Morning Report

Friday, November 4th 2016

Team on duty
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.
dr.

Nizarli
Munawar
Raja Raharja
Jauhari Deslo Angkasa
Muhammad Reza
Bobby HE Fermi S
Herdi Gunanta
Ahmad Muhtadi
Moch Iskandar Islam

(Chief)
(Jaga 1)
(Jaga
(Jaga 2)
(Jaga
(Jaga
(Jaga 4)
(Jaga 4)
(Jaga

2)
3)
3)
5)

Patient identity
Name
Age
Sex
Address
CM
Phone
Admission Time
Body weight

Chief complaint

:
:
:
:
:
:
:
:

By. Ratu Al Fatin

3 Months old
Girl
Ilie, Ulee Kareng, Banda Aceh
110-31-56
0852 61 38 37 24
21.00
5000 gr

Head enlargement
Patient illnes History

The patient referred from Meuraxa district hospital with chief complaint
head enlargement for 1 month
The babys parents also complaint of seizure.
The patient was born aterm by cesarean section. History of regular
antenatal care to obstretrician.
History of vomiting and nausea(-). History of fever (-)
Head CT Scan already perfomed

Physical examination
General appearance
: Moderate
Crying
: Loud
Sucking reflex
: Moderate
Grasping reflex
: Moderate
Neck Ridity
: None
HR
: 142 x/ minute
RR
: 38 x/ minute
Temp
: 36,6 C
LS at head region
I : Sunset phenomenon (+), head circumference 48 cm
P : Greater fontanella was distented
Diagnose
Hydrocephalus
Management

IVFD 4: 1 500 cc/24 hours

Laboratory examination

Laboratory result

Hb
White blood count
Platelet
Ht
CT
BT

:
:
:
:
:
:

15,9 gr/dl
14,2/ul
287/ul
37%
2minute
7minute

Radiology result
Head Ct-Scan

SCALP in normal limit

Sulcus and gyrus were narrow
Periventicle edema (+)
Ventricular system was dilated
There was no midline shift

Babygram

In normal limit

Diagnose:

Hydrocephalus

Consult to Neurosurgery Divison

VP shunt

Operation Report

Performed kocher incision at the right parietal region

Performed one burr hole, duramater was opened sharply
Inserted ventricular tube blew out LCS serenely
Tube was connected to shunt

Post Op Diagnose

Hydrocephalus

DATE

Nov
6th
2016

General
condition HR
: 138
beats/min
RR : 42
breaths/min
LS head
I : wound
was covered
by gauze
P : Chamber
was
effective

Post VP
shunt due to
:
Hydrocephal
us

IVFD 4 : 1 500 cc/ 24

hours
Inj. Ceftriaxon 250
mg/24 hours
Inj Novalgin 100
mg/8 hours

Breast feeding ad
libitum

Evaluation head
circumference