. She only noticed since 2 months ago, and
since then it has grown bigger, pain is denied. She felt her left sides are
weaker than her right sides. She said she has felt it since one and a half
months before. She denied any double visions complained, blurred vision,
impairment of smell function, nausea, vomits, loss of conciousness or
seizures. Her husband denied any changes in her personalities for the past
months.
Summary
On examination, patient is conscious (GCS: E4M6V5), with BP
130/80, PR 92x/min, RR 20x/min, and T 36,8. Theres a facialis
nerve (N.VII) lesion are observed when she tried to show her
teeth. An accessory nerve (N XI) lesion when she tried to uplift
her shoulder. A hypoglossal nerve (N.XII) lesion are observed
when she stuck her tongue out. And there is a hemiparesis of
her left sides with muscle strength for left upper and lower
extremities 4444. Hemihypethesia of the left side are also
observed.
 Laboratory Examinations
May 12th 2017
May 13th 2017
Leucocytes: 10.000 /L
Erithrocytes 4.9 million/L
BT 2 min
Hb 13.9 g/dL CT 10.5 min
Hematocrit 42%
Thrombocytes 247000 thou /L
Blood glucose 114 mg/dL
Triglycerides 76 mg/dL
Total Cholesterol 203* mg/dL
SGOT 21 U/I
SGPT 25 U/I
Total protein 7.3 g/dL
Albumin 4.1 g/dL
Globulin 3.2 g/dL
Ureum 16* mg/dL
Creatinine 0.8 mg/dL
Uric Acid 2.9 mg/dL
Natrium/Sodium 144 mmol/L
Kalium/Potassium 4.08 mmol/L
Chlorida 110 mmol/L
Imaging
Imaging
Assesment
Dx
Clinical: Left Hemiparesis
Left Hemihypethesia
Secondary Cephalgia
Central left paresis of N. VII, XI and XII
Etiological: Neoplasma
Topical: Frontal skull and frontal lobe
Pathological: Osteoma
Treatment
Non-pharmacological : Elevation head of the bed
Consult to Neurologist and Neurosurgeon
Pharmacological:
Mefenamic Acid 3 x 500 mg
FOLLOW UP: DAY 1 May 12th 2017
S Headache (+). Weakness of the left sides
O Consciousness : GCS E4M6V5
BP 130/90mmhg PR 96x/min T: 36,7 RR 20x/min
General examination : Normal
Neurological examination :
- Cranial nerve lesions : N.VII, XI and XII paresis sinistra
- Meningeal signs: (-)
- Physiological reflexes : upper ++/++ lower ++/++
- Pathological reflexes: upper -/- lower -/-
- Muscle strength: upper 5555/4444
lower 5555/4444
- Sensoric : Hemihyphestesia sinistra
A Clinical dx : Hemiparesis sinistra, Hemihipesthesia sinistra, central left
pareses of N. VII, N.XI and N.XII, secondary cephalgia
Etiological dx: Neoplasm
Pathologic dx Osteoma
Topical dx: Frontal skull and frontal lobe
P IV RL/8 hr
Mefenamic Acid 3 x 500 mg
Elevation the head of the bed
FOLLOW UP: DAY 2 May 13th 2017
S Headache (+). Weakness of the left sides
O Consciousness : GCS E4M6V5
BP 130/80mmhg PR 92x/min T: 36,9 RR 20x/min
General examination : Normal
Neurological examination :
- Cranial nerve lesions : N.VII, XI and XII paresis sinistra
- Meningeal signs: (-)
- Physiological reflexes : upper ++/++ lower ++/++
- Pathological reflexes: upper -/- lower -/-
- Muscle strength: upper 5555/4444
lower 5555/4444
- Sensoric : Hemihyphestesia sinistra
A Clinical dx : Hemiparesis sinistra, Hemihipesthesia sinistra, central left
pareses of N. VII, N.XI and N.XII, secondary cephalgia
Etiological dx: Neoplasm
Pathologic dx Osteoma
Topical dx: Frontal skull and frontal lobe
P Mefenamic Acid 3 x 500 mg
Elevation the head of the bed
Pro. Craniotomy
FOLLOW UP: DAY 3 May 14th 2017
S Headache (+). Weakness of the left sides
O Consciousness : GCS E4M6V5
BP 130/80mmhg PR 92x/min T: 37,0 RR 20x/min
General examination : Normal
Neurological examination :
- Cranial nerve lesions : N.VII, XI and XII paresis sinistra
- Meningeal signs: (-)
- Physiological reflexes : upper ++/++ lower ++/++
- Pathological reflexes: upper -/- lower -/-
- Muscle strength: upper 5555/4444
lower 5555/4444
- Sensoric : Hemihyphestesia sinistra
A Clinical dx : Hemiparesis sinistra, Hemihipesthesia sinistra, central left
pareses of N. VII, N.XI and N.XII, secondary cephalgia
Etiological dx: Neoplasm
Pathologic dx Osteoma
Topical dx: Frontal skull and frontal lobe
P Mefenamic Acid 3 x 500 mg
Elevation the head of the bed
Pro. Craniotomy
FOLLOW UP: DAY 4 May 15th 2017
S Headache (+). Weakness of the left sides
O Consciousness : GCS E4M6V5
BP 130/80mmhg PR 92x/min T: 37,0 RR 20x/min
General examination : Normal
Neurological examination :
- Cranial nerve lesions : N.VII, XI and XII paresis sinistra
- Meningeal signs: (-)
- Physiological reflexes : upper ++/++ lower ++/++
- Pathological reflexes: upper -/- lower -/-
- Muscle strength: upper 5555/4444
lower 5555/4444
- Sensoric : Hemihyphestesia sinistra
A Clinical dx : Hemiparesis sinistra, Hemihipesthesia sinistra, central left
pareses of N. VII, N.XI and N.XII, secondary cephalgia
Etiological dx: Neoplasm
Pathologic dx Osteoma
Topical dx: Frontal skull and frontal lobe
P IV Line NaCl 0,9%/12 hr
Inj. Dexamethason 1 x 2 amp
Inj. Ranitidin 2 x 1 amp
Mefenamic Acid 3 x 500 mg
Elevation the head of the bed
THANK YOU!