LAPORAN INTENSIF 11 JANUARI 2022

BED NAME SEX AGE POD / PH GCS/CCS GCS/CCS DIAGNOSIS PROCEDURE PROBLEM THERAPY KS
INITIAL TODAY

GICU 1 WING A

Post Craniectomy Decompression + Evacuation due to

Moderate Head Injury + close linear fracture at left Craniectomy Nasal Canul 3 lpm
temporoparietal SDH traumatic at Left Decompression +
Bed 3 L POD 2 Frontotemporoparietal Evacuation FY
Tn. Asep 44 yo E3M5V4=12 E4M6V4=14 Advice :
ICD10: Traumatic Subdural Hemorrhage (S06.5); ICD9 : Craniectomy Move to general
Concussion (S06.0); initial encounter for closed fracture (01.25) ward
(S02. 91XA)

Ventilator Mode
Supratentorial SOL at Sellar Region extend to Suprasellar Trans Sphenoid
Tumor Removal CPAP (PEEP 5 FiO2
due to suspect TSM DD/ MAH 50%)
Breathing
Bed 5 Ny. Mulyati P 52 yo POD 1 GCS 15 E4M6VT=10T ICD9: Trans Polyuria RS
Advice :
ICD10: Intracranial, space-occupying (R90.0); Benign sphenoidal approach Weaning
neoplasm of brain, unspecified (D32.9) (07.65) Urine Collection

Ventilator mode
PS (PS10 PEEP 5
FiO2 50%)
Acute Non Communicating Hydrocephalus due to
Spontaneous SAB + IVH due to Suspect Aneurysm VP Shunt Blood Pressure
Breathing
Tn. Ahmad Rupture DD/ Hypertension + Hypertension Emergency + Hypertension Regulation
Bed L POD 2 GCS 2M4V2 = Hypernatremia ICD9 : AD
11 Fauz 71 yo GCS E4M5VT=9T Hypoalbuminemia
8 Ventricular shunt Advice :
Hypernatremia
ICD10: Hydrocephalus (G91.9); Nontraumatic (02.34) Albumin
subarachnoid hemorrhage (160.9); Cerebral aneurysm correction
(I67.1); Hypertension (I10.1); Hypernatremia (E87.0) Electrolyte
correction
Thorax X-Ray
BED NAME SEX AGE POD / PH GCS/CCS GCS/CCS DIAGNOSIS PROCEDURE PROBLEM THERAPY KS
INITIAL TODAY

NICU
ventilator dengan
mode PC(F40 R40
PC10 peep 5 FiO2
Respiratory failure due to Sepsis(improvement) + Right 50%)
Bronchopneumonia + Macrocephaly + Ventriculomegaly
R/ EVD Sepsis
+ Meningocele at Mid Occipital + Preterm Infant 35 Antibiotic Therapy
  Macrocephaly
Weeks + Low Birth Body Weight + Necrotizing TC Transfusion
Enterocolitis Grade II + Anemia + Thrombocytopenia + ICD 9 : Insertion or Respiratory Failure
Bed 3 By. Ny. Sri P PH 17 CCS 11 / pGCS CCS E21M3VT/ replacement of Spectic shoc MS
Hartini 17 Days 15 Hyperbilirubinemia Advice:
pGCS E2M4VT=6T external ventricular Anemia
Trombositopenia X-ray thorax
ICD 10: Respiratory failure (J96. 90); drain (EVD) (02.21)
Hypoalbuminemia Antibiotik
bronchopneumonia (J18. 0); macrocephaly (Q75.3); evaluation
Right
meningocele (Q05.9); unspecified anemia (D64.9); Bronchopneumonia Albumin
Trombocytopenia (D69.6); Hyperbilirubinemia (E80.6) Correction
PRC transfusion
BED NAME SEX AGE POD / GCS/CCS INITIAL GCS/CCS TODAY DIAGNOSIS
PH

GICU WING A

Post Craniectomy Decompression + Evacuation due to Moderate

Head Injury + close linear fracture at left temporoparietal SDH
Bed 3 L 44 POD 2 traumatic at Left Frontotemporoparietal
Tn. Asep E3M5V4=12 E4M6V4=14
yo
ICD10: Traumatic Subdural Hemorrhage (S06.5); Concussion
(S06.0); initial encounter for closed fracture (S02. 91XA)

PROCEDURE PROBLEM THERAPY KS

GICU WING A

Nasal Canul 3 lpm

Craniectomy Decompression +
Evacuation
FY
Advice :
ICD9 : Craniectomy (01.25) Move to general ward
Thorax X-Ray at Hasan Sadikin Hospital, Bandung Thorax X-Ray at Hasan Sadikin Hospital,
Bandung
January, 11th , 2022 January, 7th , 2022

Within Normal Limit Within Normal Limit

Non- Contrast Head CT-Scan at Hasan Sadikin Hospital, Bandung
January 7th, 2021
BED NAME SEX AGE POD / GCS/CCS INITIAL GCS/CCS TODAY DIAGNOSIS
PH

GICU

Supratentorial SOL at Sellar Region extend to Suprasellar due to

suspect TSM DD/ MAH
Bed 5 P 52 POD 1
Ny. Mulyati GCS 15 E4M6VT=10T
yo
ICD10: Intracranial, space-occupying (R90.0); Benign neoplasm of
brain, unspecified (D32.9)

PROCEDURE PROBLEM THERAPY KS

GICU

Ventilator Mode CPAP (PEEP 5 FiO2 50%)

Trans Sphenoid Tumor Removal
Breathing Advice : RS
ICD9: Trans sphenoidal approach Polyuria Weaning
(07.65) Urine Collection
Thorax X-Ray at Hasan Sadikin Hospital, Bandung Thorax X-Ray at Hasan Sadikin Hospital,
Bandung
November, 11th , 2021 November, 29th , 2021

Within Normal Limit Within Normal Limit

Contrast Head CT Scan at Cicendo Hospital, Bandung
September 14th, 2021
Contrast Head CT Scan at Cicendo Hospital, Bandung
September 14th, 2021
Contrast Head MRI at Hasan Sadikin Hospital, Bandung
November 2nd, 2021
Contrast Head MRI at Hasan Sadikin Hospital, Bandung
November 2nd, 2021
Contrast Head MRI at Hasan Sadikin Hospital, Bandung
November 2nd, 2021
BED NAME SEX AGE POD / GCS/CCS INITIAL GCS/CCS TODAY DIAGNOSIS
PH

CICU

Acute Non Communicating Hydrocephalus due to Spontaneous

SAB + IVH due to Suspect Aneurysm Rupture DD/ Hypertension +
Bed 71 POD 2 Hypertension Emergency + Hypernatremia
Tn. Ahmad Fauz L GCS 2M4V2 = 8 GCS E4M5VT=9T
11 yo
ICD10: Hydrocephalus (G91.9); Nontraumatic subarachnoid
hemorrhage (160.9); Cerebral aneurysm (I67.1); Hypertension
(I10.1); Hypernatremia (E87.0)

PROCEDURE PROBLEM THERAPY KS

CICU

Ventilator mode PS (PS10 PEEP 5 FiO2

50%)
VP Shunt Breathing Blood Pressure Regulation
Hypertension AD
ICD9 : Ventricular shunt (02.34) Hypoalbuminemia Advice :
Hypernatremia Albumin correction
Electrolyte correction
Thorax X-Ray
Thorax X-Ray at Hasan Sadikin Hospital, Thorax X-Ray at Hasan Sadikin Hospital, Bandung
Bandung
January, 6th , 2021 January, 10th , 2021

Cardiomegaly Right Bronchopneumonia

Contrast Head CT Scan at Hasan Sadikin Hospital, Bandung
January 6th, 2022
BED NAME SEX AGE POD / GCS/CCS INITIAL GCS/CCS TODAY DIAGNOSIS
PH

NICU

Respiratory failure due to Sepsis(improvement) + Right

Bronchopneumonia + Macrocephaly + Ventriculomegaly +
Meningocele at Mid Occipital + Preterm Infant 35 Weeks + Low
CCS E1M3VT=4T/ Birth Body Weight + Necrotizing Enterocolitis Grade II + Anemia +
Bed 3 By. Ny. Sri Hartini P 17 PH 17 CCS 11 / pGCS 15 pGCS Thrombocytopenia + Hyperbilirubinemia
Days
E2M4VT=6T
ICD 10: Respiratory failure (J96. 90); bronchopneumonia (J18. 0);
macrocephaly (Q75.3); meningocele (Q05.9); unspecified anemia
(D64.9); Trombocytopenia (D69.6); Hyperbilirubinemia (E80.6)

PROCEDURE PROBLEM THERAPY KS

NICU

ventilator dengan mode PC(F40 R40 PC10

peep 5 FiO2 50%)
Sepsis
R/ EVD Macrocephaly Antibiotic Therapy
  Respiratory Failure TC Transfusion
ICD 9 : Insertion or replacement of Spectic shoc MS
external ventricular drain (EVD) Anemia Advice:
(02.21) Trombositopenia X-ray thorax
Hypoalbuminemia Antibiotik evaluation
Right Bronchopneumonia Albumin Correction
PRC transfusion
Thorax X-Ray at Hasan Sadikin Hospital, Bandung Thorax X-Ray at Hasan Sadikin Hospital,
Bandung
January, 08th , 2022 December, 30th , 2021

Bilateral Bronchopneumonia Right

Bronchopneumonia
Abdominal X-Ray at Hasan Sadikin Hospital, Bandung
December 23rd , 2021

Necrotizing Enterocolitis Grade II

Head Ultrasonography at Hasan Sadikin Hospital, Bandung
December 24th , 2021

Suspect Hydrocephalus
Suspect Holoprosencephaly
Contrast Head MRI at Hasan Sadikin Hospital, 29th, December, 2021
Contrast Head MRI at Hasan Sadikin Hospital, 29th, December, 2021
Contrast Head MRI at Hasan Sadikin Hospital, 29th, December, 2021
THANK YOU