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Fungal Infections of The Brain
Fungal Infections of The Brain
Resume Mr. N, 51 Yr
23 Januari 2014
Subjective :
A male patient aged 51 years, came with a chief complaint of headache.
Objective :
Dari hasil CT scan didapati multiple intrakranial SOL ( Temperopariental
dextra dan pariental sinistra ). Pada pemeriksaan status neurologi, tidak didapati
kelemahan saraf cranial. Pada pemeriksaan rectal toucher, tidak didapati
kelainan. Pada pemeriksaan fisik leher, tidak didapati kelainan (tidak didapati
benjolan dan lympadenopaty ). Pada pemeriksaan fisik paru-paru, didapati
suara nafas vesikular pada paru kiri dan kanan, tidak didapati ronchi dan
wheezing.
Hasil konsultasi dari Spesialis penyakit dalam: (Dr. Erwin Sp.PD)
Hasil ECHOCARDIGRAFI : dalam batas normal.
Hasil pemeriksaan thorax : tidak didapati kelainan
Pemeriksaan PCR TB, HIV, TORCH.
Subjective:
Objective:
From the results of the CT scan found multiple intracranial SOL
(Temperopariental dextra and the left parietal). On examination of the
neurological status, cranial nerve weakness was not found. In toucher rectal
examination, no abnormalities were found. On physical examination of the neck,
no abnormalities were found (not found lumps and lympadenopaty). On physical
examination the lungs, vesicular breath sounds are found on the left and right
lung, was not found Ronchi and wheezing.
The results of the consultation of specialists in internal medicine (Dr.
Erwin Sp.PD)
Results ECHOCARDIGRAFI: within normal limits.
The results of the examination of the thorax: not found abnormalities
PCR TB, HIV, TORCH.
Ig G (ul) Ig M (ul)
Toxoplasma 20 -
Rubella - -
CMV 76 -
HSV II - -
Kesimpulan hasil laboratorium :
Sudah pernah terinfeksi toxoplasma dan CMV
Toleransi operasi : disetujui operasi
Diagnosa :
Multiple SOL intrakranial, DD: - Infeksi (HIV, TBC)
- Metastasis
- Astrocytoma
Planing :
Pro craniectomy tumor removal
1 February 2014
Post craniectomy tumor removal
Analisis jaringan patologi anatomi menunjukan (10 February 2014) Papilary
metastase.
Investigasi metastase thyroid dan prostate, menunjukan USG thyroid tidak
didapati kelainan, T3 , T4, TSH, menunjukan tidak didapati kelainan.
Hasil konsul Bedah Onkologi tinjau ulang hasil pemeriksaan Patology
anatomi, karena tidak sesuai dengan kondisi pasien.
Pemeriksaan HW 3 metode & CD 40 : hasil menyusul
3 February 2014
Pasien mengeluh stomatitis akut, pasien dicurigai imunocompromise
Tampak hematoma didaerah kulit operasi curiga hematologic disorders
Laboratorium dalam batas normal tranfusi FFP 3 hari KU: membaik
Kesimpulan : menunggu hasil tinjauan PA, CD4 , dan Elisa 3 metode.