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Neurosurgery Morning Report

Saturday, March 7th, 2015


Chief on call : dr. Oskar A. Widarta
Chief on site : dr. Guata Naibaho
Jaga 2 : dr. Petra O.P. Wahjoepramono
Jaga 3 : dr. Rhonaz P. Agung
Jaga 5 : dr. Lukas Galileo
Jaga 5b : dr. Festus Andrianto Susilo
New Patients :2
Emergency Patients :1
Urgent Consults :-
Emergency Operations :-
Pre Op :-
Post Op :-
Death Case :-
NCCU/ICU/PICU/HCU-RIK/NPIU: 4/-/-/-/1
New Patients
NP 1: Sami Kedira Ramadan//6 mo/1500006758/Pediatrics/MS
CC : Seizures
History :
Since 1 day before hospital admission, the patient had 2x seizures,
each 5 minutes, before and after seizures the patient was conscious.
Since 3 days before hospital admission, the patient had fever,
highest temperature 40C. History of coughing (-), vomiting (-), diarrhea
(-). Begins to lose body weight.
8 hours before admission, the patients face turned blue after the
last seizure. Due to this complaint he was brought to Sumedang
hospital, and referred to Hasan Sadikin hospital.
Past history:
3 months ago, when he was 3 months old, the patients head
started to look bigger than other children, until 45 cm. Due to this
complaint, he was brought to Borromeus hospital, diagnosed with
hydrocephalus, and had VP shunt insertion by neurosurgeon on
November 27th, 2014. After the shunt, his head still got larger in time.
The patient was born from P2A0 mother, 30 weeks gestation,
delivered by C-section in Sumedang hospital due to prenatal bleeding,
not directly crying. BBW 900 gr, head circumference at birth 24 cm.
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NP 1: Sami Kedira Ramadan//6 mo/1500006758/Pediatrics/MS

Head got larger Head Seizure 2x, @ 5


3 months BHA

1 day BHA
3 days BHA
than other kids. progressive minutes. Before
Diagnosed enlarged. Fever and after seizure
hydrocephalus. (+), 40C. conscious. Bluish
Performed VP- appearance.
Diarrhea (-), Taken to
shunt. coughing (-), Sumedang
vomiting (-), hospital
Physical Examination
General Status:
P : 148 BPM, RR : 28 BPM Temp: 38,4C Weight 5 kg
Local Status:
Head circumference 53 cm (40-44 cm)
Anterior fontanelle open, convex, tense, 10x9 cm.
At left Keens point: shunt pump effective, slow filling
Neurological Status:
CCS 11, nuchal rigidity (-)
Pupil round equal ODS 3mm, LR ODS +/+
Visus : difficult to be evaluated
Funduscopy: difficult to be evaluated
Eye ball movement: dolls eye (+)
Other cranial nerve: difficult to be examined
Motoric : no hemiparesis
Sensoric: difficult to be examined
Physiologic Reflex : +/+
6
Pathologic Reflex : Babinski (-/-)
Chest X-Ray, RSHS, 07/03/2015
within normal limits

7
Non-Contrast Head CT Scan, RSHS,
08/03/2015
Shunt placement in
posterior horn, left
lateral ventricle
Multiple septa (+)

8
Lab Result Ur/Cr 11/0,17
Hb 9,0 Na/K 133/4,9
Hct 30 Glucose 83
Leu 8,600 NS1 Dengue Non Reactive
Thro 70,000

WD/ Shunt malfunction due to post VP shunt due to hydrocephalus +


Seizure observation + thrombocytopenia + severe malnutrition

ICD 10 : Febrile convulsions (R56.0), Presence of cerebrospinal fluid


drainage device (Z98.2) + Communicating hydrocephalus (G91.0) +
Unspecified severe protein-calorie malnutrition (E43) + Secondary
thrombocytopenia (D69.5)

Th/ Improve general condition, anticonvulsants (Pediatrics)


Endoscopic Septa Fenestration + VP-shunt (Neurosurgery)

CCS this morning: 11 NPIU - 4

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NP 2: Risye Krisnawaty//65 yo/15060232/Oncology/BW
CC : Generalized Weakness
History :
Since 3 days before hospital admission, the patient felt
generalized weakness, and was unable to stand. Because of this she fell
to the floor when getting out of bed in the morning. Complaint of
headache (+), vomiting (+), seizures (-), disturbance of vision (-). She
was taken to Santosa hospital, and referred to Hasan Sadikin hospital.
Past history:
1 year before admission, the patient started feeling headaches,
which can still be relieved with medication. The complaint was not
accompanied with vomiting, seizures, or motoric weakness.
7 months before admission, the patient felt weakness of her left
extremities. Also, her headache was getting worse, vomiting (+). She
had confused speech. She was taken to Santosa hospital, diagnosed
with brain tumor, and had craniotomy tumor removal in July, 2014 by
dr. Beny A.W., SpBS. After the operation, she felt her headache has
resolved, and had no other complaints. She had 24x radiotherapy in
December, 2014
1 month before admission, the patient started feeling the same
headaches again.
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NP 2: Risye Krisnawaty//65 yo/15060232/Oncology/BW

Started feeling Generalized

1 month BHA
7 months BHA
Headaches, Headache

3 days BHA
1 year BHA

can be relieved getting worse. the same Weakness. Fell


with Decreased headaches. to the floor
medication. consciousness. Vomiting (+). when getting
Vomiting (+), out of bed.
Other
motoric complaints (-).
weakness (+), CTR in Santosa
seizures (-), hosp w/ dr.
disturbance of Beny A.W., SpBS
vision (-)
Physical Examination
General Status:
T: 150/90 mmHg P : 84BPM, RR : 16 BPM Temp: 37,4C
Local Status:
At right temporal: post operative scar (+), horseshoe shape
Neurological Status:
GCS 15, nuchal rigidity (-)
Pupil round equal ODS 3mm, LR ODS +/+
Visus : ODS > 6/60
Funduscopy: difficult to be evaluated
Eye ball movement: within normal limits
Other cranial nerve: within normal limits
Motoric : within normal limits
Sensoric: within normal limits
Physiologic Reflex : +/+
Pathologic Reflex : Babinski (-/-)
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Contrast enhanced MRI, Santosa hosp,
26/07/2014

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Contrast enhanced MRI, Santosa hosp,
26/07/2014

14
Contrast enhanced MRI, Santosa hosp,
26/07/2014

15
Contrast enhanced MRI, Santosa hosp,
26/07/2014

16
Postop Contrast enhanced CT scan, Santosa
hosp, 18/12/2014

17
Postop Non - Contrast CT scan, Santosa hosp,
26/02/2015

18
Comparison of Post-Op CT scans

Postop Contrast Enhanced CT scan, Postop Non - Contrast CT scan,


Santosa hosp, 18/12/2014 Santosa hosp, 26/02/2015 19
Lab Result Ur/Cr 33/0,57
Hb 15,1 Na/K 137/3,9
Hct 44 SGOT/SGPT 16/23
Leu 7,900 Glucose 118
Thro 208,000 Protein/Alb 5,8/3,8

WD/ SOL supratentorial at right temporoparietal due to susp. recidive


glioblastoma multiforme

ICD 10 : Malignant neoplasm of overlapping sites of brain (C71.8)

Th/ Re- Craniotomy Tumor Removal (01.24)

GCS this morning: 15 Parahyangan Ward 411W

20
Emergency Patients
ER 1: Yasid//8 yo/1500006708/Trauma/MZ

CC : Headache
History :
1 hour before hospital admission, while the patient was playing in his house in
Pasteur area, he slipped from the second floor stairs, with his head hitting the
ground. History of unconsciousness (+), vomiting (-), bleeding from ear, nose or
mouth (-). He was brought directly to emergency department, Hasan Sadikin
hospital.

General Status:
BP: 110/70 mmHg, P : 80x, Temp: afebrile, RR : 18x
Local Status:
At right parietal: hematoma (+), multiple lacerated wounds
each 1x0,5x0,5 cm based on subcutaneous tissue
At right shoulder: swelling (+), bruising (+), deformity (-)
At right wrist: swelling (+), bruising (+), deformity (-)
Neurological Status:
GCS : 15, Pupils round, isocor RLO 3 mm, LR ODS +/+
No motoric paresis.
22
Cervical and Chest X-Ray, RSHS, 07/03/2015
No fracture line

23
Skull X-ray, RSHS, 07/03/2015
No fracture line

24
Lab Result
Hb 15,1
Hct 43
Leu 12,200
Thro 169,000

WD/ Mild head injury + multiple lacerated wound of right parietal + closed
fracture of right distal radius, incomplete buckle type

ICD 10 : Concussion (S06.0), Laceration without foreign body of scalp (S01.01)


Fracture of lower end of radius (S52.5)

Th/ Neurosurgery Conservative


Orthopaedics Closed reduction & immobilization with short arm cast

GCS when sent home: 15 Sent home

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Urgent Consults
Emergency Operations
Pre Op
Post Op
NCCU
POD /
Bed Name Sex Age GCS initial GCS today Diagnosis Procedure Problem Therapy KS
HR

NCCU
SOL supratentorial at right frontal due to susp. Craniotomy Tumor Removal R/ Pindah ruangan
1 Agus M 45 yo POD 1 15 15 FM
Oligodendroglioma (01.2) biasa

Craniotomy Tumor Removal


(01.2) Breathing R/ weaning
Multiple SOL supratentorial at Right Sphenoid wing
Temporary Tracheostomy (31.1) Hypoalbumiin Ventilator CPAP
3 Tati F 46 yo POD 48 15 E4M5Vtc = 9tc and Left Parieto-occipital due to susp Meningioma RS
Continuous invasive mechanical Hypernatremia PEEP 5 FiO2 50%
ICD 10 : Neoplasm of cerebral meningens (D32.0)
ventilation for 96 Consecutive Hypokalemia FU IPD
Hours Or More (96.72)

SOL supratentorial at biparietal due to suspected Craniotomy Tumor Removal


recidivist parasagittal meningotheliomatous (01.2)
Hyponatremia Closed observation
4 Maemunah F 64 yo PH 10 E2M5V2 = 9 E1M1Vt = 2t meningioma + Acute Kidney Injury Continuous invasive mechanical RS
Hypoalbumin FU IPD
ICD 10 : Neoplasm of cerebral meningens (D32.0), ventilation for 96 Consecutive
Acute renal failure (N17) Hours Or More (96.72)

5
Closed observation
SOL Supratentorial at Right Sphenoorbital due to Hiponatremia
K/ IPD
susp. Sphenoorbita Meningioma Craniotomy Tumor Removal Hipokalemia
6 Entin F 38 yo POD 3 15 E1M1Vt = 2t Tampung Urin 24 RS
ICD 10: Benign Neoplasm of Cerebral Meninges (01.2) Polyuria
Jam
(D.32.0) CPP 2 CmH2O
Loading cairan

POD /
Bed Name Sex Age GCS initial GCS today Diagnosis Procedure Problem Therapy KS
HR

NPIU
Shunt malfunction due to post VP shunt due to
hydrocephalus + Seizure observation +
thrombocytopenia + severe malnutrition
Sami Kedira ICD 10 : Febrile convulsions (R56.0), Presence of Endoscopic Septa Fenestration +
6 M 6 mo PH 1 CCS 11 CCS 11 Rawat bersama IKA MS
Ramadan cerebrospinal fluid drainage device (Z98.2) + VP-shunt (02.34)
Communicating hydrocephalus (G91.0) +
Unspecified severe protein-calorie malnutrition
(E43) + Secondary thrombocytopenia (D69.5)
Thank You for Your Attention
Chief on call : dr. Oskar A. Widarta
Chief on site : dr. Guata Naibaho
Jaga 2 : dr. Petra O.P. Wahjoepramono
Jaga 3 : dr. Rhonaz P. Agung
Jaga 5 : dr. Lukas Galileo
Jaga 5b : dr. Festus Andrianto Susilo