Ny.

Susilowati
UC 5 Mrs. Susilawati/25 yo//1306395/Infection/IM
Patient was consulted from Neurology Department
CC : Headache
History :
Since 2 months prior to admission the patient complained about headache that got
worse during time and relieved partially with analgesics. The complaint was also
accompanied with fever and seizure. The patient also complained about foul discharge
from her left ear and from a hole behind it. History of trauma (-). Due to her complaint
she was hospitalized 2 weeks ago in RSUD Majalengka for 9 days and went home with
improvement, but the complaint got back so she went back to RSUD Majalengka and
then referred to RSHS, hospitalized by Neurology Department, performed CT-Scan and
then consulted to Neurosurgery Department.
Previous Medical History : The patient was hospitalized and operated by Neurosurgery
and ENT Department at 2008 and went home with improvement. She controlled
regularly to RSHS and then RSUD Majalengka for several times.
Physical Finding :

General States :
BP : 130/70 mmHg ; HR : 88x/min ; RR : 22x/min ; T afebrile

Local States :
At Left Eye : Ptosis (+)
At Left Frontal and Left Temporal : Scar Post Op (+)
At Left Retroauricula : Fistula (+), Pus (+)
At Left MAE : Discharge (+)

Neurogical State :
GCS = 15, Nuchal rigidity (+)
Pupil : Round equal ODS : 3 mm, LR +/+
Visus : OD> 6/60 OS 4/60
Funduscopy : ODS papil define border (normal)
Eye ball movement : good to all direction
Other cranial nerve : Paresis of Left 7th and XII Cranial Nerves
Motorik : paresis -/-
Sensoric : within normal limite
Proprioceptive : within normal limits
Vegetative : within normal limite
Physiologic Reflex : +/+
Patologic Reflex : -/-
Clinical Picture

CT Scan
Isodense mass with air
fluid level with ring
enhancement after
contrast at left temporal
Multiple hipodense mass
at left temporal
Perifocal edema (+)
Sulci and gyri are
compressed
Ventricle and cistern are
compressed
Midline Shift > 5 mm to
the right


Lab :










WD/ Cerebral Abscess at Left Temporal (G06.1) + Susp Bacterial Meningitis (G00.9) +
Left Chronic Suppurative Medial Otitis (H66.4)+ Fistula at Left Auricula (H70.8)

Th/ Plan for Resection (NC)
Plan for Mastoidectomy (ENT)
Triple Antibiotics (Neurology)


GCS this morning 15 EMG Neurology
Hb 12.9
HMT 37
Leko 18.300
Trombo 363.000
SGOT 122
SGPT 180
Ureum 17
Kreatinin 0.56
Blood glucosa 111
Na 137
K 3.6