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UC 5 Mrs. Susilawati/25 yo//1306395/Infection/IM

Patient was consulted from Neurology DepartmentCC : Headache

History :Since 2 months prior to admission the patient complained about headache that gotworse during time and relieved partially with analgesics. The complaint was alsoaccompanied with fever and seizure. The patient also complained about foul dischargefrom 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 withimprovement, but the complaint got back so she went back to RSUD Majalengka andthen referred to RSHS, hospitalized by Neurology Department, performed CT-Scan andthen consulted to Neurosurgery Department.Previous Medical History : The patient was hospitalized and operated by Neurosurgeryand ENT Department at 2008 and went home with improvement. She controlledregularly 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 (+)

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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 limitsVegetative : within normal limite

Physiologic Reflex : +/+

Patologic Reflex : -/-

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CT Scan

Isodense mass with airfluid level with ringenhancement aftercontrast at left temporal

Multiple hipodense massat left temporal

Perifocal edema (+)

Sulci and gyri arecompressed

Ventricle and cistern arecompressed

Midline Shift > 5 mm tothe right

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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 137K 3.6