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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