CASE REPORT
Hospital: Zhongnan Hospital of Wuhan University
Department: Neurosurgery department
Name: Dousagon Kasempongtongdee
Chinese Name: ChenDongHai
ID Number: 2013326660119
Personal Profile of patient
Name: Zhu-en-ze
Gender: Male
Age:4
Date of Birth:2013
Marital Status: -
Phone No: 18607172323
Address: Hubei province, Jiang-an city, Dalian road, number 64(father)
Date of Admission: 3/8/2017
Case Reporting Time: 17:34
Admission No: 0001094273
Bed No: 13 Neurosurgery area number2
Present illness:
Chief complaint: headache, vomiting 5day PTA.
Patient feel headache and vomiting then goes to Children hospital for exam, CT scan result
show: Sella turcica & posterior fossa have cystic tumor associated with sellar calcification,
Hydrocephalus, no unconsciousness, no 4 limbs weakness or paralysis.
1/8/2017 He goes to WHU Chang-jiang corporation hospital for Lt. Frontal lobe surgery for
drainage of cystic tumor, after surgery he has fever, highest temperature is 39C.
Today he comes to the hospital for requiring of next step surgery.
Past history disease
1/8/2017 Lt. frontal lobe surgery for drainage of cystic tumor.
The underlying disease of patient is Craniopharyngioma and hydrocephalus.
Patient refuses drug and food allergic history.
Patient refuses severe traumatic injury history.
Personal history
Han ethic group nationality.
No drinking, no smoking.
Family history
No history.
Current medicine
None.
Systemic review
General Appearance: young boy no weakness, no dyspnea, arousal consciousness.
Skin and nail: no rash, no petechial, no purpura, no ecchymosis.
Head eye ear Norse throat:
Head: surgical scar, no hair loss, no mass, refuses head traumatic history.
Eyes: visual intact, no diplopia, no red, no swelling.
Ears: hearing intact, no otalgia, no tinnitus, no discharge.
Nose: Smelling intact, no runny nose, no discharge.
Throat and mount: no wound, no leukoplakia, no mucosal bleeding.
Neck: no neck stiffness symptom, no Lymphadenopathy, no sore throat, swallowing intact, no neck pain.
Respiratory Symptoms: no dyspnea, no cough, no sputum, no emphysema, refuses Tuberculosis history.
Circulatory Symptoms: no orthopnea, no paroxysmal nocturnal dyspnea, no palpitation, no chest pain,
no cyanosis .
GI Symptoms: Nausea vomiting, normal appetite, no dysphagia, no abdominal pain, no diarrhea, no
melena, no bloody feces.
Urinary Symptoms: normal urinate, no nocturnal polyuria, no turbid urine, no dysuria, no bloody
discharge, no frothy urine.
Hematologic Symptoms: no nonstop bleeding, no pale.
Endocrine Symptoms: no mass at anterior neck, no hot or cold intolerance, no palpitation .
Neuropsychiatric Symptoms: Headache, arousal conscious, no weakness, no numbness, no seizure.
Reproductive Symptoms: intact.
Musculoskeletal Symptoms: intact.
Infectious Diseases: no fever.
Others: -
Physical Examination
Vital sign: BT 38.4C, BP:-no history, PR: 105bpm. RR: 22bpm. O2sat100%: room air, body weight: -no
history.
GA: Young boy, arousal consciousness, no pale, no jaundice, no central/ peripheral edema, no dyspnea
Skin and nail: normal skin turgor, no rash, no petechial, no purpura, no ecchymosis, no skin lesion, no
tea spoon nail, no sublingual hemorrhage.
Head eye ear Norse throat:
Head and scalp: no evidence of head trauma.
Eye: normal pupillary diameter (3mm.), sense to light reflex, no eyelid swelling, no pale
conjunctiva anicteric sclera.
Nose: no nasal ulcer or discharge.
Mouth: no oral ulcer, no glosstitis, no oral thrust, no hairy leukoplakia, pharynx and tonsil are
not injection.
Neck: no thyroid gland enlargement, no buffalo hump, no parotid gland enlargement, no neck mass.
Lymph node: no cervical, supraclavicular, infra-clavicle, axillary, inguinal lymphadenopathy.
Breast: no gynecomastia.
Heart: : no neck vein engorge, no cyanosis, no active precordium, no heaving, no thrill, PMI at 5th ICS
MCL, full pulse all extremity, normal S1,S2 regular rhythm, no murmur.
Lung: Trachea in midline, normal chest contour, no spider nevi, normal tactile fremitus, vocal fremitus,
clear and equal breath sound both lung, no adventitious heart sound.
Abdomen: flat shape, no surgical scar, no superficial vein dilate, no purplish striae, normal active bowel
sound, soft , not tenderness, no guarding rigidity, no rebound tenderness, liver and spleen cannot
palpitated, splenic dullness negative.
Genitourinary: kidney no palpitated by manual palpitation, CVA not tenderness.
Extremities: no pitting edema, no deformity, no palmar erythema.
Nervous system:
Mental status: arousal consciousness, follow to command, E4V5M6.
Language: normal comprehension and confluence.
Speech: no dysarthria.
CN: intact.
Motor: normal muscle tone, no muscle atrophy, no fatigue ability.
Sensory: intact pinprick sensation, Proprioception, pain temp sensation.
Deep tendon reflex: intact.
Babinski sig: negative.
Hoffmans sign: negative.
Invert radial reflex: negative.
Clonus: negative.
Arm abduction sign: negative.
Spurling sign: negative.
Axial compression test: negative.
Traction sign: negative.
Finger flexion test: negative.
Lhermittes sign: negative.
Cerebellar sign: negative.
Meningeal sign: negative.
Problem list
1. Headache
2. Nausea vomiting
3. Underlying disease: Craniopharyngioma and hydrocephalus
Investigation
8/8/2017 CT result show cystic lesion on anterior and posterior sellar turcica area associated
with Sellar calcification, brain stem structure is irregular determined.
Brain stem and cerebellum is depressed.
Lt. shift of sulcus is relieve after previously surgery.
Bilateral durra matter edema.
Third ventricle, fourth ventricle is hydrocephalus associated with white matter and stoma
edema.
Chest anatomical is intact.
definite Diagnosis
Craniopharyngioma from sellar turcica invade to brain stem associated with Cystic lesion, hydrocephalus
and sellar calcification.
Treatment
Surgery resect tumor around sellar turcica area and drainage cystic tumor .
If excision is not clear may need radiotherapy.
Follow up by CT scan, exam optic nerve function , Hormone replacement may require after surgery.
Summary
Patient: Zhu-en-ze, male, 4 years old.
31/7/2017 Patients Chief complaint is headache and vomiting.
3/8/2017 Acceptance cause is fever after cystic tumor drainage surgery.
Vital sign: BT 38.4C, BP:-no history, PR:105bmp., RR: 22bpm., O2sat100%: room air, Body
weight: -no history, GCS is E4V5M6, normal pupillary diameter(3mm.), arousal consciousness,
response to light reflex, speech intact, answer question is clear, nuchal rigidity 4+, lung sound
clear, heart sound clear, no murmur, soft abdomen, no rigidity or rebound tenderness, 4 limbs
muscle tone is intact, reflex intact.
CT scan result show Sella turcica & posterior fossa have cystic tumor associated with sellar
calcification, Hydrocephalus.
Definite diagnosis is Craniopharyngioma from sellar turcica invade to brain stem associated with
Cystic lesion, hydrocephalus and sellar calcification.
Treatment plan is 10/8/2017 Surgery for excision of tumor around sellar turcica area and
drainage of cystic tumor.
If excision is not clear may need radiotherapy.
11/8/2017 Follow up by CT scan, exam optic nerve function, Hormone replacement may require
after surgery.
