24022016 jd
TRANSCRIPT
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Konsulen Jaga : dr. Agung Budi
Sutiono, Ph.D Sp.BS
Jaga Rumah : dr. Bobby W Hasan.
Jaga : dr. Andi !ugraha S.
Jaga " : dr. Jusu# Desman B.
Jaga $ : dr. % &hsan 'irdaus.
Jaga ( : dr. Rendy Badri.
!eurosurgery ReportWednesday, ")th 'ebruary "*+
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New Patient : 3
Emergency Patient : -
Urgent Consult : 1
Emergency Operation : 1
Pre – Op : 2
Post – Op : 2
Death Case : -NCCU!CUP!CU"CU #!$%!C:&-2--
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New Patient
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!P . By. Aisah S')mo+*+*-)Pediatri%S
// : Head 0nlargment
History :
()out * months prior to a+mission, the parentsnotice+ that their )a)ys hea+ loo. )igger than other)a)ies/ 0he hea+ .eep getting )igger until now/ "istoryo omiting -4, sei5ure -4, an+ eer -4/ 6ecause o thecomplaint the )a)y was )rought to NeurosurgeryOutpatient Unit in "asan 7a+i.in "ospital an+perorme+ "ea+ C0 7can/
0he )a)y was )orn rom P8(9 mother, aterm, helpe+)y o)stetrician, spontaneous +eliery with acuum,+irectly crying, 66 2/;99 gr/
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1eneral States :
"# : 129
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4hora3 5 Ray at Hasan Sadi6in Hospital'ebruary th "*+
Within normal limit
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Head /4 san at Hasan Sadi6in Hospital'ebruary, $rd "*+
• Cortical mantle -4
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WD "y+rancephalyICD 10 : Other Congenital Hydrocephalus (Q03.8)
4h Plan to P-7hunt
CC7 this morning: 11 $emuning 2n+ ar+
2ab Result
") 12/;
"t 3@Beu 1*/;99
0hro *31/999
2aboratory7ndings :
2ab Result
Na 13F
$ &/96loo+
Glucose19*
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K8 : Penurunan KesadaranAnamnesis : H 19 Iam 7%#7 .eti.a os se+ang +i)onceng nai. motor +i+aerah%alang)ong +engan helm >4, ti)a-ti)a motor pasien +iserempet oleh tru.+ari arah +epan sehingga os terlempar +engan .epala mem)entur aspal,pingsan >4, muntah >4, per+arahan telinga -4, hi+ung -4, mulut -4/Pasien lalu +i)awa .e #7UD +r 7lamet Garut, lalu +iruJu. .e !nstalasi gawat
+arurat #7/ "asan 7a+i.in 6an+ung +engan am)ulance +an perawat/
Primary Sur9ey :(: Clear, C-spine control6: ##: 2* 4
!P." 'ahmi .) thM(;))$4raumaAB
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'oto /er9ial dan 4hora3 di RS Hasan Sadi6in") 'ebruary "*+
Dalam 6atas Normal
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/4 San Kepala di RS Hasan Sadi6in ") 'ebruari"*+
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• Pem)eng.a.an Jaringanluna. +i rontoparietal.anan
• 0ampa. +is.ontinuitastulang +i regio
rontoparietal .anan• 7ulcus an+ girus
ter.ompresi
• 7ylan ssure entri.elter.ompresi
• Cisterna se)agianter.ompresi
• Gam)aran 7alt +an Pepper+i regio rontoparietal.anan
• %i+line shit -4
/4 San Kepala di RS Hasan Sadi6in ") 'ebruari"*+
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D Ce+era $epala 7e+ang > ?ra.tur tertutup linier arrontoparietal +e Contusio cere)ri arrontoparietal .anan > E+ema Cere)ri
ICD 10 : Concussion (0!.0)" #ocal $rain In%ury (0!.3)"#racture o& 'ault o& sull (0.0)" Cere*ral +de,a
(-3.!)
4h $onserati
") 12,;
"t 3@
Beu 1*/999
0rom) *31/999
2aboratorium:
Ur$r 1&9,3&
Na$ 13F&
GD7 19*
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K8 : Penurunan Kesadaran
Anamnesis : H 1 Jam 7%#7 .eti.a os se+ang mengen+arai sepe+a motor +i+aerah Cihampelas +engan helm >4, ti)a-ti)a motor pasientergelincir +an pasien terJatuh +engan .epala mem)entur aspal,pingsan >4, muntah >4, per+arahan telinga -4, hi+ung >4, mulut-4, riwayat !nto/ %otoric: no paresisSeondary Sur9ey:#egio nostril : rhinorrhagi >4
#egio palper)ra superior et inerior : / laserasi >4u.uran 3
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'oto /er9ial dan 4hora3 di RS HasanSadi6in") 'ebruary "*+
Dalam Batas !ormal
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'oto Shaedel di RS Hasan Sadi6in ") 'ebruari"*+
4ida6 ada garis #ra6tur
b i
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DCe+era $epala 7e+ang > (l.ohol !nto.si.asi > ulnusBaserasi ar palpe)ra superior et inerior
ICD 10 : Concussion (0!.0)" /lcohol Intoication (#10.1)"Open ound on the in (281.31)
4h O)serasi $etat NC4
De)ri+ement > 7uture primer Plastic4
GC7 pagi ini E3%8*: 13 E%G
menun u ruan an
") 13,&
"t *9
Beu 11/*99
0rom) *31/999
2aboratorium:
Ur$r 1&9/3&
Na$ 13@3/@
GD7 19*
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Emergency Patient
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Urgent Consult
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8/ . By. Arsyila !'*mo)))*""Pediatri%S
The patient was consulted from Pediatric
Department // : Head de#ormity
History :()out 19 months prior to a+mission when the )a)y
was )orn, the parents notice+ that their )a)ys hea+loo. +ierent than other )a)ies, the hea+ shape li.e acloer lea/ 0he hea+ shape not return to normal untilnow / "istory o omiting -4, sei5ure -4/
"istory o cough >4 an+ eer >4 a)out 19 +ays
prior to a+mission/ 6ecause o the complaint the )a)ywas )rought to Pe+iatric Departmen in "asan 7a+i.in"ospital an+ consulte+ to Neurosurgery Department/
0he )a)y was )orn rom P2(9 mother, aterm, helpe+
)y o)stetrician, sectio caesarean, +irectly crying, 662/;99 gr/
i l 0 i ti
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1eneral States :
"# : 139
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4hora3 5 Ray at Hasan Sadi6in Hospital'ebruary "(th "*+
Bronhopneumonia Bilateral
2 b t
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WD Pancraniosynostosis > 6ronchopneumonia > aricella >(cute $i+ney !nJury
ICD 10 : Craniosynostosis (Q4.0)" $ronchopneu,onia (518.0)"6aricella ($01.0)"
/cute 7idney In%ury (1.)
4h Plan to "ea+ C0 7can > 7uturectomy NC4
!mproe General Con+ition Pe+iatric4
2ab Result
") 19/F
"t 3*Beu 29/*99
0hro 33;/999
2aboratory7ndings :
2ab Result
Na$ 1313/;
UrCr 8*1/3&6loo+
Glucose;3
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Pre Operatie
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Pre =p
1/ Ny/ Qernawati P &1 thn 1898918& $emuning * (6
D$ 7upratentorial 7OB at #ight Parietal +ue to
susp/ Cone
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Post Operatie
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Post =p
1/ 0n/ (pit ** th % 1898912F %7
D. 7OB 7upratentorial at lettemporoparietal +ue to 7usp/ "ighGra+e Glioma
0h 7tereotactic 0umor #emoal
DO at Bet 0emporoparietal:
• +itemu.an massa tumor hasil )iopsi
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Post =p
2/ 0n/ #i+wan Perma+i 33 th B 18989118 (6
D. oun+ +ehiscence at rontal +ue to rupture )ul)iOD7 > ?racture Be ?ort !!!
0h Craniotomy +e)ri+ementDO ar rontal:
• Ditemu.an pus )erwarna putih .e.uningan ,.ental
• Ditemu.an )atas – )atas ine.si
•
Ditemu.an tulang rapuh, .e.uningan• Ditemu.an +uramater putih, inta., ti+a. tegang
• Ditinggal.an +ee. tulang u. H 12 < * cm
• GC7 pre op : 1&
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Emergency Operation
By 4io > mo 2 (;*
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By. 4io > mo 2 (;*
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NCCU
6e 7e (g POD GC7
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6e+
Name7e<
(ge
POD "#
GC7initial
GC7 to+ay Diagnosis Proce+ure Pro)lem 0herapy $7
!//8
1 Di.+i. %18yo
POD1
E2%&2K ;
E3%&* K12
%o+erate "ea+ !nJury > 7.ull )aseracture let me+ia
ossa > 7u)+ural "ematoma atright
temporal
ICD 10 : Concussion (0!.0)"#racture o& *ase o& sull
(0.1)" 2rau,atic DH (0!.4)")
CraniotomyEacuation
91/2*4
#Pin+ahruangan
)iasa
(6
2Eman
#%
*3yo
POD23
1&33333R*****99999R
99999
E*%80c*****R*****11111R
11111
%ultiple "NP at leel erte)ra
cerical
C*-C&, C&-C8, C8-CF >
)ronchopneumonia
ICD 10 : Cer'ical disc disorder
unspeci;ed ,id
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6e+
Name7e<
(ge
POD "#
GC7CC7initial
GC7CC7 to+ay
Diagnosis Proce+ure Pro)lem 0herapy $7
P&/8
1 ?atir % 1mo
POD2
E2%32tK F
E3%3tK8t
7pontaneus 7D" at let?rontotemporoparietooccipitalan+ interhemispheric +ue to
7usp/ (PCD
ICD 10 : Other intracranial(nontrau,atic) he,orrhages o&ne*orn (>4.8) ? /c@uiredcoagulation &actor de;ciency
(D!8.A) ? 6ita,in 7 de;ciency o&ne*orn (>43)
CraniotomyEacuation
91/2*46reathing
entilator%o+e
7!%-P7,?iO2 39S,PEEP &, !PB19, ## 3&
%7
2 0io %1
moPOD
9E2%3%2
K F
DPO$esan
E2%3tK&t
7pontaneus 7D" at let?rontotemporoparietooccipital >!C" at let 0emporoparietal +ue
to 7usp/ (PCD > "yponatremia >
(nemiaICD 10 : Other intracranial(nontrau,atic) he,orrhages o&
ne*orn (>4.8) ? /c@uiredcoagulation &actor de;ciency
(D!8.A) ? 6ita,in 7 de;ciency o&ne*orn (>43) ? Hypo8.1)" /ne,ia unspeci;ed (D!A.)
CraniotomyEacuation
91/2*46reathing
") post op: 19,8 gr+l
entilator%o+e
7!%-P7,?iO2 *9S,PEEP &, !PB&, ## 3&
%7
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Konsulen Jaga : dr. Agung Budi
Sutiono, Ph.D Sp.BS
Jaga Rumah : dr. Bobby W Hasan.
Jaga : dr. Andi !ugraha S.
Jaga " : dr. Jusu# Desman B.
Jaga $ : dr. % &hsan 'irdaus.
Jaga ( : dr. Rendy Badri.
4han6 ou