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Wahidin Sudirohusodo Hospital CASE REPORT July, 2014

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CASE REPORT July, 2014
Wahidin Sudirohusodo Hospital
CEREBELLOPONTIN ANGLE TUMOR
By :
WIDYAWAN SYAHPUTRA
Supervisor : dr. Abdul Muis, Sp.S (K)
DEPARTMENT OF NEUROLOGY
FACULTY OF MEDICINE
HASANUDDIN UNIVERSITY
2014

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CASE REPORT
By : Widyawan Syahputra
Supervisor : dr.Abdul Muis, Sp.S (K)
I. REGISTRATION
Name : Mr. J
Age : 57 years-old
Address : Toli - Toli
Registration number : 66 59 77
Admission date : June 2
nd
, 2014
II. ANAMNESIS
Chief complaint : Severe headache (NPRS 7-8)
It occurred since 2 years ago and worsened recently in 2 months. The pain was felt like
throbbing starting at the back of head and then radiating to all region of head. The pain was
intermittent. The pain wasn’t aggravated by activities and could appear anytime but more often
in the morning. The pain was reduced by taking medicine. Sometimes he vomited when he got
headache. He also complaint dizziness everytime he did activities and he was difficult to take
goods and focused with left extremities. Sometimes he felt as if he would have felt down. Last
1 year, he also complaint buzzing voice together with hearing loss at the left ear. There was
history of hypertension and there was no history of fever, head trauma, diabetic and heart
disease.
III. PHYSICAL EXAMINATION
General status : Looks moderate to severe
Vital sign :
BP : 160/90 mmHg RR : 20 x/minute, thoraco abdominal
HR : 86 beats per minute, regular T : 36,8
0
C
Head : Within normal limit
Eyes : Anemic conjunctiva (-), icteric sclera (-)
Thorax : Lungs : Vesiculer, ronchi -/- wheezing -/-

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CASE REPORT July, 2014 Wahidin Sudirohusodo Hospital CEREBELLOPONTIN ANGLE TUMOR By : WIDYAWAN SYAHPUTRA Supervisor : dr. Abdul Muis, Sp.S (K) DEPARTMENT OF NEUROLOGY FACULTY OF MEDICINE HASANUDDIN UNIVERSITY 2014 CASE REPORT By : Widyawan Syahputra Supervisor : dr.Abdul Muis, Sp.S (K) I. REGISTRATION Name : Mr. J Age : 57 years-old Address : Toli - Toli Registration number : 66 59 77 Admission date : June 2nd, 2014 II. ANAMNESIS Chief complaint : Severe headache (NPRS 7-8) It occurred since 2 years ago and worsened recently in 2 months. The pain was felt like throbbing starting at the back of head and then radiating to all region of head. The pain was intermittent. The pain wasn’t aggravated by activities and could appear anytime but more often in the morning. The pain was reduced by taking medicine. Sometimes he vomited when he got headache. He also complaint dizziness everytime he did activities and he was difficult to take goods and focused with left extremities. Sometimes he felt as if he would have felt down. Last 1 year, he also complaint buzzing voice together with hearing loss at the left ear. There was history of hypertension and there was no history of fever, head trauma, diabetic and heart disease. III. PHYSICAL EXAMINATION General status : Looks moderate to severe Vital sign : BP : 160/90 mmHg RR : 20 x/minute, thoraco abdominal HR : 86 beats per minute, regular T : 36,8 0 C Head : Within no ...
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