Neurosurgery Report

Wednesday, 24th February 2016

Konsulen Jaga

: dr. Agung Budi

Sutiono, Ph.D Sp.BS

Jaga Rumah

: dr. Bobby W Hasan.

Jaga 1

: dr. Andi Nugraha S.

Jaga 2

: dr. Jusuf Desman B.

Jaga 3

: dr. M Ihsan Firdaus.

Jaga 5

: dr. Rendy Badri.

New Patient
:3
Emergency Patient
:Urgent Consult
:1
Emergency Operation
:1
Pre Op
:2
Post Op
:2
Death Case
:NCCU/ICU/PICU/HCU RIK/MIC
:5/-/2/-/-

New Patient

NP 1. By. Aisah S//4mo/16060174/Pediatric/MS

CC

: Head Enlargment

History :
About 4 months prior to admission, the parents
noticed that their babys head look bigger than other
babies. The head keep getting bigger until now. History
of vomiting (-), seizure (-), and fever (-). Because of the
complaint the baby was brought to Neurosurgery
Outpatient Unit in Hasan Sadikin Hospital and
performed Head CT Scan.
The baby was born from P6A0 mother, aterm, helped
by obstetrician, spontaneous delivery with vacuum,
directly crying, BBW 2.900 gr.

Physical Examination :
General States :
HR : 120 x/min ; RR : 30 x/min ; T : 36,5 0C
Local States :
HC : 61 cm (N : 40-44 cm), frontal bossing (+), venectation (+), sunset
eyes (+/+)
Anterior Fontanele : open, bulging, not-tense, size : 8x6cm
Transilumination : (+)
Neurological State :
CCS 11, Nuchal rigidity (-)
Pupil : Round equal RLO : 3/3 mm, LR +/+
Visus : RLO : difficult to be examined
Funduscopy : difficult to be examined
Eye ball movement : difficult to be examined
Other cranial nerve : difficult to be examined
Motoric : no paresis
Sensoric : (+) with pain stimuli
Physiologic Reflex : +/+

Thorax X Ray at Hasan Sadikin Hospital

February 11th 2016
Within normal limit

Head CT scan at Hasan Sadikin Hospital

February, 3rd 2016

Cortical mantle (-)

Laboratory
findings
:
Lab
Result
Hb
Ht
Leu
Thro

12.9
38
14.900
431.000

Lab

Result

Na

137

5.0

Blood
Glucose

104

WD/ Hydrancephaly
ICD 10 : Other Congenital Hydrocephalus (Q03.8)

Th/

Plan to VP-Shunt

CCS this morning: 11

Ward

Kemuning 2nd

NP.2 Fahmi Y./14 th//1518443/Trauma/AB

KU : Penurunan Kesadaran
Anamnesis :
10 Jam SMRS ketika os sedang dibonceng naik motor didaerah
Malangbong dengan helm (+), tiba-tiba motor pasien diserempet oleh truk
dari arah depan sehingga os terlempar dengan kepala membentur aspal,
pingsan (+), muntah (+), perdarahan telinga (-), hidung (-), mulut (-).
Pasien lalu dibawa ke RSUD dr Slamet Garut, lalu dirujuk ke Instalasi gawat
darurat RS. Hasan Sadikin Bandung dengan ambulance dan perawat.
Primary Survey :
A: Clear, C-spine control
B: RR: 24 x/min. Simetris. VBS Kanan=kiri
C: BP: 120/80 mmHg, P: 98 x/min
D: GCS E3M5V3 = 11
Pupil round equal, RLO 3 mm, LR +/ +. Motoric: no paresis
Secondary Survey:
Regio Frontoparietal kanan : Hematome (+)

Foto Cervical dan Thorax di RS Hasan Sadikin

24 February 2016
Dalam Batas Normal

CT Scan Kepala di RS Hasan Sadikin 24 Februari

2016

CT Scan Kepala di RS Hasan Sadikin 24 Februari

2016

Pembengkakan jaringan
lunak di frontoparietal
kanan
Tampak diskontinuitas
tulang di regio
frontoparietal kanan
Sulcus and girus
terkompresi
Sylfian fissure & ventrikel
terkompresi
Cisterna sebagian
terkompresi
Gambaran Salt dan Pepper
di regio frontoparietal
kanan
Midline shift (-)

Laboratorium:
Hb

12,9

Ur/Kr

15/0,35

Ht

38

Na/K

137/5

Leu

14.000

GDS

104

Tromb

431.000

D/

Cedera Kepala Sedang + Fraktur tertutup linier ar

frontoparietal dextra + Contusio cerebri ar
frontoparietal kanan + Edema Cerebri
ICD 10 : Concussion (S06.0); Focal Brain Injury (S06.3);
Fracture of vault of skull (S02.0); Cerebral Edema
(G93.6)

Th/ Konservatif

NP.3 Deri/31 th//1518469/Trauma/AB

KU : Penurunan Kesadaran
Anamnesis :
1 jam SMRS ketika os sedang mengendarai sepeda motor di
daerah Cihampelas dengan helm (+), tiba-tiba motor pasien
tergelincir dan pasien terjatuh dengan kepala membentur aspal,
pingsan (+), muntah (+), perdarahan telinga (-), hidung (+), mulut
(-), riwayat Intoxicasi Alkohol tidak diketahui. Pasien lalu dibawa ke
Instalasi Gawat Darurat RS Hasan Sadikin Bandung oleh polisi .
Primary Survey :
A: Clear, C-spine control
B: RR: 22 x/min. Simetris. VBS Kanan=kiri
C: BP: 120/70 mmHg, P: 84 x/min
D: GCS E3M5V3 = 11
Pupil round equal, RLO 3 mm, LR +/ +. Motoric: no paresis
Secondary Survey:
Regio nostril : rhinorrhagi (+)
Regio palperbra superior et inferior : v. laserasi (+)
ukuran 3x3 cm dasar

Foto Cervical dan Thorax di RS Hasan

Sadikin
24 February 2016
Dalam Batas Normal

Foto Schaedel di RS Hasan Sadikin 24 Februari

2016
Tidak ada garis fraktur

Laboratorium:
Hb

13,5

Ur/Kr

15/0.35

Ht

40

Na/K

138/3.8

Leu

11.400

GDS

104

Tromb

431.000

D/

Cedera Kepala Sedang + Alkohol Intoksikasi + Vulnus

Laserasi ar palpebra superior et inferior
ICD 10 : Concussion (S06.0); Alcohol Intoxication (F10.1);
Open wound on the Skin (T81.31)

Th/ Observasi Ketat (NC)

Debridement + Suture primer (Plastic)
GCS pagi ini E3M6V4: 13
EMG
menunggu ruangan

Emergency Patient

Urgent Consult

UC 1. By. Arsyila N//10mo/1444022/Pediatric/MS

The patient was consulted
Department
CC
: Head deformity

from

Pediatric

History :
About 10 months prior to admission when the baby
was born, the parents noticed that their babys head
look different than other babies, the head shape like a
clover leaf. The head shape not return to normal until
now . History of vomiting (-), seizure (-).
History of cough (+) and fever (+) about 10 days
prior to admission. Because of the complaint the baby
was brought to Pediatric Departmen in Hasan Sadikin
Hospital and consulted to Neurosurgery Department.
The baby was born from P2A0 mother, aterm, helped
by obstetrician, sectio caesarean, directly crying, BBW
2.900 gr.

hysical Examination :
General States :
HR : 130 x/min ; RR : 38x/min ; T : 38,2 0C BW: 6 Kg
Local States :
HC : 44 cm (N : 44-48cm), Anterior Fontanele : closed, Clover
leaf head shape (+)
Neurological State :
CCS 11, Nuchal rigidity (-)
Pupil : Round equal RLO : 3/3 mm, LR +/+
Visus : RLO : difficult to be examined
Funduscopy : difficult to be examined
Eye ball movement : good to all direction
Other cranial nerve : difficult to be examined
Motoric : no paresis
Sensoric : (+) with pain stimuli
Physiologic Reflex : +/+

Thorax X Ray at Hasan Sadikin Hospital

February 25th 2016
Bronchopneumonia Bilateral

Laboratory
findings
:
Lab
Result
Hb
Ht
Leu
Thro

10.7
34
20.400
339.000

Lab

Result

Na/K

131/3.9

Ur/Cr

64/1.35

Blood
Glucose

93

WD/ Pancraniosynostosis + Bronchopneumonia + Varicella +

Acute Kidney Injury
ICD 10 : Craniosynostosis (Q75.0); Bronchopneumonia (J18.0);
Varicella (B01.0);
Acute Kidney Injury (N17.9)

Th/

Plan to Head CT Scan + Suturectomy (NC)

Improve General Condition (Pediatric)

Pre Operative

Pre Op
1. Ny. Zernawati / P / 51 thn / 16060165 /
Kemuning 4 / AB
DK/ Supratentorial SOL at Right Parietal due to
susp. Convexity Meningioma
Th/ Craniotomy Tumor Removal
2. Ny. Eli Laela / P / 46 thn / 16060143 /
Kemuning 5 / RS
DK/ Supratentorial SOL at left sphenoorbita
due to susp. meningioma
Th/ Craniotomy Tumor Biopsy

Post Operative

Post Op
1. Tn. Apit / 44 th / M / 16060127 / MS
Dk/ SOL Supratentorial at left
temporoparietal due to Susp. High
Grade Glioma
Th/ Stereotactic Tumor Removal
DO at Left Temporoparietal:
ditemukan massa tumor hasil biopsi

Post Op
2. Tn. Ridwan Permadi / 33 th / L / 16060116 / AB
Dk/ Wound dehiscence at frontal due to rupture bulbi
ODS + Fracture Le Fort III
Th/ Craniotomy debridement
DO ar frontal:
Ditemukan pus berwarna putih kekuningan ,kental
Ditemukan batas batas infeksi
Ditemukan tulang rapuh, kekuningan
Ditemukan duramater putih, intak, tidak tegang
Ditinggalkan defek tulang uk 12 x 4 cm
GCS pre op : 15

Emergency Operation

By. Tio // 1 mo / L / 1518093 / MS

Intraoperative Findings
At left frontotemporoparietal :
Found duramater bluish, tense,
and intact
Found SDH clot 10 cc, lysis 5 cc
Found ICH clot 15 cc, lysis 5cc
CCS pre op E2M3V2 : 7
Interval op 2 days

NCCU

Be
d

Name

Se
x

Ag
e

POD /
HR

GCS
initial

GCS today

Diagnosis

Procedure

Problem

Therapy

KS

R/Pindah
ruangan
biasa

A
B

NCCU

Dikdik M

Eman
R

Apit

Lia
Yulia

16
yo

43
yo

44
yo

POD
1

POD
23

POD
0

32 POD
yo
18

Moderate Head Injury + Skull base

fracture left media
fossa + Subdural Hematoma at
E2M5V2 E3M5V4 =
right
=9
temporal
12
ICD 10 : Concussion (S06.0);
Fracture of base of skull
(S02.1); Traumatic SDH (S06.5);)

15
33333|
44444
00000|
00000

E4M6VTc
44444|
44444
11111|
11111

E4M6V4 E4M6V4 =
= 14
14

E2M5Vt
= 7t

15

Multiple HNP at level vertebra

cervical
C4-C5, C5-C6, C6-C7 +
bronchopneumonia
ICD 10 : Cervicaldiscdisorder,
unspecified, mid-cervicalregio
(M50.92)
Supratentorial SOL at left
temporoparietal
due to Susp. High Grade Glioma
ICD 10 : Malignant neoplasm of
brain, unspecified
(C71.9)

Craniotomy
Evacuation
(01.24)

Anterior
Cervical
Ventilator
Mode PS,
Discectomy
and Fusion Breathing FiO2 45%,
PEEP 5, PS
(81.02)
5
Tracheosto
FU
IPD
my
(31.1)

R
D

Stereotactic
Tumor
Biopsy
(01.15)

F
M

Hb Post
Op :

FU Obgyn
BP
Spontaneous intracerebral
Craniotomy
Regulation
hemorrhage at right frontoparietal
Evacuation
Perdipine
due to hypertension due to
(01.24)
Hyperten
0,3
eclampsia + P1A0 + partial HELLP
Sectio
sion
mcg/KgBB/
syndrome
Cesarean
Menit
ICD 10 : Non traumatic ICH (I61.0);
(669.7)
R/ Pindah
Primary hypertension (I10.0)
ruang
biasa
Supratentorial SOL at Right frontal
due to suspect parasagital

Craniectom

R/ Pindah

A
D

Be
Se Ag POD GCS/CCS GCS/CC
Name
d
x e / HR
initial
S today

Diagnosis

Procedure

Problem

Therapy

KS

PICU

Fatir

Tio

Spontaneus SDH at left

Frontotemporoparietooccipital
Ventilator
and interhemispheric due to
Mode
Susp. APCD
Craniotomy
1 POD E2M3V2t E3M3Vt=
SIMV-PS,
ICD 10 : Other intracranial
M
Evacuation Breathing
MS
(nontraumatic) hemorrhages of
mo
2
=7
FiO2 30%,
6t
(01.24)
newborn (P52.8) + Acquired
PEEP 5, IPL
coagulation factor deficiency
10, RR 35
(D68.4) + Vitamin K deficiency of
newborn (P53)

1 POD
mo
0

Spontaneus SDH at left

Frontotemporoparietooccipital +
ICH at left Temporoparietal due
Hb post op
to Susp. APCD + Hyponatremia +
: 10,6 gr/dl
Anemia
Ventilator
DPO
ICD 10 : Other intracranial
Craniotomy
Mode
E2M3M2 Kesan
(nontraumatic) hemorrhages of
Evacuation Breathing SIMV-PS, MS
newborn (P52.8) + Acquired
=7
E2M3Vt=
(01.24)
FiO2 40%,
coagulation
factor deficiency
5t
PEEP
5, IPL
(D68.4) + Vitamin K deficiency of
5, RR 35
newborn (P53) + Hypo-osmolality
and hyponatremia (P87.1);
Anemia, unspecified (D64.9)

Thank You
Konsulen Jaga

: dr. Agung Budi

Sutiono, Ph.D Sp.BS

Jaga Rumah

: dr. Bobby W Hasan.

Jaga 1

: dr. Andi Nugraha S.

Jaga 2

: dr. Jusuf Desman B.

Jaga 3

: dr. M Ihsan Firdaus.

Jaga 5

: dr. Rendy Badri.