Case referred from HRPZ
Case of Cerebral metastasis lesions with possible primary from Lung lesion.
Che Kamaruzaman bin Che Ahmad
620105036155

Medical HRPZ refer at 1245H

Patient name: 
Che Kamaruzaman bin Che Ahmad

IC: 620105036155

Diagnosis: 
Brain metastasis with cerebral edema with midline shift 
- Possible Ca lung with brain metastasis 

59 years old Malay male Ex smoker

P/w severe headache 3/12
- Unable to sleep due to pain
- Worsening 3/52

Associated with:
+ Lethargy
+ Poor oral intake
+ LOW
+ On & off cough
+ Unable to walk
+ Bedbound

On arrival at HRPZ, 
Gcs full, Vitals stable 

Neurological exam: Normal 
Cranial n exam: Intact
CVS/resp/abdomen: Not significant 

CXR: Lt perihilar mass

CT brain finding: 
- Cerebral edema with left midline shift
- Imp:
Multiple brain lesions (supra and infratentorial regions) likely brain metastasis 
Ddx: Brain abscesses

Blood:
Hb 13.1 / twc 10. 9/ plt 366
Pt 13.0 / APTT 42.6 / INR 0.96
Na 135/ K 4.4 /Urea 5.5/ Cr 64

MRI and CT Staging arrangement to be done at HRPZ