cerebral abcess

8/11/2019 Cerebral abcess

1/15

Case Report

Cerebral Abcess

Faculty of MedicineSriwijaya University


2/15

Neurology Medical Record

IDENTIFICATION

Name : Miss. INA

Age : 27 yearsSex : Female

Address : Desa Tugu Mulyo, RT.04

RW.01 Kel.Tugu Mulyo, Lempuing, OKIReligion : Islam

Admission date: September 13th, 2014


3/15

ANAMNESIS

The patient was admitted in neurology ward

due to the decrease of consciousness.

1 week before hospitalized the patient

complain about headache and felt her body was

fainted. She didnt has fever, but she suffered

from snezzing and coughing that often occurs.2 days before hospitalized, the patient was

treated in the private clinic due to headache

accompany by nausea and vomiting,

approximately 2-3x a day. One body side

weakness was not found, lips deviation was not

found, and also there is no disarthria.


4/15

12 hours before hospitalized, she feltthe decrease of consciounnessprogresivelly. Seizure (-).

Hypertension DM, chronic headache,high fever, stroke history, was denied

heart disease and liver disease was stillunknown. Thyroid diesease was not foundBoth of her eyes were bulged since shewas young

This was the first time she complainabout these symptom


5/15

Physical Examination

Present State:

Sense : GCS 10 (E3M5V2)

Nutrition : sufficient

Pulse : 65 beats/min

Respiratory rate : 26 times/min

Blood pressure : 130/80 mmHg

Temperature : 38,0 0C


6/15

Cranial Nerves:

N. I : Anosmia in her left nose

N. III : pupil anisochor, round pupil 3mmOD light reflex (+), round pupil 6 mm

midriasis OS light reflex decrease. EdemaPapil OS

,dropping of the left eyelid

N. VII : lagophtalmus (+) ODS

N. XII : not yet assesed


7/15

Motoric Function

Motoric

function

Arm Leg

Right Left Right Left

Motion No lateralization No lateralization No

lateralization

No

lateralization

Power Still active at both

arms

Still active at both

legs

Tones Normal Normal Normal Normal

Clonus - -

Physiological

reflex

Normal Normal Normal Normal

Pathological

reflex

- - - -


8/15

Sensory function : not yet assesed

Vegetative function : using catheter

Limbic function : no abnormality Abnormal Movement : No

Gait & Stability : not yet assesed

Meningeal Irritation : Kerniq sign andLaseque sign positive in both legs


9/15

DIAGNOSIS

Clinical Diagnoses : - consciousness decrease

-Anisochor pupil

-Ptosis in her left side-Meningeal Irritation

Topic Diagnose : Regio frontalis sinistra Etiology diagnose : Abcess cerebri DD/Meningioma


10/15

Laboratory Findings

BLOOD (13-9-2014)

Hb : 13,9 (11,7-15,5)

Eritrosit : 4,32 (4,20-4,87)

Leucocyte : 12,4 (4,5-11,0)

Hematocrit : 40 ( 38-44 ):

Diff Count : 0/0/0/83/9/8

(0-1/1-6/2-6/50-70/25-40/2-8)

Thrombocyte : 2130000 (150-450)


11/15

Ureum : 16 (16,6-48,5)

Creatinin : 0,56 (0,50-0,90)

Total Bilirubin: 0,25 (0,1-1,0)

Direct Bilirubin: 0,10 (0-0,02) Indirect Bilirubin: 0,15 (


12/15


13/15

MANAGEMENT

Medicine : IVFD RL gtt x/mins (Makro)

O2 10 lt/m Endo tracheal tube andrespiratory observation

Cefixime 2x2 gr i.v

Gentamycin 2x80 mg i.vMetronidazol inf 4x500 mg i.v

Dexamethasone 3x1 mg i.v

Omeprazole 1x40 mg i.v

Planning : CT scan with contrast, VCT,Toxoplasmosis examination, consulted to ENTdivision


14/15

PROGNOSIS

Quo ad vitam : malam

Quo ad functionam : dubia ad malam


15/15

cerebral abcess

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