Scribd Logo
Upload

Welcome to Scribd!

  • 10 views

    Visual Disturbance Et Parese of Left Temporal Branch

    Uploaded by

    Rahmanda Taqwa
    This document contains a medical report for a 53-year-old female farmer who underwent craniotomy and tumor excision surgery in August 2023. She presented with weakness of the left upper face. The report details her medical history, examination findings, diagnostic imaging results, and impression. Key findings include no residual or enhancing mass seen on post-op MRI at the surgical site in the tuberculum sellae region, and encephalomalacia and small vessel ischemic changes noted in the left frontal lobe.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Visual Disturbance Et Parese of Left Temporal Branch

    Uploaded by

    Rahmanda Taqwa
    10 views6 pages
    This document contains a medical report for a 53-year-old female farmer who underwent craniotomy and tumor excision surgery in August 2023. She presented with weakness of the left upper face. The report details her medical history, examination findings, diagnostic imaging results, and impression. Key findings include no residual or enhancing mass seen on post-op MRI at the surgical site in the tuberculum sellae region, and encephalomalacia and small vessel ischemic changes noted in the left frontal lobe.

    Original Description:

    Visual Disturbance et Parese of Left Temporal Branch

    Original Title

    Visual Disturbance et Parese of Left Temporal Branch

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document contains a medical report for a 53-year-old female farmer who underwent craniotomy and tumor excision surgery in August 2023. She presented with weakness of the left upper face. The report details her medical history, examination findings, diagnostic imaging results, and impression. Key findings include no residual or enhancing mass seen on post-op MRI at the surgical site in the tuberculum sellae region, and encephalomalacia and small vessel ischemic changes noted in the left frontal lobe.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    10 views6 pages

    Visual Disturbance Et Parese of Left Temporal Branch

    Uploaded by

    Rahmanda Taqwa
    This document contains a medical report for a 53-year-old female farmer who underwent craniotomy and tumor excision surgery in August 2023. She presented with weakness of the left upper face. The report details her medical history, examination findings, diagnostic imaging results, and impression. Key findings include no residual or enhancing mass seen on post-op MRI at the surgical site in the tuberculum sellae region, and encephalomalacia and small vessel ischemic changes noted in the left frontal lobe.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 6

    Identity (October 26th, 2023) RAN/LIS/ dr. AL, Sp.K.F.R., M.S.

    (K)
    Name : Mrs. Siti Aminah
    Age : 53 years old
    Sex : Female
    Religion : Moslem
    Marital Status : Married
    RM : 12951654
    HP : 082331505449
    Address : Tuban
    Occupation : Farmer
    Reffered from Neuro Surgery OPC with Post Craniotomy Eksisi Tumor & Osteoplasty

    Chief complaint: Kelemahan pada sisi wajah atas sebelah kiri


    History of Present Illness
     2015  There was a gradual decrease in vision in the left eye
     2017  Her left eye was unable to see anything and can't differentiate between dark and light
     2020  Vision began to decrease in her right eye
     2022  The Patient seek treatment at Tuban Hospital, the vision in the right eye becomes
    more blurry
     2023  The patient goes to Soetomo to the eye, from there she reffered to Neuro surgery to
    do further examination
     2023, August  Patient underwent Post Craniotomy Tumor Excision & Osteoplasty. She
    wasa hospitalized around 2 weeks in there and never went to rehabilitation therapy
     After surgery the vision in the right eye improved, but there was weakness above the left
    eyebrow. The patient could not lift his left eyebrow
     The patient is able to fully smile and fully close both eyelids. No watery and dry in the eye.
    Drooling (-). There is no mention of ear pain or a decrease in hearing. Moreover, no weakness
    in chewing and no problems in swallowing. There is no history of slurred speech.

    History of Functional Ability


    The patient still could do all activities of daily living independently

    History of Medication and Rehabilitation


    DM : Metformin 3x500, Glimepiride 1x1, Insulin Novorapid 3x6 iu , Levemir 1x14 iu

    History of Past Illness


    No history of hypertension and Stroke before.
    DM + Since 2 years ago

    History of Work and Hobby


    No spessific hobby, The patient work as a farmer near her house. Right now she is able to work again
    but with limited activity

    History of Psycho-Socio-Economic
    The patient lives with her husband (56 yo). Lives in a one-story house, with a squatting toilet. The
    patient Using BPJS for insurance

    Family History
    History of diabetes +,
    No history of stroke, or hypertension in the family.

    Patient’s Expectation
    Facial muscles to be normal again.
    III.1. General Status
    GCS E4 V5 M6 BP: 120/80 mmHg, HR: 91x/min, RR: 18x/min, Temp: 36.5oC, SpO2: 99%
    Height: 133 cm, Weight: 50 kg, BMI 31.09% (Obese Grade I)
    Posture: Forward head, rounded shoulder, pelvic, ankle knee symetrical
    Dominant extremity: Righthanded.
    Gait: normal. Ambulation: independent without a walking aid

    Head and neck : Anhidrosis (-) Ptosis (-|-) Enophthalmus (-|-) Miosis (-|-) Lagophthalmos (-|-)
    Conjunctiva anemia (-|-), icterus (-|-), cyanosis (-), enlargement lymph node (-)
    Cor : S1-S2 normal, regular, murmur (-), gallop (-)
    Pulmo : Vesicular (+|+), wheezing (-|-), ronchi (-|-)
    Abdomen : Soefl, peristaltic (+), tenderness (-)
    Extremities : Warm acral (-|-), cyanosis (-), edema (-|-)

    III.2. Head/Neck/Trunk,
    Look : redness (-|-), swelling (-|-), skin lesion (-|-),
    Feel : tender point (-|-), warmth (-|-), edema (-|-)
    Move : pain when move (-)
    Region Range of Motion MMT
    Neck F|F 5|5
    TMJ F|F 5|5
    Trunk F|F 5|5

    Neuromuscular :
    Cranial Nerve Right Left Reflex / Special Test
    Cranial Nerve I Normal Normal
    Cranial Nerve II Visus 3/60 Visus - Direct Light Reflex (+|-)
    Visual field: - Indirect Light Reflex (+|-)
    Papil Atrofi
    Cranial Nerve III Normal Normal
    Cranial Nerve IV Normal Normal
    Cranial Nerve V Sensory: normal Sensory: normal Corneal Reflex (normal|normal)
    Motoric: Normal Motoric: Normal
    Cranial Nerve VI Normal Normal
    Cranial Nerve VII Musc. Frontalis: 5 Musc. Frontalis: 1 Schirmer Test (+|+)
    Musc. Corrugator: 5 Musc. Corrugator: 1
    Musc. Orbic. Oculi: 5 Musc. Orbic. Oculi: 1 Taste 2/3 anterior third: normal|
    Musc. Nasalis: 5 Musc. Nasalis: 5 normal
    Musc. Zygo. Mayor: 5 Musc. Zygo. Mayor: 5
    Musc. Orbic. Oris: 5 Musc. Orbic. Oris: 5 Stethoscope scratch: normal|normal
    Musc. Bucinator: 5 Musc. Bucinator: 5
    Cranial Nerve VIII Rubbing Finger: Normal Rubbing Finger: Normal Tinnitus (-|-)
    Whisper Test Normal Whisper Test Normal
    Cranial Nerve IX Normal Normal
    Cranial Nerve X Normal Normal
    Cranial Nerve XI Normal Normal
    Cranial Nerve XII Normal Normal

    III.3. Upper Extremities Region


    Look : redness (-|-), swelling (-|-)
    Feel : warmth (-|-), tender point (-|-), crepitation (-|-)
    Move : pain (-|-)
    Neuromuscular :
    - Muscle tone : Normal
    - Deep Tendon Reflex : BPR (+2|+2), TPR (+2|+2)
    - Pathological reflex : Hoffmann (-|-), Tromner (-|-)
    - Sensorics : normal
    Region ROM MMT
    Shoulder F/F 5/5
    Elbow F/F 5/5
    Wrist F/F 5/5
    Fingers F/F 5/5

    III.4. Lower Extremities Region.


    Look : redness (-|-), swelling (-|-), deformity (-|-)
    Feel : warmth (-|-), crepitation (-|-), tenderness (-|-)
    Move : pain when move (-|-)
    Neuromuscular :
    - Tonus : normal
    - Deep Tendon Reflex : KPR +2|+2; APR +2|+2
    - Pathological reflex : Babinski (-|-)
    - Sensorics : Normal

    Region ROM MMT


    Hip F/F 5/5
    Knee F/F 5/5
    Ankle F/F 5/5
    Big Toes F/F 5/5
    Toes F/F 5/5

    III.5. Functional Status


    Balance : Sitting balance (static and dynamic) is good, standing balance (static and
    dynamic) is good
    Transfer : lying to sitting independent, sitting to standing independent
    Barthel Index : 90
    Feeding 10/10 Bladder 10/10
    Grooming 5/5 Toilet use 10/10
    Bathing 5/5 Mobility 10/15
    Dressing 10/10 Transfer 15/15
    Bowel 10/10 Stairs 5/10

    SUPPORTING EXAMINATION:

     Pemeriksaan Foto Thorax PA 20-07-2023


    Cor : bentuk dan besar normal
    Pulmo : tak tampak infiltrat / nodul
    Trachea tampak di tengah
    Sinus phrenicocostalis kanan kiri tajam
    Hemidiafragma kanan kiri tampak baik
    Tak tampak proses osteolitik / osteoblastik
    Soft tissue tak tampak kelainan
    Kesimpulan
    - Tak tampak proses metastase pada paru dan tulang-tulang yang tervisualisasi
    - Cor tak tampak kelainan
     TS Yth, Pemeriksaan MSCT 2023-08-02 Post Operasi
    - Tampak defek calvaria regio fronto temporal kiri disertai densitas darah (65 HU) dan multiple foci
    udara (-1112 HU) di frontal kanan kiri dan temporal kiri, tampak lesi disertai perifokal edema yang
    mendesak dan menyempitkan ventrikle lateral kiri dan menyebabkan midline shift sejauh +/- 0,4 cm
    ke sisi kanan
    - Tak tampak gambaran abnormal contrast enhancement pada brain parenchyma
    - Sulci tampak effacement
    - Sistem ventrikel dan cysterna normal
    - Pons dan cerebellum normal
    - Tak tampak kalsifikasi abnormal
    - Tampak penebalan mukosa (36 HU) di sinus sphenoid kanan
    - Orbita, mastoid dan sinus paranasalis kanan kiri di luar lesi tak tampak kelainan

    Kesimpulan
    - Defek calvaria regio fronto temporal kiri disertai hemorrhage dan pneumocephaly di frontal
    kanan kiri dan temporal kiri merupakan
    gambaran post surgical disertai midline shift sejauh +/- 0,4 cm ke sisi kanan
    - Brain edema
    - Sinusitis sphenoid kanan

     MRI Kepala irisan axial, tanpa dan dengan kontras 20-10-2023


    - Tak tampak lesi hipointense/hiperintense di brain parenchyme, yang dengan pemberian kontras tak
    tampak abnormal contrast enhancement
    - Tampak area di surgical bed di tuberculum sellae dengan hypointense signal pada T1WI,
    hyperintense pada T2WI, hypointense pada T2FLAIR, unrestricted pada DWI, yang dengan
    pemberian kontras tak tampak kontras enhancement
    - Tampak small vessel ischemic di subcortical lobus frontalis kiri
    - Sulci dan gyri di luar lesi tampak normal
    - Sistem ventrikel dan cysterna tampak baik
    - Tak tampak deviasi midline struktur
    - Pons dan cerebellum tampak baik
    - Mastoid, orbita kanan kiri tampak baik
    - Tampak penebalan concha nasalis inferior kanan kiri yang tampak hypointense pada T1WI,
    hyperintense pada T2WI; tampak deviasi septum nasi ke kanan
    - MR Angiography : Circulus Willisi tampak patent, tak tampak aneurysma maupun vascular
    malformation

    Kesimpulan
    - Tak tampak residual/resistive mass di surgical bed di tuberculum sellae
    - Encephalomalaceal cyst di di surgical bed di tuberculum sellae
    - Small vessel ischemic di subcortical lobus frontalis kiri
    - Hypertrophy concha nasalis inferior kiri disertai deviasi septum nasi ke kanan

     Laporan Operasi 1 Augutus 2023


    Flattening dari sphenoid ridge Insisi duramater C shape dengan pedicle ke arah Ridge dilakukan
    Spliting sylvian untuk mempermudah retraksi hingga expose tumor Identifikasi Tumor dan batas-
    batas tumor detachment tumor dari arah base (tuberculum sellae dan planum sellae) pisahkan tumor
    sesuai arachnoid plane Debulking tumor dan kontrol perdarahan Evakuasi Tumor secara piece meal
    Jahit duramater watertight Dilakukan osteoplasty Jahit kulit lapis demi lapis
    Craniotomy Tumor Excision + Osteoplasty
    Diagnosa: Tumor Supra sella ec Susp Tubercullum Sellae Meningioma + OS Optic Atrophy ec
    Compressive Optic Neuropathy + DM Type 2 Hiperglikemia
    PROGNOSIS
    Ad vitam : Bonam
    Ad sanactionam : Dubia
    Ad functionam :
    - Transfer : Independent
    - Ambulation : Independent
    - Other ADL : Independent

    PROBLEM LIST
    o Visual disturbance
    o Left temporal parese
    o Supra Sella Meningioma Post Osteoplasty et Craniotomy Excision (2 Months)
    o DM type II
    o Obese Grade I

    ICF
    Body Function :
    b730 Muscle power function (left weakness on Musc. Frontalis, Corrugator, and Orbic. Oculi )
    b749 Muscle functions, other specified and unspecified (Inability to frown)
    b210 Seeing functions (Visual disturbance)
    b530 Weight maintenance functions (Obese grade I)

    Body Structure :
    s198 Structure of nerve system (Parese of Left Temporal Branch)
    s110 Structure of brain
    (Supra Sella Meningioma Post Osteoplasty et Craniotomy Excision (2 Months))
    s298 Eye, ear and related structures, other specified (Optic Atrophy)
    s580 Structure of endocrine glands (DM type II)

    Activities and Participation :


    d475 Driving (afraid to ride a motorcycle)
    d710 Basic interpersonal interactions (embarrassed with her facial condition)

    Environmental Factors :
    e580 Health Services, System and Policy (patient covered by BPJS)

    ASSESSMENT
    Visual Disturbance et Parese of Left Temporal Branch ec Supra Sella Meningioma Post Osteoplasty
    et Craniotomy Excision (2 Months) + Diabetes Mellitus Type II (Controlled) + Obese Grade I

    Goals:
    Short Term :
    1. Left facial muscle MMT improved by 1-2 point
    2. Decrease body weight 0,5 kg/ week reach until normal BMI
    3. Maintain other MMT of facial

    Long Term :
    1. Prevent complication
    2. Achieved normal MMT of left facial muscle and symmetrical face
    3. Improved quality of life
    4. Achieved normal weight
    PLAN
    PDx: -

    Therapeutic Plan
    Modality:
    • NMES Galvanic current motor point method at left frontalis muscle until visible muscle contraction

    Thera Exc :
    - Facial expression exercise (Especially frontalis muscle)
    - Strengthening frontalis muscle
    - Endurance exercise (F: 3-5x/weeks; I: 40-50% HRR; I: 30 minutes; T: static cycle)

    PMx: Clinical, Vital signs, facial muscle, sensory, visual, other cranial nerve

    Educational Plan

    - Explain patient's condition, goals, and treatment plan


    - Continue exercise at home
    - Strengthening facial muscle in front of the mirror (3-5x/day 3 sets 10 repetitions)
    - Facial expression exercise
    - Warm compress
    - Gentle massage of the facial muscles
    - Strengthening facial muscle in front of the mirror
    - Routinely control to Eye and Neuro Surgery OPC

    You might also like