Morning Report

Friday, Desember 21th 2018

Team On Duty

dr. Novli Ardiansyah (Chief)

dr. Andrian (Jaga 1)
dr. M. Taqwa (Jaga 1)
dr. Jufrialdy (Jaga 1)
dr. Indra Yudhika (Jaga 2)
dr. Yudi Nugraha (Jaga 3)
dr. Saddam Husein D (Jaga 4)
dr. Indra Wisesa (Jaga 5)
dr. Ahmad Affandi (Jaga 6)
Patient Identity:
Name : Armansyah
Sex : Male
Age : 25 years old
Address : Darussalam, Aceh Besar
CM : 113-21-37
Phone : 081263729692
Admission time : 09.58 WIB

Time Response

Chief Complain :
Persistent headache

Present illness history

The patient was consulted from neurology division with chief complaint persistent
headache. Patient feel left extremity weakness for 1 day. Initially patient was doing in his
activity , suddenly felt headache and fell down, history of vomiting was present.
History of headache in 1 year.
History of uncontrolled hypertension unknown.
History of family hypertension (+)
Patient already performed Head CT-Scan and laboratories from neurology division
Physical examination
Vital Sign:
• Blood pressure : 140/100 mmhg
• Pulse : 99 x/min
• Respiratory rates : 22 x/min
• Body temperature : 36,9 oC
• Consciousness : GCS : E4 M6 V5 : 15, Isochoric pupil 3mm/3mm,
light reflect (+/+)

Laboratory result:
Hb : 15,5 gr/dl
White blood count : 12.000/ul
Platelet : 209.000 /ul
Ht : 43 %
CT : 7 minute
BT : 2 minute
Ureum : 30 mg/dL
Creatinine : 0,78 mg/dL
Radiology examination
Head CT-Scan :
 No SCALP hematoma
 There was hyperdense appearance at the right temporoparietal region  ICH with
volume + 80 cc
 Sulcus and gyrus was narrow
 Ventricle and cysterna was starting compress
 There was midline shift to the left less than 0,5 cm
Diagnose:
1. Intracranial hemorrhage at the right temporoparietal region due to Hemorrhagic
stroke (ICD 10 S06.36A)
2. Left hemiparesis (ICD 10 I69.354)
3. Hypertension (ICD 10 S39.A2)

Consult to neurosurgery division:

Craniectomy decompression ICH evacuation

Management:
 Stop oral intake
 Head up 30°
 O2 4 L/min (via nasal cannula)
 IVFD NaCl 0,9% 20 drips/min
 Inj Ceftriaxone 1 gr
 Inj. Metamizole Sodium 500 mg
Operation report
• Performed reverse question mark incision
• Performed 5 burrholes
• Bone was saw by gigly
• Perfomed dura hit stiches
• Duramater was opened sharply  performed evacuation ICH + 70 cc
• Fragment Bone was put subgalea
• Left 1 tube drain

Post operative diagnose

Post craniectomy decompression due to :

1. Intracranial hemorrhage at the right temporal region due to Hemorrhagic stroke
(ICD 10 S06.36A)
2. Left hemiparesis (ICD 10 I69.354)
3. Hypertension (ICD 10 S39.A2)

Follow up