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KERAJAAN MALAYSIA

SIJIL KELAHIRANAkta Pendaftaran Kelahiran dan Kematlan. 1957

[Seksyen 14. Kaedah 7]

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061125 - 07 - 0213

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Kawasan Pendaftaran Pusat Pendattaran

PULAU PINANG

JPN GEORGETOWN

KANAK-KANAK

Nama PUVARASANTarikh dan Waktu Kelahiran

Jantina25 NOVEMBER 2006

02:52 AMLELAKI

Tempat Kelahiran

Tarat Kewarg~negaraanHOSPITAL BERSALIN P PINANG

WARGANEGARA----SAPANama SEt VARAJA AlL KR!SHNAN

II ,No. Kad PengenalanUmJrJenis dan No. Dokumen Lain

780926 - 08 - 5475

28 TAHUN-Tidak Berkenaan-

Tarat Pemastautin

KeturunanAgamaWARGANEGARA

INDIAHINDU

ISUNama Kill MOll AlP VIJIAN

No. Kad Pengenalan

UmurJenis dan No. Dokumen Lain830918 - 07 - 5544

23 TAHUN-Tidak Berkenaan-

Tarat Pemastautin

KeturunanAgamaWARGANEGARA

INDIAHINDU

Tempat Tinggal

I12 BLORONG SEMPADAN ENAM11400AVER (TAM

PULAU PINANG

81660

Disahkan bahawa maklumat di atas adalah serertiNo. Daftar

. BU

yang dioatat dalam Dta, KelahimnTarikh Pendaftaran

01 DISEMBER 2006"""",Mi.--.'"-. -' ..r

,PENDAFTAR BESAR

KELAHIRAN & KEMATIAN MALAYSIA

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(PER·PD 302)

DISCHARGE SUMMARYCONFIDENTIAL

HOSPITAL., .

I. NAME 2. RN 3. IIC No. 4. DATE OF BIRTH

5. ADDRESS 6.

?:; ~ ()I Y L' 7 ss Y If'SEX I 7. DATE OF

ADMISSION8. DATE OF

DISCHARGE

9. FINAL DIAGNOSIS

10. SUMMARY

(Including history, physical signs, relevant investigations. clinical course, treatment. medical leave, disability CIC.

Please use appendix if necessary)

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II. NAME OF MEDICALOFFICERIIC NUMBER

14. OFFICIAL CliOI'

PNMB., K.L.

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12. SICiNATUlm \

.13. DATE C( 1(,/ u ~

HOSPITAL KUALA LUMPURJABATAN PATOLOGIJalan Pahang, 50586 Kuala Lumpur

LAPORAN MAKMAL'

GIRCPA~]~~~ Tht!oralCo~oC~lbaIopmrlAnmluia

ACCREDITATION NO : 14845

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----------------------------------------------------------------------

NamaNo. K/PUmurJantinaKeturunanwad/Klinik:Diagnosa

PUVARASAN SELVARAJA A/L83091807554411 No. Makmal1 Year Sampel diambilMale Sampel diterima:

Peminta Ujian

HOSP KL WAD NWl7 (17)

08 - 129043013/03/08 14:0013/03/08 15:07

HISTOPATHOLOGYHPE NO: 4205/2008MACROSCOPIC:Dimension: Anteroposterior (26mm), Horizontal (27mm),

Vertical (25mm).

Length of optic nerve: 4mmTumour: SolitarySize/dimension: 18x15x20mmGross involvement of ocular structures: NoLocation: posterior chamberGross extension into optic nerve: CloseRepresentative sections are submitted as follows:

Block 1: optic nerve margin (cross section)2&3: cross section of the eyeball

NoNoNoNoNo

NoNoNo

MICROSCOPIC:Arrangement of tumour cells: Diffuse sheetsGrowth pattern: MixedLevel of invasion:

Bruch's membrane: No(if no, then is purely retinal)Superficial aspect of choroid:Choroidal vesselsDeep aspect of choroidSclera and extrascleral tissue:

Optic nerve headLamina cribrosaExcision margin of optic nerve:Tumour into anterior compartment:

Excision is complete."-

DIAGNOSIS:Left eye: Retlnoblastoma.

Dicetak

ditaip: 27/3/2008 @ 8.35amNot legible

DateNa.T XX M 91503Tarikh/masa laporanRequesting doctor:

08:4927/03/08

Yusoff/v~ .Dr. Haryati Husin/Dr. suryati Mohd.

(M.O.) (Pathologist)of reporting: 25/3/2008

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JABATAN PERK}-""'"'jv1ATANPENGIMEJAN DIAGNOSTIK HOSPITAL (- \ ~ "l> (PER SS-RA 301)

BORANG Pr.RMOHONAN PEMERIKSAAN RAD10LOGI \'>:J.

(Sila isi da/am 2 salinan)

KEGUNAAN JABATAN

:. No. Kad Pengenalan 14. K~runan~ t Iv~ - 01 ...(})../3 l..AJ

7. Umur 125. Bilik

131n-26. Waktu Terima

27. Juru X-Ray

23. Tarikh 124. No. X-Rayo 9 rlAR 200h {Jl'.2

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;. No. Pendaftaran Hospital

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2. Pegawai Kerajaan

o Ya ..0 Tidak

5. AsmalAlergi

13. Kelas

16. Berat Badiin

i4. Bayaran 129. Ukuran dano Bayar' 0 Percuma Jumlah Filem

17. Mengandung

o Ya 0"Tidak

30. WaktuSelesai

32. Temujanji

31. Komen

'" h h-e

fo Angio

19. Mudah Gerak

oOM.R.1.

o Berjalan Kaki

o Lain-lain (Sila Nyatakan)

'r 7 ,~//10.;;

o Ultrasound

L t'.{ -\ \/\ <, \(Jv.~"'\-A"""

Nyatakan Bahagi~~ :" •

~1. Data Klinikal

LMP 6.

.8. Keadaari P~sakit .

o Kerusi Roda . 0 Troli

.9. PEMERIKSAAN

OX-Ray

----EJC.r. /</' ,""

Both globes show normal size and shape. No proptosis noted. There is an ill defined lesion in the

retrolental region of left globe. It is associated with coarse calcification. This is suggestive of leftretinoblastoma. There is also an irregular mass in the retrolental region/vitreous chamber of rightglobe. No significant enhancement seen. It measures 9mmx 8mm. No calcification seen within.This may represent right retinoblastoma. Differential is toxocara infection.Both intraconal and extraconal fat planes appear normal bilaterally. Both optic nerves appearsymmetrical with no focal lesion seen. No lens dislocation seen. Cavernous sinus enhancesnonnall. No focal lesion seen in brain parenchyma. No mass effect or midline shift noted.

Ventricles appear nonnal. No hydrocephalus seen. No abnormal enhancement seen.Basal cisterns appear nonnal. Normal gray white matter differentiation .

. '¥,. I

Imp: Left intraocular calcified lesion and right intraocular W~Ss!:~.~atll~e·Sare suggestive of

bilateral retinoblastoma. Please correlate clinic,\~ly:~':,~:.,.::.:<.:".:, __"i.'

.~\\·.i':\ \.',:~~~:_~'_',.·,,~,:·:,.\>£·'.:uuu 0 .. \ ,,'~:'~':;.,.:," ... ,,\ . Nama, TlTangan dan Cop Pakar Radiologi

Tarikh: ,.~711J~f .

Complete respond /Partial respond fNo respond /Progressive disease

Fonn complete b

J. Next EUADate:

Treatment plan:

(joocJ nartial resoond : 90% resolution of rumour