Name: Mrs. Beatriz F.

Matrins
Gender: Female
MR No : 51 39 94
age: thirty eight
MRS: Two June two thousand and nineteen

History
Patients refer from Leona Kefa Hospital with complaints of headache since about 5 months ago,
accompanied by sudden loss of vision in both eyes since 2 months ago. At first the patient
complained of severe headaches and often felt dizzy, then the vision began to blur, so the patient
went to the doctor and was treated at the leona kefa hospital and then referred to the hospital
wz johannes kupang. seizures (-), vomiting (-), nausea (-), normal defecation and urinate.

Past ilness hypertension

physical examination
GCS E4 V5 M6
Blood pressure:
Pulse
RR
temperature

status generalis
Head: Normochepal (in normally)
eye: anemic konjuctive - / -, SI - / - VOD / VOS 0/0
ears: othorea - / -
Pulmo: Ves + / + Rh - / - Wh - / -, normal chest development, crepitation (-)
Cor: S1S2 single / regular, m (-), G (-)
Abdomen: supple, convex, tender (-), intestinal noise (+)
Extremities: warm akral, CRT <2 seconds, edema - / -
motor upper limb
motor lower limb

laboratory results
Hb: 12.0 g / dl
Htc: 34.1%
Wbc: 22670
Plt: 306000 (tree hundret and six thousand)
PT / APTT: 10.3 / 25.2 seconds
SGPT / SGOT: 16/11 u / L
GDS: 173 mg / dL
BUN: 9.0 mg / dL
Cr: 0.69 mg / dL
Na: 142 mmol / L
K: 3.8 mmol / L
cl: 102 mmol / L
total calcium: 2.5 mmol / L
CT-Scan results
Soft tissue swelling(-)
fracture (-)
Sylvian fisser compresses
sulcus and gyrus compresses
ventricles and sisterna compressed
there is hyperdens mass in the left frontal region
mid line shift to the right

Assistance: SOL

planning:
Pro CTR
Diet high karbo high protein
Obs GCS and vital signs
Head up 30 degrees
futrolit (one thousand five hundret)1500cc / 24 hours
Omeprazole 2x 40 mg
KTC 2x30mg
dexa 4x10 mg
mannitol 3x150cc (one hundret fifty)

Name: Mr. David Lanmani

Gender: Male
MR No: 51 41 11
age : forty nine
MRS: five June two thousand and nineteen

History
Patients came to be referred from the bayangkara hospital with a diagnosis EDH post KLL on
the road from Oesao. the patient carries his own motorbike and hits the track from behind when
the track is parked. the patient fell and fainted, then under the police to the hospital. history
bleeding from the nose and mouth, left eye swelling and fracture of the left leg. raccon eyes (-),
Battle sign (-)

physical examination
GCS E4 V5 M6
Blood pressure:
Pulse
RR
temperature

generalist status
Head: Normochepal, hematome in the right frontal region
eye: KA - / -, SI - / - hematome right periorbita
ear: othorea - / -
Pulmo: Ves + / + Rh - / - Wh - / -, normal chest development, crepitation (-)
Cor: S1S2 single / regular, m (-), G (-)
Abdomen: supple, convex, pain press (-), Intestinal Noisy (+)
Extremities: warm akral, CRT <2 seconds, inferior edema - / + and frakturleft proksimal os tibia

Laboratory results
Hb: 11.0 g / dl GDS: 154 mg / dL
Htc: 31.7% BUN: 11.0 mg / dL
Wbc: 20030 Cr: 0.72 mg / dL
Plt: 203000 (two hundred and three Na: 140 mmol / L
thousand) K: 3.6 mmol / L
PT / APTT: 10.6 / 32.3 seconds cl: 106 mmol / L
SGPT / SGOT: 16/11 u / L total calcium: 1.9 mmol / L

CT-Scan results
There is Soft tissue swelling (+)
fracture (+)
sylvian fisser compresses
sulcus and gyrus compresses
ventricles and cysterna compresses
There is hyperdens mass in the left frontal region and right occipital region
mid line shift to the right

Assumption: EDH + ICH + fraktur proksimal os tibia sinistra

planning:
Instal NGT +Catheter
O2 4 lpm
IVFD futrolit 1500cc (one thousand five hundret) / 24 hour
terfacef 1x1 gr
Inj. Ranitidine 2x 50 mg
Inj. Ketorolac 2 x30 mg
plaminex 3 x500 mg
inj. vit k 1 amp
pro craniotomi evaluation in RSU
RO thoracic
blood Prepare 2 bag
consul Sp.An

Identity
Name; Mrs. Waty
Age: 45thy.o
Sex: female
Date of admission to hospital: may, 30th 2019 (thirty may two thousand and) nineteen
Anamnesis
a. Chief complaint
Decreased of consciousness
b. History

Patient referral from the Soe General Hospital with a diagnosis of decreased meningioma ec
awareness.at this time the patient has decreased consciousness. initially the patient felt full
body relief since yesterday afternoon. the patient does not want to eat or drink. the patient
cannot walk alone and does not respond when invited to speak. defecation and urination
normal. history of hypertension, diabetes mellitus, heart disease (-)
Physical examination

General condition: The patient appears to be moderately

Awareness: GCS = E4V5M6
TTV
TD: mmHg
Temperature: OC (axillary)
Pulse: x/ minute
Breathing: 20 times / minute,

Skin: pale (-), cyanosis (-), jaundice (-), skin hyperpigmentation (-)
Heat: Normochepal (looks swollen)
Eyes:
Conjunctiva: anemis - / -
Sklera: jaundice - / -
Pupil: isokor + / +, size ± 3mm / ± 3mm, Light Reflex + / +, Pupil Reflex + / +
Nose: rhinore (- / -)
Mouth:
Moist lip mucosa
The tongue looks normal
Ears: secretions: - / -
Neck:
Enlarged lymph nodes (-)
Pulmo
Inspection: symmetrical chest development, rib retraction (-)
Palpation: tactile (-) fremitus →cannot be evaluated
Percussion: Sonor in both lung fields
Auscultation: vesicular Rhonki Wheezing
Cor
Auscultation: S1 - regular S2 single, murmur (-), gallop (-)

Abdomen
Inspection: the abdomen looks flat
Auscultation: bowel sounds (+) 10 x / minute
Palpation: distention (-), tenderness (+) in the iliac region dextra, liver and spleen not palpable,
mass (-)
Percussion: timpani
Extremitas
Warm akral to all four extremities, CRT <2 "
Edema

CT Scan
hypodense lesions appear on the left frontal area
the midline shift to the right
compressed sulcus and gyrus
the left ventricle is compressed and pushed to the right
compressed cysterna
left sylvian fissure compressed

Assesment
Post craniotomi tumor renoval e.c SOL

Therapy
 Obs GCS and vital sign
 Heat up 30 degree
 futrolit 1500 cc / 24 hours
 O2 via nasal cannula 4 liters per minute
 ceftriaxone 2 x 1 gram (iv)
 ketorolac 2 x 30 mg (iv)
 omeprazole 2x40 mg
 plasminex 3x50mg
 vit k 3x10mg
 mannitol 4 x 150 cc
 dexametason 4x10mg