NEUROSURGERY REPORT

Sunday, October 06th, 2019

Chief on Call : dr. M. Azhary Lazuardy

Chief on Site : dr. M. Rainda Farhan

Jaga 2 : dr. Meviraf Benny Tanio

Jaga 3 : dr. M. Abdul Aziz

Jaga Stase (Bedah Umum) : dr. Albar

• New Patient :1
• Emergency Patient :3
• Urgent Consult :1
• Emergency Operation :-
• Pre Operative :2
• Post Operative :-
• Death Case :-
• Outpatient Clinic :-
• NCCU/ICU/PICU/HCU-RIK/HCU-KMG/NICU : -/-/-/-/-/-
NEW PATIENT
 NP 1. Mrs. Komariah / ♀ / 32 yo / 1793058 / Trauma / MZ
CC: Headache
History:
± 12 hours prior to admission, when she was a ridding motorcycle at
Cicalengka area, with helmet, suddenly she was strucked by a motorcycle and
fell down with her head hit the asphalt. History of unconscious (-), vomiting (-),
bleeding from ear (-), nose (+), and mouth (-). Because of the complaint, she
was brought to Cicalengka Hospital, underwent debridement and referred to
Melinda 2 Hospital Bandung, underwent Non Contras Head CT Scan, then
referred to Emergency Unit at Hasan Sadikin Hospital using a private car.
General State:
BP : 120/80 mmHg P: 88 x/minute RR: 18 x/minute S: 37.0
Local State:
At Right Frontal : Lacerated Wound, Post Suture (+)
At Left and Right Maxilla : Swelling (+), Deformity (+)
At Nostril : Rhinorrhea (+), Halo Test (+)
At Left Wrist Joint : Swelling (+), Deformity (+)
Neurological State:
GCS 15
Pupil round equal, RLO 3mm/3mm, LR +/+
Motoric parasis -/-
Laboratory Findings at Hasan Sadikin Hospital
October 06th, 2019

Labs Result
Hb 13.0
Ht 36.5
L 12270
Tr 183000
Cervical and Thorax X-Ray at Hasan Sadikin Hospital Bandung
October 06th, 2019

Within Normal Limit

Forearm X-Ray at Hasan Sadikin Hospital Bandung
October 06th, 2019

Fracture at Distal End Radius (+)

Non Contras Head CT Scan at Melinda 2 Hospital Bandung
October 06th, 2019
Non Contras Head CT Scan at Melinda 2 Hospital Bandung
October 06th, 2019
• Soft tissue swelling at mid
frontal, right and left maxilla
• Bone discontinuity (+) at right
frontal
• Sulcus and gyrus arenot
compressed
• Sylvian fissure are not
compressed
• Ventricles and cistern are not
compressed
• Midline shift (-)
WD/ Mild Head Injury + Closed Fracture Depressed > 1 lamina at Mid
Frontal + SBF Anterior + Panfacial Fracture + Closed Fracture at Left
Radius

ICD 10: Concussion (S06.0); Fractures of other skull and facial bones (S02.80);
Fracture of base of skull (S02.1); Unspecified fracture of facial bones
(S02.92X); Unspecified fracture of the lower end radius (S52.501A)

Th/ NC (Leader) : Conservative

Orthopedic : Plan for ORIF Elective
Plastic Surgery : Plan for ORIF Elective

GCS this morning: 15 EMG Ward

EMERGENCY PATIENT
 EP 1. Mr. Iyang / ♂ / 23 yo / 1793407 / Trauma / MZ
CC: Headache
History:
± 8 hours prior to admission, when he was a ridding motorcycle at Ciwidey
area, without helmet, suddenly he was lost balance and fell down with his
head hit the asphalt. History of unconscious (-), vomiting (-), bleeding from ear
(-), nose (+), and mouth (-). Because of the complaint, he was brought to
Soreang Hospital, and referred to Emergency Unit at Hasan Sadikin Hospital
using a private car.

General State:
BP : 120/80 mmHg P: 88 x/minute RR: 18 x/minute S: 37.0

Local State:
At Right Femur : Swelling (+), Deformity (+)

Neurological State:
GCS E3M6V5 = 14
Pupil round equal, RLO 3mm/3mm, LR +/+
Motoric parasis -/-
Laboratory Findings at Hasan Sadikin Hospital
October 06th, 2019

Labs Result
Hb 14.6
Ht 41.7
L 29940
Tr 354000
Skull X-Ray at Hasan Sadikin Hospital Bandung
October 06th, 2019

No Fracture Line
Femur X-Ray at Hasan Sadikin Hospital Bandung
October 06th, 2019

Fracture at right femur middle third

communitive displaced
WD/ Mild Head Injury + Closed Fracture at Right Femur Middle Third
Communitive Displaced

ICD 10: Concussion (S06.0); Unspecified Fracture of Femur (S72.91XA)

Th/ NC : Conservative
Orthopedic (Leader) : Plan for ORIF Elective

GCS this morning: 15 EMG Ward

 EP 2. Mr. Marhum / ♂ / 79 yo / 1793413 / Trauma / MZ
CC: Headache
History:
± 8 hours prior to admission, when he was a ridding motorcycle at Ciwidey
area, without helmet, suddenly he was lost balance and fell down with his
head hit the asphalt. History of unconscious (-), vomiting (-), bleeding from ear
(-), nose (+), and mouth (-). Because of the complaint, he was brought to
Soreang Hospital, underwent debridement and referred to Emergency Unit at
Hasan Sadikin Hospital using a private car.
General State:
BP : 120/80 mmHg P: 88 x/minute RR: 18 x/minute S: 37.0
Local State:
At Left Palpebra Superior : Lacerated Wound 4x1x0.5 cm, base on bone
At Nostril : Rhinorrhagia (+), Halo Test (-)

Neurological State:
GCS 15
Pupil round equal, RLO 3mm/3mm, LR +/+
Motoric parasis -/-
Laboratory Findings at Hasan Sadikin Hospital
October 06th, 2019

Labs Result
Hb
Ht
L
Tr
Skull X-Ray at Hasan Sadikin Hospital Bandung
October 06th, 2019

No Fracture Line
WD/ Mild Head Injury +

ICD 10: Concussion (S06.0); Fractures of other skull and facial bones (S02.80);
Fracture of base of skull (S02.1);

Th/ NC (Leader) : Conservative

Plastic Surgery : Plan for ORIF Elective

GCS this morning: 15 EMG Ward

 EP 3. Mr. Sopandi / ♂ / 51 yo / 1793418 / Trauma / MZ
CC: Headache
History:
± 8 hours prior to admission, when he was a ridding motorcycle at Ciwidey
area, without helmet, suddenly he was lost balance and fell down with his
head hit the asphalt. History of unconscious (-), vomiting (-), bleeding from ear
(-), nose (+), and mouth (-). Because of the complaint, he was brought to
Soreang Hospital, underwent debridement and referred to Emergency Unit at
Hasan Sadikin Hospital using a private car.
General State:
BP : 120/80 mmHg P: 88 x/minute RR: 18 x/minute S: 37.0
Local State:
At Left Frontal : Hematoma (+)
At Palpebra Superior : Hematom (+)

Neurological State:
GCS 15
Pupil round equal, RLO 3mm/3mm, LR +/+
Motoric parasis -/-
Laboratory Findings at Hasan Sadikin Hospital
October 06th, 2019

Labs Result
Hb
Ht
L
Tr
Skull X-Ray at Hasan Sadikin Hospital Bandung
October 06th, 2019

No Fracture Line
WD/ Mild Head Injury +

ICD 10: Concussion (S06.0); Fractures of other skull and facial bones (S02.80);
Fracture of base of skull (S02.1);

Th/ NC (Leader) : Conservative

Plastic Surgery : Plan for ORIF Elective

GCS this morning: 15 EMG Ward

URGENT CONSULT
 UC 1. By. Imas Masitoh / ♀ / 12 days / 1790825 / Pediatric / MS

Patient was consult from Pediatric departement

CC: shortness of breath
History:
Since birth, the parents noticed that their child had shortness of breath.
History of seizure (-), unconsciousness(-), trauma (-). Because of the
complaint since birth the patient was hospitalized by Pediatrician of Pediatric
Departement Hasan Sadikin Hospital at Intensive ward for 12 days until now
with diagnostic Preterm Infant and Respiratory Distress Syndrome . When
the patient as 9 days performed control Head USG with the result was
Germinal Matrix Hemorrhage with Hydrocephalus, and then the patient
consulted to Neurosurgery Department
Patient was born from P1A0 mother, preterm (32-33 weeks), Forceps due
to Pre Eclampsia helped by Obstricians at Hasan Sadikin hospital Bandung,
directly crying, and BBW 1750 gr. History of vitamin K Injection(+). History of
ANC (+) regularly to midwife and obstrician. History of infection during
prenatal care (-). History of drug consumption during pregnancy (-).
 Physical Examination
General State:
P: 170 x/mnt RR: 40 x/mnt Temp: 37,00 BW: 1757 gram
Ventilator mode: PC (IPL 13.0, PEEP 6 FiO2 21%)

Local State:
Head circumference: 32 cm (N: 28-33 cm)
Anterior fontanelle: opened size 4x2 cm, flat, not tense
At Thorax: Symmetry, VBS Right = Left, Rhonchi +/+, Wheezing -/-,
 Physical Examination
Neurological State:
CCS E3M4VT=7T, pGCS E3M5VT = 8T, nuchal rigidity (-)
Pupils: round equal, RLO Ø 3 mm/3 mm, LR +/+
Visus: difficult to be examined
Funduscopy: difficult to be examined
Eye ball movement: Good to all direction
Other cranial nerve: difficult to be examined
Motoric: within normal limit
Sensoric: response to pain
Physiological reflex: +/+
Babinski reflex: +/+
 Laboratory Finding at Hasan sadikin Hospital Bandung
October 01st, 2019

Labs Result Labs Result Labs Result

Hb 11.7 Albumin 2.50 PH 7.397
Ht 32.6 CRP 3.18 PCO2 24.2
L 22200 Na/K 135/4.3 PO2 73.2
Tr 255000 HCO3 15.0
tCO2 15.7
Beb -7.6
Sat O2 94.3
Thorax X- Ray at Hasan Sadikin Hospital Bandung
September 29th, 2019
Pneumonia
 Head USG at Hasan Sadikin Hospital Bandung
October 03rd, 2019

Germinal Matrix hemorrhage grade III+ Hydrocephalus

WD/ Normocephalic + Spontaneous IVH at Lateral Ventricle due to
Suspect Germinal Matrix Hemorrhage Grade III + Suspect
Hydrocephalus + Preterm Infant (32-33 week) + LBBW (Low Birth
Body Weight) + Respiratory Distress Syndrome + Sepsis Neonatorum +
Pneumonia + Hypoalbuminemia

ICD 10: Other intracranial (nontraumatic) hemorrhages of newborn (P52.8);

Preterm newborn ((P07.30); Acute respiratory distress (R06.03);
Sepsis of newborn (P36.10); Pneumonia (J18.0); Hypoalbuminemia
(E88.09)

Th/ NC : Closed Observation

Head circumference observation
Head USG Serial
Pediatric (Leader): Improve general condition and Antibiotic Therapy

CCS this morning E3M4VT=7T NICU Ward

EMERGENCY OPERATION
PRE OPERATIVE
POST OPERATIVE
INTENSIVE PATIENT
OUTPATIENT CLINIC
 THANK YOU

Chief on Call : dr. M. Azhary Lazuardy

Chief on Site : dr. M. Rainda Farhan

Jaga 2 : dr. Meviraf Benny Tanio

Jaga 3 : dr. M. Abdul Aziz

Jaga Stase (Bedah Umum) : dr. Albar