IDENTITY OF PATIENT

• Name : Mr. YD
• Sex : Male
• Age : 30 years old
• No MR : 52 09 41

1
ANAMNESIS
 Chief complain : Unconscius
 History of disease:
The patient came with complaint unconscius at the date 4 december 2019. patients complained
of headache since 2 months before entering the hospital. headaches felt disappear and arise
increasingly heavy at 1 week before entering the hospital.
now the patient has a headache

2
PHISYCAL EXAMINATION
General state : severe illness
GCS : E4V5M6
Blood Pressure : 110/60 mmHg
Pulse : 60x/minute
RR : 21x/minute
S : 36,7 C
 SECONDARY SURVEY

Head : Normocephal, bruise (-), bleeding (-), swelling (-), deformity (-),
Eye : anemic conjungtive(-/-), icteric sclera(-/-), bruise (-/-)
Ear : otorhagia (-/-)
Nose : Rhinorea (-/-), blood (-/-)
Mouth : pale (-) ,cyanosis (-)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : symmetrical chest expansion , lesion (-) bruise (-) wound (-)
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultasi : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)

4
Abdomen:
 Inspection : flat, symetric,
 Ausculation : bowel sound (+) normal
 Palpation : Supel, organomegaly (-)
 Percussion : Tympanic
Extremities:
 Warm
 edema (-/-)
 CRT < 2 sec

5
 ASSESMENT
 SOL supratentorial

7
 PLANNING
 Pro

8
IDENTITY OF PATIENT
• Name : Mr. MS
• Sex : Male
• Age : 41 years old
• No MR : 52 08 04

9
ANAMNESIS
 Chief complain :cramps all over the right side of the body
 History of disease: patient came with complaints of cramps in the right half of the body to the
nerve poly which also has seizure in july and there was another seizure in September. Then CT
scan is done. and from the CT scan there is a mass in the brain and is consulted to the
neurosurgery department.

10
PHISYCAL EXAMINATION
General state : moderate illness
GCS : E4V5M6
Blood Pressure : 110/80 mmHg
Pulse : 72x/minute
RR : 18x/minute
S : 36,8 C
 SECONDARY SURVEY
Head : Normocephal, bruise (-), bleeding (-), swelling (-), deformity (-),
now it has been operated on and there are bandaged wounds and drain drains
Eye : anemic conjungtive(-/-), icteric sclera(-/-), bruise (-/-)
Ear : otorhagia (-/-)
Nose : Rhinorea (-/-), blood (-/-)
Mouth : pale (-) ,cyanosis (-)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : symmetrical chest expansion , lesion (-) bruise (-) wound (-)
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultasi : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)

12
Abdomen:
 Inspection : flat, symetric,
 Ausculation : bowel sound (+) normal
 Palpation : Supel, organomegaly (-)
 Percussion : Tympanic
Extremities:
 Warm
 edema (-/-)
 CRT < 2 sec

13
 ASSESMENT
 SOL Supratentorial

15
 PLANNING
 Pre op:
 Pro craniotomi tumor removal
 Premed inj. Ceftriaxon 1 gr
 Post Op:
 Obs. GCS and vital sign
 Head up 30 degree
 O2 2-4 lpm via nasal canul

change pads per day
 IVFD NS 0,9 % 1500 cc/24 jam
 Inj. Ketorolac 2 x 30 mg
 Inj. Omeprazole 1 x 40 mg
 Inj. Kalnex 3 x 100 mg
 Inj. Manitol 4 x 100 cc
16
IDENTITY OF PATIENT
• Name : Mr. JR
• Sex : Male
• Age : 52 years old
• No MR : 44 91 09

17
ANAMNESIS
 Chief complain : head bone shape that is not appropriate
 History of disease:
Patients present with complaints of deformity of the head bone that is not appropriate. the patient
is a post cranioectomy in August 2019

18
PHISYCAL EXAMINATION
General state : moderate illness
GCS : E4V5M6
Blood Pressure : 110/80 mmHg
Pulse : 84x/minute
RR : 20 x/minute
S : 36,8 degree C
 SECONDARY SURVEY
Head : there is a bone bulge in the right temporal region
Eye : anemic conjungtive(-/-), icteric sclera(-/-), bruise (-/-),
Ear : otorhagia (-/-),
Nose : Rhinorea (-/-), blood (-/-)
Mouth : pale (-) ,cyanosis (-)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : symmetrical chest expansion , lesion (-) bruise (-) wound (-)
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultasi : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)

20
Abdomen:
 Inspection : flat, symetric,
 Ausculation : bowel sound (+) normal
 Palpation : Supel, organomegaly (-)
 Percussion : Tympanic
Extremities:
 Warm
 edema (-/-)
 CRT < 2 sec

21
 ASSESMENT
 post craniotomy bone defects

22
 PLANNING
 Pre op:
 Pro Cranioplasty
 Premed inj. Ceftriaxon 1 gr
 Post Op:
 Obs. GCS and vital sign
 Head up 30 degree
 O2 2-4 lpm via nasal canul
 change pads POD 2
 IVFD NS 0,9 % 1500 cc/24 jam
 Inj. Ceftriaxon 2 x 1 gr
 Inj. Ketorolac 2 x 30 mg
 Inj. Omeprazole 1 x 40 mg
 Inj. Kalnex 3 x 100 mg
23
IDENTITY OF PATIENT
• Name : Mrs. JR
• Sex : female
• Age : 78 years old
• No MR : 52 33 83

24
 Chief complain:
 History of disease: Referral traffic accident patient from Naibonat Hospital with a diagnosis of
moderate head injury. the patient was hit by a motorcycle at 07.00 a.m while walking.
Motorcycle from the opposite direction of the patient. The patient fainted for 1 hour and was
also accompanied by vomiting 3 times containing brown water and stolsel, not spraying.
Blood from the left ear and there are also sores on the right cheekbone and bruises on the right
eye.
PHISYCAL EXAMINATION
General state : moderate illness
GCS : E3V3M5
Blood Pressure : 110/80 mmHg
Pulse : 84x/minute
RR : 20 x/minute
S : 36,8 degree C
 SECONDARY SURVEY
Head : hematoma wrapped in gauze in the temporal sinistra
Eye : anemic conjungtive(-/-), icteric sclera(-/-), bruise (-/-), racoon ayes on the right eye
Ear : otorhagia (-/+) blood, bleeding (-)
Nose : Rhinorea (-/-), blood (-/-)
Mouth : pale (-) ,cyanosis (-)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : symmetrical chest expansion , lesion (-) bruise (-) wound (-)
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultasi : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)

27
Abdomen:
 Inspection : flat, symetric,
 Ausculation : bowel sound (+) normal
 Palpation : Supel, organomegaly (-)
 Percussion : Tympanic
Extremities:
 Warm
 edema (-/-)
 CRT < 2 sec

28
 ASSESMENT
 SDH Minimal

29
 PLANNING
 Plug NGT and catheter
 O2 2-4 lpm via nasal canul
 IVFD Frutrolit1500 cc/24 jam
 Inj. terfacef 1 x 1 gr
 Inj. Ketorolac 2 x 30 mg
 Inj. Omeprazole 1 x 40 mg
 Inj. plasminex 3 x 500 mg
 Vit. K 3 x 10 mg
 Manitol 4 x 125 cc
30
THANK YOU

32