NEUROSURGERY REPORT

Friday, March 15th 2019

Chief on Call : dr. Muhammad Ichsan F. Firdaus

Chief on Site : dr. Elvira Sutanto

Jaga 2 : dr. Muhammad Rainda Farhan

Jaga 3 : dr. Ayu Iswandari Raharjo

Jaga 5 : dr. Firman Nur Choliq

dr. Syailendra Fii Sulaiman

• New Patient :2
• Emergency Patient :4
• Urgent Consult :4
• Emergency Operation :-
• Pre Operative :-
• Post Operative :3
• Death Case :-
• Outpatient Clinic : 10
• NCCU/ICU/PICU/NICU/HCU-RIK/HCU-KMG :2/1/-/1/-/-
NEW PATIENT
 NP 1. Mr. Dudin S. / ♂ / 41 yo / 1722675 / Trauma / AF

CC: Bone defect

History:
± 4 months ago the patient underwent Craniectomy Decompression and
Evacuation at Hasan Sadikin Hospital after pedestrian accident, and
diagnosed with Severe Head Injury + SDH at Right Temporoparietal +
Traumatic ICH at Right Temporoparietal + Subarachnoid Bleeding + Fracture
of Left Clavicle Middle Third + Bilateral Lung Contusion. He was hospitalized
for 1 month, and sent home with weakness of left extremity. Now he came to
close his bone defect.
 Mr. Dudin S. / ♂ / 41 yo / 1722675 / Trauma / AF
Past History (06/11/2019)
CC: Decrease of consciousness
History:

3 hours before admission, History of He was brought to Local

when he was walking at
Subang area, suddenly he
was hit by a car from behind
and thrown with his head hit
the asphalt.
Clinic then referred to
unconsciousness (+),
Emergency Unit of Hasan
vomiting (+), bleeding
from ear (+), nose (+), Sadikin Hospital with private
car.
mouth (-)

Survei Primer
A : gurgling  suctioning  intubation with C-spine control
B : RR: 24 x/min, Symmetrical shape and movement, VBS right = left
C : P: 117 x/min, BP: 137/80 mmHg
D : GCS: E2M4V2 = 8  E2M4VT = 6T
Pupil round equal Ø RLO 3 mm/3 mm, LR +/+
Motoric: left hemiparesis

Secondary Survey:
At Left MAE: Otorrhagia (+), Halo test (-)
At Left Clavicle : Deformity (+), Crepitation (+)
Cervical and Thorax X-Ray at Hasan Sadikin Hospital, Bandung
November 5th, 2018

Fracture of left clavicle middle third

Bilateral lung contusion
Non Contrast Head CT Scan at Hasan Sadikin Hospital, Bandung
November 5th, 2018
Non Contrast Head CT Scan at Hasan Sadikin Hospital, Bandung
November 5th, 2018
• Soft tissue swelling at left
temporoparietal
• No bone discontinuity
• Sulci and gyri are compressed
• Sylvian fissure and ventricles
are compressed
• Cistern are compressed
• Hyperdense mass crescent
shaped at right
temporoparietal with
thickness < 1 cm
• Hyperdense mass at right
temporoparietal with volume
± 25 cc
• Perifocal edema (+)
• Hyperdense shadow (+)
• Midline shift (+) > 5 mm to
the left
 Mr. Dudin S. / ♂ / 41 yo / 1722675 / Trauma / AF
INTRAOPERATIVE FINDINGS (06 / 11 / 2018)

DO at right frontotemporoparietal :
• Tidak ditemukan garis fraktur pada tulang
• Ditemukan duramater kebiruan, intak dan
tegang.
• Ditemukan SDH clot 5 cc, lisis 5 cc
• Ditemukan ICH clot 15 cc, lisis 10 cc
• Dilakukan duroplasty menggunakan graft
pericranial
• Left bone defect 12x10 cm
• GCS pre op E1M4VT = 5T
• Interval op 16 jam
 Physical Examination

General State:
BP: 110/70 mmHg HR: 72 x/min RR: 18 x/min T: 37,3ºC

Local State:
At Right Frontotemporoparietal: bone defect size 12 x 10 cm, scar post op (+)
At Mid Frontoparietal: bone flap (+)

Neurological State:
GCS: 15, nuchal rigidity (-)
Pupils: round, equal, Ø RLO 3 mm/3 mm, LR +/+
Visus: RLO > 6/60
Funduscopy: papil defined border
Eye ball movement: good to all direction
Other cranial nerves: within normal limit
Motoric: left hemiparesis 5 1
Sensoric: within normal limit 5 1
Physiologic reflex: +/+
Pathologic reflex: babinski -/+
 Laboratory Findings

Labs Result Labs Result

Hb 14.4 Na/K 142/3.7
Ht 42.3 RBG 84
L 6.140
Tr 301.000
Skull X-Ray at Hasan Sadikin Hospital, Bandung
October 11th, 2018
Bone defect (+) at right frontotemporoparietal,
Bone flap (+)
WD/ Bone Defect at Right Frontotemporoparietal due to Post Craniectomy
Decompressive and Evacuation due to Severe Head Injury + SDH at Right
Temporoparietal + Traumatic ICH at Right Temporoparietal + Subarachnoid
Bleeding + Fracture of Left Clavicle Middle Third + Bilateral Lung Contusion

ICD 10: Disorder of bone, unspecified (M89.9); Other postprocedural status

(V45.89); Traumatic Hemorrhage of Cerebrum (S06.363); Traumatic
Subarachnoid Hemorrhage (S06.6); traumatic subdural hemorrhage
(S06.5); Fracture of Clavicle (S42.0) ; Contusion of lung (S27.329);

Th/ NC : Plan for Cranioplasty elective

ENT : Plan for Tracheostomy Tube Decanulation

GCS this morning: 15 Kemuning 5th Ward

 NP 2. Boy Andika Pratama / ♂ / 9 yo / 1751764 / Trauma / MZ
CC: Headcahe
History:
± 1 day prior to admission, when the patient was walking at Garut area,
suddenly he was hit by a motorcycle and he fell down with his head hit the
asphalt. History of unconscious (+), vomiting (-), bleeding from mouth (-), ear
(-), nose (+). Because of the complaint, he was brought to Slamet General
Hospital Garut, performed head CT Scan then referred to Emergency Unit of
Hasan Sadikin Hospital using a private car.

General States:
BP: 100/70 mmHg P: 98 x/min RR: 22 x/min T: 36,9C

Local States:
At Right Parietal: hematoma (+),
Lacerated wound 4x0.5 cm, based on fascia
Lacerated wound 2x0.5 cm, based on fascia

Neurological States:
GCS: 15
Pupils: round, equal, Ø RLO 3 mm/3 mm, LR +/+
Motoric paresis: -/-
Laboratory Findings

Labs Result
Hb 10.3
Ht 31.3
L 8.640
Tr 364.000
Head CT Scan at Slamet General Hospital, Garut
March 15th, 2019
Head CT Scan at Slamet General Hospital, Garut
March 15th, 2019
• Soft tissue swelling at right
parietal
• Bone discontinuity > 1 table at
right parietal
• Sulci and gyri are not
compressed
• Sylvian fissure and ventricles
are not compressed
• Cistern are not compressed
• Midline shift (-)
 WD/ Mild Head Injury + Closed Depressed Fracture > 1 table at Right
Parietal + Lacerated Wound at Right Parietal

ICD 10: Concussion (S06.0); Fracture of vault of skull (S02.0); Open wound of
scalp (S01.0)

Th/ Debridement and Primary Suture

Plan for Craniotomy Elevation

GCS this morning: 15 Kemuning 2nd Ward

EMERGENCY PATIENT
 EP 1. Boy Rafa / ♂ / 4 yo / 1751722 / Trauma / MZ
CC: Headache
History:
± 3 hours prior to admission, when the patient was going down the stair at
his house in Pasir Koja area, suddenly he slipped and fell down with his head
hit the floor. History of unconscious (-), vomiting (+), bleeding from mouth (-),
ear (-), nose (-). Because of the complaint, he was brought to the local clinic,
then referred to Emergency Unit of Hasan Sadikin Hospital using a private car.

General States:
BP: 90/60 mmHg P: 102 x/min RR: 24 x/min T: 36,5C

Local States:
At Mid Paritooccipital: hematoma (+)

Neurological States:
GCS: 15
Pupils: round, equal, Ø RLO 3 mm/3 mm, LR +/+
Motoric paresis: -/-
Laboratory Findings

Labs Result
Hb 11.6
Ht 32.0
L 9.770
Tr 254.000
Skull X-Ray at Hasan Sadikin Hospital, Bandung
March 15th, 2019

No Fracture Line
WD/ Mild Head Injury

ICD 10: Concussion (S06.0);

Th/ Conservative

GCS when sent home: 15 Sent Home

 EP 2. Boy Rifki / ♂ / 3 yo / 1751724 / Trauma / MZ
CC: Headache
History:
± 1 hours prior to admission, when the patient was crossing the road in
Pasteur area, suddenly he was hit by a motorcycle and fell down with his head
hit the asphalt. History of unconscious (-), vomiting (-), bleeding from mouth
(-), ear (-), nose (-). Because of the complaint, he was brought to Emergency
Unit of Hasan Sadikin Hospital using a private car.

General States:
BP: 90/50 mmHg P: 108 x/min RR: 26 x/min T: 36,8C

Local States:
At Mid Occipital: hematoma (+)

Neurological States:
GCS: 15
Pupils: round, equal, Ø RLO 3 mm/3 mm, LR +/+
Motoric paresis: -/-
Laboratory Findings

Labs Result
Hb 12.4
Ht 35.2
L 10.200
Tr 286.000
Skull X-Ray at Hasan Sadikin Hospital, Bandung
March 15th, 2019

No Fracture Line
 WD/ Mild Head Injury

ICD 10: Concussion (S06.0)

Th/ Conservative

GCS when discharged: 15 Force Discharged

 EP 3. Mr. M Jatnika K / ♂ / 19 yo / 1751751 / Trauma / MZ
CC: Decreased of consciousness
History:
± 6 hours prior to admission, when the patient was riding a motorcycle at
Cicadas area, helmet (-), suddenly he hit a car from behind and fell down with
his head hit the asphalt. History of unconscious (+), vomiting (+), bleeding from
mouth (-), ear (-), nose (-). Because of the complaint, he was brought
Emergency Unit of Hasan Sadikin Hospital using a private car.

General States:
BP: 120/70 mmHg P: 76 x/min RR: 16 x/min T: 36,9C

Local States:
At Left Frontal: excoriated wound (+), hematoma (+)
At Left Zygoma: lacerated wound 2 x 0.5 cm
based on subcutaneous
At Left Periorbital: lacerated wound (+) 1 x 0.5 cm
based on subcutaneous

Neurological States:
GCS: E3M6V5 = 14
Pupils: round, equal, Ø RLO 3 mm/3 mm, LR +/+
Motoric paresis: -/-
Laboratory Findings

Labs Result
Hb 16.1
Ht 46.5
L 13.190
Tr 234.000
Skull X-Ray at Hasan Sadikin Hospital, Bandung
March 15th, 2019

No Fracture Line
WD/ Mild Head Injury + Multiple Lacerated Wound at Left Zygoma and
Left Periorbital

ICD 10: Concussion (S06.0); Open wound of head (S01)

Th/ Debridement and Primary Suture

GCS when discharged: E3M6V5 = 14 Force Discharged

 EP 4. Mr. Surya / ♂ / 64 yo / 1751631 / Spine / RD
CC: Decrease of consciousness
History:
± 2 hours prior to admission, when the patient was working at construction
site at Buah Batu area, suddenly he slipped and fell down from 4 meters high
with his head hit the floor. History of unconscious (+), vomiting (-), bleeding
from mouth (-), ear (-), nose (+). Because of the complaint, he was brought to
Muhammadiyah Hospital, then referred to Emergency Unit of Hasan Sadikin
Hospital using a private car.
Primary Survey:
A: Clear, C-Spine control (+)
B: RR: 36 x/min, asymmetrical shape and movement, VBS right < left,
Hypersonor percussion on right hemithorax
C: BP: 90/60 mmHg, P: 122 x/min, JVP ↑
D: GCS: E3M6V4 = 13
Pupil round equal Ø RLO 3 mm/3 mm, LR +/+
Motoric: Tetraparesis
Secondary Survey:
At Nostril: Rhinorrhea (+), halo test (+)
At Cervical: tenderness (+), deformity (-)
At Bilateral Periorbital: Ecchymosis (+)
At Left Frontal: lacerated wound(+), 3x0.5 cm,
based on subcutaneous
At Left Periorbital: lacerated wound (+), 3x0.5cm,
based on subcutaneous
 Physical Examination (16/03/2019)
General States:
BP: 100/60 mmHg P: 90 x/min RR: 24 x/min Temp: 36,00C

Local State:
At Cervical: tenderness (+), deformity (-)
At Right Hemithorax: CTT (+), WSD (+), air bubble (+)

Neurological State:
GCS 15, nuchal rigidity (-)
Pupils : Round equal, RLO Ø 3 mm/3 mm, LR +/+
Sensoric : Hypesthesia at level C6 below
Propioseptif : Disrupted
Vegetative : Urinary catheter (+)
Motoric :
Elbow flex 4/4 Hip flexion 1/1
Sacral Sparing :
Wrist 1/1 Knee extension 1/1
• Perianal sensation (+), hypesthesia (+) extension
• Voluntary anal contraction (+)
Extend elbow 1/1 Ankle 1/1
• Great toe extension (-) dorsoflexion
Physiological Reflex : +/+ Flexion middle 1/1 Great toe 1/1
Pathological Reflex : Babinsky +/+ distal phalanx extension
Finger abduct 1/1 Ankle plantar 1/1
flexion
 Laboratory Findings

Labs Result Labs Result Labs (BGA) Result

Hb 11.6 SGOT/SGPT 77/33 pH 7.366
Ht 35.1 Ur/Cr 54/1.02 pCO2 38.1

L 13.500 Na/K 140/3.4 pO2 74.7

RBG 91 HCO3 22.0
Tr 216.000
tCO2 23.2
BE -2.4
SaO2 93.5
Thorax X-Ray at Hasan Sadikin Hospital, Bandung
March 15th, 2019
CTT (+)
 Cervical X-Ray at Hasan Sadikin Hospital, Bandung
March 15th, 2019
AP Lateral • Malalignment (-)
• Fracture line (-)
• Narrowed disc at C5-C6
• Normal spinosus, facet
spaces
• Retropharyngeal soft tissue
space 7.4 mm (N: 5-7 mm)
• Retrotracheal soft tissue
space 18 mm (N: 18-22 mm)
• Interpedicular distance
• C3: 28 mm (N: 25-31 mm)
• C4: 31 mm (N: 26-32 mm)
• C5: 31 mm (N: 28-33 mm)
• C6: 30 mm (N: 28-33 mm)
SLIC Score 3 • C7: 31 mm (N: 24-32 mm)
• Morphology: 0
• Integrity of Disco-Ligamentous Complex: Indeterminate: 1
• Neurological status: Incomplete SCI: 2
Head CT Scan at Hasan Sadikin Hospital, Bandung
March 16th, 2019
Head CT Scan at Hasan Sadikin Hospital, Bandung
March 16th, 2019
• Soft tissue swelling at left
parietal
• No bone discontinuity
• Sulci and gyri are not
compressed
• Sylvian fissure and ventricles
are not compressed
• Cistern are not compressed
• Midline shift (-)
 WD/ Moderate Head Injury (improvement) + SBF Anterior + Spinal Cord
Injury Frankel C at level vertebrae C5-C6 due to suspect HNP
Traumatic + Right Tension Pneumothorax

ICD 10: Concussion (S06.0); Unspecified injury at unspecified level of cervical

spinal cord, initial encounter (S14.109A); Traumatic pneumothorax
(S27.OXXA)

Th/ NC : Plan for Cervical MRI

Thoracic surgery (Leader) : CTT

GCS this morning: 15 Kana Ward

URGENT CONSULT
UC 1. Mrs. Kokom Komariah / ♀ / 62 yo / 1707914 / Oncology / RS
The patient was directly consulted to dr. Roland Sidabutar Sp.BS(K) from
Neurology Department
CC: Decrease of consciousness
History:
Since 5 days ago, the patient looked drowsy and difficult to be awaken.
History of headache (-), fever (-), trauma (-), and seizure (-). Because of the
complaint, she was brought to Karawang General Hospital, performed Head
CT scan, hospitalized for 4 days, referred to Internal Medicine Emergency Unit
of Hasan Sadikin Hospital, then consulted to Neurosurgery Department.
Since 1.5 years ago, she was diagnosed with Right Breast Cancer with
Metastasis Carcinoma of Right Axilla after performed FNAB at Karawang
Hospital by a Surgeon. She underwent Mastectomy by Oncologic Surgeon at
Hasan Sadikin Hospital at November 2018, hospitalized for 2 weeks and sent
home with improvement.
History of balance disturbance, hearing disturbance, swallowing
disturbance, double vision, and lump on any part of body (-).
 Physical Examination
General States :
BP: 150/70 mmHg HR : 82 x/min RR : 18 x/min T : 37.5°C

Local States :
Ar Thorax: VBS right < left, rh -/- wh -/-, Scar post op (+) at right hemithorax

Neurological State :
GCS E3M5V2 = 10, Nuchal rigidity (-)
Pupil : Round equal, Ø ODS 3 mm/ 3 mm, LR : +/+
Visus : difficult to be examined
Funduscopy : bilateral papil edema
Eye ball movement : Doll’s eyes (+)
Other cranial nerves : difficult to be examined
Motoric : no paresis
Sensoric : response to pain (+)
Physiologi reflex : +/+
Babinski : -/-
 Laboratory Findings

Labs Result Labs Result

Hb 12.4 SGOT/SGPT 15/20
Ht 37.7 Ur/Cr 154/4.34
L 11.060 Na/K 142/3.7
Tr 326.000 RBG 109
Thorax X-Ray at Hasan Sadikin Hospital, Bandung
March 14th, 2019
Right pleural effusion
Contrast Head CT Scan at Karawang General Hospital, Karawang
March 11th, 2019
• Bone lytic (+) at left parietal
• Sulci and gyri are not
compressed
• Sylvian fissures are not
compressed
• Cistern are not compressed
• TH > 2 mm
• FH/ID = 40%
• Evans ratio 0.30
• Periventricular edema (+)
• Calcification at bilateral basal
ganglia and bilateral cerebellum
• Midline shift (-)
 Histopathological Result of FNAB
(Dewi Sri Hospital, January 2nd 2018)
Carcinoma of right mammae with metastasis carcinoma of right axilla
WD/ Acute Communicating Hydrocephalus due to suspect Carcinomatous
Meningitis + Skull Tumor at Right Parietal due to suspect Metastasis +
Right Breast Cancer with Metastasis to Right Axilla + Acute Kidney
Injury DD/ Acute on Chronic Kidney Disease + Right Pleural Effusion

ICD 10: Other specified disorders of brain (G93.89); Malignant neoplasm of

bones of skull (C41.0); Malignant neoplasm of breast (C50);
Malignant pleural efusion (J91.0)

Th/ NC: Plan for VP Shunt cito (the family refused)

Internal medicine: Improve general condition
Oncologic Surgery: Plan for Adjuvant Chemotherapy

GCS this morning: E2M5V2 = 9 RIK Ward

 UC 2. Mrs. Euis Ismawati / ♀ / 38 yo / 1721596 / Spine / RD

The patient was consulted from Neurology Department

CC: Weakness of lower extremities
History:
Since 2 years ago, the patient complained of weakness of lower extremity
followed by numbness and tingling sensation of her lower extremity since 2
months ago. History of back pain, radiating pain, urinary and defecation
disturbance, trauma, and fever (-). Because of the complaint, she was
brought to Neurologist at Sumedang General Hospital, referred to Neurology
Outpatient Clinic of Hasan Sadikin Hospital, underwent Thoracolumbar MRI
(February 8th 2019), then consulted to Neurosurgery Department.
History of TB contact, progressive body weight loss, and lump on any part
of body (-)
The patient was diagnosed with Sjogren’s Syndrome since 2 years ago,
controlled regularly at Internal Medicine Outpatient Clinic.
 Physical Examination
General States:
BP: 120/80 mmHg P: 76 x/min RR: 16 x/min Temp: 36,7ºC

Local State:
-

Neurological State:
GCS 15, nuchal rigidity (-)
Pupils : Round equal, RLO Ø 3 mm/3 mm, LR +/+
Sensoric : Paresthesia at level Th 4 below, bilateral symmetric
Vegetative : Within normal limit
Motoric : Elbow flex 5/5 Hip flexion 0/0
Sacral Sparing : Wrist 0/0 Knee extension 0/0
extension
• Perianal sensation (+)
Extend elbow 0/0 Ankle 0/0
• Voluntary anal contraction (+) dorsoflexion
• Great toe extension (+) Flexion middle 0/0 Great toe 0/0
Physiological Reflex : ++/++ distal phalanx extension

Pathological Reflex : Babinski +/+ Finger abduct 0/0 Ankle plantar 0/0
flexion
 Laboratory Findings

Labs Result Labs Result

Hb 12.7 SGOT/SGPT 97/142
Ht 39.7 Ur/Cr 28.0/0.28
L 7.350 Na/K 141/4.1
Tr 404.000 RBG 78
Thorax X-Ray at Hasan Sadikin Hospital, Bandung
December 19th, 2018
Within normal limit
Thoracolumbar X-Ray at Hasan Sadikin Hospital, Bandung
January 11th, 2019
Within normal limit
Contrast Cervicothoracal MRI at Hasan Sadikin Hospital, Bandung
February 9th, 2019
Contrast Cervicothoracal MRI at Hasan Sadikin Hospital, Bandung
February 9th, 2019
Contrast Cervicothoracal MRI at Hasan Sadikin Hospital, Bandung
February 9th, 2019
Contrast Cervicothoracal MRI at Hasan Sadikin Hospital, Bandung
February 9th, 2019

Syringomyelia at level
vertebrae Th 1 - Th 9
WD/ Myelopathy at level Vertebra Th 4 below due to suspect Transverse
Myelitis and Syringomyelia at Level Vertebrae Th 1 – Th 9 + Sjogren’s
Syndrome

ICD 10: Myelopathy in disease classified elsewhere (G99.2); Acute transverse

myelitis (G37.3); Sjogren syndrome (M35.0)

Th/ NC: Conservative

Neurologic Department: Lumbar puncture

GCS this morning: 15 Fresia 2nd Ward

Motoric 55555|55555
44444|33333
UC 3. Baby Adila Khirunnisa / ♀ / 7 mo / 1751547 / Pediatric / MS
The patient was consulted to from Pediatric Department
CC: Decrease of consciousness
History:
Since 3 weeks ago, the parents noticed that the patient looked drowsy and
difficult to be awaken. The complaint was preceded by seizure 1 time, whole
body, duration < 5 minutes, during and after seizure she was unconscious.
History of intermittent fever (+) since 2 months ago. History of trauma and
vomiting (-). Because of the complaint of decrease of consciousness, 3 weeks
ago she was brought to Mitra Plumbon Hospital Cirebon, performed Head CT
scan, hospitalized for 3 weeks, referred to Pediatric Emergency Unit of Hasan
Sadikin Hospital, performed Lumbar Puncture, then consulted to
Neurosurgery Department.
The patient was born from P1A0 mother, aterm, sectio caesarean helped
by Obstetrician at Arjawinangun General Hospital Cirebon, directly crying
with BBW 3800 gr. History of ANC (+) regularly at midwife. History of infection
and drug consumption during pregnancy (-). History of developmental delay
(-), the patient was able to sit by herself and started to crawl.
 Physical Examination
General States :
HR : 104 x/min RR : 26 x/min T : 37.0°C BW: 3800 gr

Local States :
Ar Thorax: VBS right = left, rh -/- wh -/-, slem -/-
Head Circumference: 45.5 cm (N: 41- 46 cm)
Anterior Fontanelle: Open, size 1x1 cm, flat, not tense
At Right Palpebral: Ptosis (+)

Neurological State :
CCS E3M3V2 = 8, Nuchal rigidity (-)
Pupil : Round unequal, Ø ODS 4 mm / 2 mm, LR : +↓/+
Visus : difficult to be examined
Funduscopy : difficult to be examined
Eye ball movement : difficult to be examined, doll’s eyes (+)
Other cranial nerves : paresis of right CN III
Motoric : no paresis
Sensoric : response to pain (+)
Physiologi reflex : +/+
Babinski : +/+
 Laboratory Findings

Labs Result Labs Result CSF (LP) Result

Hb 8.8 Ur/Cr 10.0/0.35 Color 10.0/0.35
Ht 26.3 Na/K 131/4.6 Clarity 131/4.6
L 3.940 CRP 0.07 Cell 3
Tr 316.000 RBG 79 PMN 33
MN 67
Nonne (-)
Pandy (-)
Glucose 45.8
Protein 68
Thorax X-Ray at Mitra Plumbon Hospital, Cirebon
February 24th, 2019
Bronchopneumonia
Contrast Head CT Scan at Ray at Mitra Plumbon Hospital, Cirebon
February 25th, 2019
• Sulci and gyri are not
compressed
• Sylvian fissures and ventricles
are not compressed
• Cistern are not compressed
• Hypodense lesion crescent
shaped at bilateral frontal
• Midline shift (-)
WD/ Subdural Fluid Collection at Bilateral Frontal region due to suspect
Subdural Hygroma DD/ External Hydrocephalus + suspect
Meningoencephalitis Tuberculosis DD/ Bacterial Partially Treated +
Anemia + Hyponatremia

ICD 10: Lymphangioma, any site (D18.1); Tuberculous meningitis (A17.0);

Hypoosmolality and hyponatremia (E87.1); Anemia, unspecified
(D64.9)

Th/ NC : Closed observation

Pediatric (Leader) : Improve general condition

GCS this morning: CCS E3M3V2 = 8 Kenanga 1st Ward

 UC 4. Baby Mrs. Eva / ♂ / 1 mo / 1744984 / Pediatric / MS
The patient was consulted from Pediatric Department
CC: Discharge from lump of the back
History:
Since the patient was born, the parents noticed that their baby had lump
on his back as big as a pingpong ball, that was getting bigger when he was
crying. History of clear discharge from the lump and weakness of lower
extremity (+) since birth, micturition and defecation disturbance (-). Because
of the complaint, he was hospitalized for 2 weeks at Anthurium Ward of
Hasan Sadikin Hospital, consulted to Neurosurgery Department (February
18th 2019), performed wound care until the wound of his lump was getting
better without discharge, and sent home with improvement. He was
scheduled for Head USG examination. After 1 week at home, the wound
worsen with yellowish discharge (+), but the parents didn’t seek any
treatment.
Since 3 days ago, the parents noticed that the patient became drowsy
and difficult to breastfed, accompanied by fever and shortness of breath.
History of trauma and seizure (-). Because of the complaint, 1 day ago he was
brought to Pediatric Emergency Unit of Hasan Sadikin Hospital, then
consulted to Neurosurgery Department for the treatment of the lump.
 By. Mrs. Eva / ♂ / 4 do / 1744984 / Pediatric / MS
Past History (18/02/2019)

1 month ago 3 days ago

Born with lump on his back,
wound (+) Discharge (+).
Hospitalized for 2 weeks with
wound care in Anthurium
ward, sent home with
improvement of the wound
Looked drowsy and difficult
1 week ago to breastfed, fever (+),
The wound became worse shortness of breath (+) 
with yellowish discharge brought to Hasan Sadikin
Hospital, consulted to
Neurosurgery Department

The patient was born from P1A0 mother, preterm (36 weeks), Spontaneous
delivery by Obstetrician at Hasan Sadikin Hospital. BBW 2030 grams, and
directly crying. History of USG Fetomaternal with suspect Ventriculomegaly.
History of ANC (+) regularly to midwife. History of mother’s infection during
prenatal care (-). History of drug consumption during pregnancy (-). History
Folat acid consumption (+).
 Physical Examination (18/02/2019)
General States:
HR: 140 x/min RR: 38 x/min T: 37° C
Local States:
Head circumference: 33 cm (N: 31 - 35 cm)
Anterior fontanelle: open, flat, not tense, size 3 x 4 cm
Frontal bossing (-)
At lumbosacral: lump size 4 x 3 x 3 cm, soft, defined border, transilumination
(+), discharge (+), pus (-).
At bilateral foot: Bilateral Congenital Talipes Equinovarus
 Physical Examination
Neurological States:
CCS 11, nuchal rigidity (-)
Pupils: round equal, Ø RLO 3 mm/3 mm, LR +/+
Visus: RLO: difficult to be examined
Funduscopy: RLO: difficult to be examined
Eye ball’s movement: difficult to be examined
Other cranial nerves: difficult to be examined
Motoric: no paresis
Sensoric: response to pain
Vegetatif: within normal limit
Physiological reflex: +/+
Babinski reflex +/+
Laboratory Finding at Hasan Sadikin Hospital Bandung
January 14th, 2019

Labs Result Labs Result

Hb 14,2 Na/K 133/5,0
Ht 41,0 RBG 56
L 16.220 CRP 0,16
Tr 244.000
Thorax X-Ray at Hasan Sadikin Hospital Bandung
February 14th, 2019

Within normal limit

 Physical Examination
General States :
HR : 148 x/min RR : 55 x/min T : 36,9°C BW: 4700 gr

Local States :
Head circumference: 35 cm (N: 35 - 39 cm)
Anterior fontanelle: open, flat, not tense, size 4 x 4 cm
Frontal bossing (-)
At lumbosacral: lump size 4 x 3 x 3 cm, soft, defined border, transilumination
(+), discharge (+), pus (-).
At bilateral foot: Bilateral Congenital Talipes Equinovarus
 Physical Examination
Neurological State :
CCS E3M4V2 = 9, Nuchal rigidity (-)
Pupil : Round equal, Ø ODS 3 mm/ 3 mm, LR : +/+
Visus : difficult to be examined
Funduscopy : difficult to be examined
Eye ball movement : difficult to be examined, Doll’s eyes (+)
Other cranial nerves : difficult to be examined
Motoric : paraparesis inferior
Sensoric : respond to pain
Physiologi reflex : +/+
Babinski reflex: +/+
 Laboratory Findings

Labs Result Labs Result

Hb 10.5 Na/K 133/4.6
Ht 29.7 RBG 107
L 7.420 CRP 0.79
Tr 445.000
Thorax X-Ray at Hasan Sadikin Hospital, Bandung
March 15th, 2019
Bilateral Bronchopneumonia
WD/ Re-Ruptured Myelomeningocele at Lumbosacral + Bilateral
Congenital Talipes Equinovarus + Bilateral Bronchopneumonia +
Sepsis

ICD 10: Myelomeningocele (Q05.0); Congenital talipes equinovarus (Q66.0);

Bronchopneumonia, unspecified (J18.0); Sepsis, unspecified organism
(A41.9)

TH/ NC: Plan for Head USG

Plan for Observation Head Circumference
Plan for MRI Lumbosacral
Pediatric Department: Improve general condition
Plastic Surgery: Wound care

CCS this morning: E3M4V2=9 Kenanga 1st Ward

EMERGENCY OPERATION
PRE OPERATIVE
POST OPERATIVE
INTENSIVE PATIENT
 GCS/CCS GCS/CCS
BED NAME SEX AGE POD / PH DIAGNOSIS PROCEDURE PROBLEM THERAPY KS
INITIAL TODAY

GICU 2

Cedera Kepala Sedang + EDH At bilateral Frontal +

Fraktur Linier at Midfrontal + Fraktur Rima Orbita
Inferior et Zygoma Sinistra Breathing
Craniotomy Advice:
1 Asep L 26 yo POD 2 E2M5V2 = 9 E2M5Vt = 7t FZ
Evacuation (01.2) Anemia PRC Transfusion
ICD 10: Concussion (S06.0); Epidural hemorrhage
(S06.4); Fracture of frontal bone (S02.0); Fracture of
other specified skull and facial bones (S02.8)

Spontaneous ICH at Left Basal Ganglia (Putamen,

Vetilator Mode :
Globus Palidus, Internal Capsule) + IVH to suspect
PS ( PS 5 PEEP 5
Hypertension + Emergency Hypertension
Craniotomy Evakuasi FiO2 55%)
2 Ervan L 32 yo POD 1 E3M5V2 = 10 E3M5Vt = 8t Breathing AD
(01.2)
ICD 10 :Nontraumatic intracerebral hemorrhage,
Advice :
unspecified (I62.00); hypertension (I10);
Weaning
Hyponatremia –hypo osmolality (E87.1)
 GCS/CCS GCS/CCS
BED NAME SEX AGE POD / PH DIAGNOSIS PROCEDURE PROBLEM THERAPY KS
INITIAL TODAY

GICU 1

Ventilator Mode
Spontaneous ICH at left Parietooccipital due to PS 6 PEEP 5 FiO2
Craniectomy
suspect Amyloid Angiopaty DD/ Hypertension + 40%)
Decompression and
Emergency Hypertension + Bronchopneumonia Antibiotic
7 Yulianti P 59 yo POD 28 E3M5V2 = 10 E3M5Vtc = 8tc Evacuation (01.24) Breathing AD
Therapy
ICD 10: Non traumatic ICH (I61.5); Primary
Tracheostomy (31.1)
hypertension (I10); Bronchopneumonia(J18.0); Advice :
Thorax xray
 GCS/CCS GCS/CCS
BED NAME SEX AGE POD / PH DIAGNOSIS PROCEDURE PROBLEM THERAPY KS
INITIAL TODAY

NICU
Mode Ventilator
Microcephaly + Spontaneous IVH at Lateral Ventricle
SIMV PC (IPL 14
due to Suspect Germinal Matrix Hemorhage Grade III
RR 24 PS 9 PEEP
+ Suspect Hydrocephalus + Preterm Infant (30 week)
6 FIO2 30%)
+ LBBW (Low Birth Body Weight) + Respiratory
By. Irnawati P 1 mo PH 3 CCS E4M4VT=8T CCS E4M4VT=8T Distress Syndrome + Bronchopneumonia - Breathing MS
Advice :
Head
ICD 10: Other intracranial (nontraumatic)
circumferrence
hemorrhages of newborn (P52.8);
observation
BRONCHOPNEUMONIA (J18.0)
Head USG Serial
OUTPATIENT CLINIC
 THANK YOU

Chief on Call : dr. Muhammad Ichsan F. Firdaus

Chief on Site : dr. Elvira Sutanto

Jaga 2 : dr. Muhammad Rainda Farhan

Jaga 3 : dr. Ayu Iswandari Raharjo

Jaga 5 : dr. Firman Nur Choliq

dr. Syailendra Fii Sulaiman