Patients List

Admission to
No Identity Diagnosis Treatment
E.R.
Treatment from Brigjen H. Hasan Basry Kandangan Hospital
• O2 10lpm (with intubation)
• IVFD NS 10 tpm
• Inj. Citicolin 500 mg / 12 hours
• Inj. Phenitoin 200 mg / 24 hours
• Inj. Mecobalamin 1 amp/12 hours
• Inj. Antrain 1 gram / 8 hours
• Inj. Ranitidin 1 gram / 12 hours
• Inj. Manitol 100 cc (stop)
• Inj. Nicardipin 0,5 mq / kgbb / menit (stop)
• Inj. Asam tranexamat 1 gram
• Inj. Diazepam 1 amp (k/p)

IVH + hidrocephalus Treatment from IGD Ulin Hospital

• Head Up 30°
Mr. Arifin/ Mar 9th 2018 ec SH (second • O2 10-15 lpm
• IVFD RL 20 tpm
43 y.o at 15.20 attack) +obs • Inj. Citicolin 3x250 mg
konvulsi • Inj. Ranitidin 2x1 amp
• Inj. Phenitoin 3x100 mg
• Inj. Diazepam 1 amp k/p kejang bolus pelan
• Inj. Antrain 3x1 amp k/p demam
• Program manitol
• Drip nicardipin

Co to Neurology
• Co to neurology surgery
• Acc therapy from IGD

Co to Neurology Surgery :
• Cito EVD 09/03/2018
• Post op ICU
 1. Mr. Arifin/ 43 y.o
Mar 9th 2018 at 15.20

Chief Complain : seizure

History :
The patient came with a seizure complaint since 14 hours
before admission. Patients seizures approximately 5 minutes
with hands flexed hard and legs palpable hard. After the
seizures, patient does not aware and taken to the hospital by
his family. The patient always sleepy at the hospital,
responding to only one or two words. Patients seizure 1x in
hospital and then become unconscious. His breathing was
disturbed so ETT was installed. Then the patient vomits 2×
yellow liquid approximately 1/4 glass aqua. Patients vomited
1× while in ambulance to ulin hospital. Patients never complain
of headaches. Patients had a history of hemorrhage stroke in
operation on 3 feb 2018. Patient have controlled Hypertension
with amlodipine 10 mg. Diabetes melitus (-)
 Vital sign

• GCS E1VxM4 (ETT installed)

• BP : 130/90 mmHg
• HR : 107 bpm, regular, strong lift
• RR : 24 tpm
• Tax : 36,6◦C
• SpO2 : 100% with jackson rees 11 lpm
 Physical Examination
• Palpebra hematoma (-/-) pale conjungtiva (-/-), sclera
Head/Neck icteric (-/-) enlargement lymph node (-)

• I : symmetric respiratory movement, retraction(-)

• P : symmetric VF
Chest • P : sonor at all lung fields
• A : symmetric VBS, no ronchi, no wheezing, crackles (-)

• I : distention (-)
• A : normal bowel sound
Abdomen • P : tymphani
• P : tenderness (-) rebound tenderness (-), muscular
rigidity (-) ascites (-)

Extremities • warm (+), edema (-/-), no paralysis

 Neurological Examination
Physiological reflexes Cranial nerve
• Biceps : 2+/3+ • N. I : normal limit
• Patella : 2+/2+ • N. II : light reflex direct +/+,
indirect +/+, pupil equal (2mm/2mm)
Pathological reflexes • N. III, IV, VI: doll’s eye movement (+/+)
• Babinsky (-/-) • N. V, VII : corneal reflex (+/+)
• N. VIII : hard to evaluated
Meningeal sign (-) • N. IX, X : vomiting reflex (+)
• N. XI : normal limit
Lateralization (-/-)
• N. XII : normal limit
Clinical Pictures
ECG
X-ray
CT Scan
Laboratory Finding
Pemeriksaan Hasil Nilai Rujukan
Hemoglobin 11,2 12,00-16,00 g/dl
Leukosit 7,00 4,0-10,5 ribu/ul
Eritrosit 3,92 3,90-5,50 juta/ul
Hematokrit 32,4 37,00-47,00 vol%
Trombosit 232 150-450 ribu/ul
RDW-CV 13,9 11,5-14,7 %
MCV 82,7 80,0-97,0 fl
MCH 28,6 27,0-32,0 pg
MCHC 34,5 32,0- 38,0 %
Basofil # 0,02 <1 ribu/ul
Eosinofil # 0,00 <3 ribu/ul
Gran # 8,51 2,50-7,00 ribu/ul
Limfosit # 0,83 1,25-4,0 ribu/ul
Monosit # 0,60 0,30-1,00 ribu/ul
Laboratory Finding

Pemeriksaan Hasil Nilai Rujukan

PT 11,7 9,9-13,5 detik
INR 1,08
APTT 21,5 22,2-37,0 detik
GDS 135 <200
SGOT 35 0-46 U/l
SGPT 27 0-45 U/l
Ureum 15 10-50 mg/dl
Creatinin 1,06 0,7-1,4 mg/dl
Natrium 135 135-146 mmol/l
Kalium 3,5 3,4-5,4 mmol/l
Chlorida 98 95-100 mmol/l
Working Diagnosis

IVH + hidrocephalus ec SH (second

attack) +obs konvulsi
 Management
Treatment from Brigjen H. Hasan Basry Kandangan Hospital
O2 10lpm (with intubation)
IVFD NS 10 tpm
Inj. Citicolin 500 mg / 12 hours
Inj. Phenitoin 200 mg / 24 hours
Inj. Mecobalamin 1 amp/12 hours
Inj. Antrain 1 gram / 8 hours
Inj. Ranitidin 1 gram / 12 hours
Inj. Manitol 100 cc (stop)
Inj. Nicardipin 0,5 mq / kgbb / menit (stop)
Inj. Asam tranexamat 1 gram
Inj. Diazepam 1 amp (k/p)

Treatment from IGD Ulin Hospital

Head Up 30°
O2 10-15 lpm
IVFD RL 20 tpm
Inj. Citicolin 3x250 mg
Inj. Ranitidin 2x1 amp
Inj. Phenitoin 3x100 mg
Inj. Diazepam 1 amp k/p kejang bolus pelan
Inj. Antrain 3x1 amp k/p demam
Program manitol
Drip nicardipin

Co to Neurology
Co to neurology surgery
Acc therapy from IGD

Co to Neurology Surgery :
Cito EVD 09/03/2018
Post op ICU
Operation Report