Patient identity

• Name : M. Akmal

• Age : 44 years old

• Sex : Male

• Address : Bireuen

• MR : 131-77-11

• Phone : 085260476656

• Consult time : 03.30 PM

Time Response
Chief complaint

• Decrease of consciousness

Patient illness History

• The patient was reffered from Bireuen district hospital to zainoel abidin emergency room with
chief complaint decrease of consciousness since 1 day ago

• Previously the patient was sitting at his house then suddenly he complained headache and got
unconscious.

• There were history of nausea and vomiting.

• There was no hystory of seizure

• There was no history of fever.

• There was history of hypertension without regular medication

Physical examination

General condition : Moderate

Vital sign

• Blood Pressure : 150/90 mmHg

• Pulse : 94 beats/minute

• Respiratory rates : 20 breaths/minute on Ventilator

• Body temperature : 36,5 oC

• GCS : E2M4V2 (8)  Performed Intubation, isochoric pupil (3/3 mm),

light reflex (+/+)

• Motoric : unevaluable

• Sensoric : unevaluable
Radiology examination

Head CT Scan result

• There was no scalp hematoma

 • Sulcus and gyrus were narrow

• Ventricle was dilated

• There was hyperdense area in the ventricle suggest intraventricular hemorrhage

• There was hyperdense area at mecencephalon, suggest ICH

• There was no periventricular edema

• Cisterna was starting compressed

• There was no midline shift

Management

• Stop oral intake

• Head up 30°

• Performed Intubation

• Performed NGT

• IVFD NaCl 0,9 % 1500 cc/24 hours

• Metamizole sodium Inj. 1 gr

• Laboratory examination

Laboratory result :

• Hb : 17.2 gr/dL

• White blood count : 23.000/mm3

• Platelet : 377.000/mm3

• Ht : 49 %

• PT : 13.60 seconds

• APTT : 32.30 seconds

Diagnosed:

1. Intracerebral Hemorrhage at the mesencephalon due to stroke hemorrhagic (ICD 10 CM I61)

2. Intraventricular hemorrhage (ICD 10 CM I61.5)

3. Non Communicating Hydrocephalus (ICD 10 CM G91.0)

4. Hypertension stage II (ICD 10 CM I10.0)

Consult to Neurosurgery division

• VP Shunt emergency
Operation Report

• Performed semilunar incison at the right parietal region (Kocher point).

• Performed one burr hole, Dura mater was opened sharply

• Insertion ventricular tube to the right parietal region

• Pulled out LCS serous serenely

• Connected the tube from ventricular to peritoneal cavity

• Wound operation closed by primary sutured

Post Operative Diagnosed:

1. Intracerebral Hemorrhage at the mesencephalon due to stroke hemorrhagic (ICD 10 CM I61)

2. Intraventricular hemorrhage (ICD 10 CM I61.5)

3. Non Communicating Hydrocephalus (ICD 10 CM G91.0)

4. Hypertension stage II (ICD 10 CM I10.0)

 Post VP Shunt insertion