Morning Report

Sunday, February 29th,

2016
Team on duty

RSUDZA

dr. Andria Saputra

(Jaga I)
dr. Munawar
(Jaga II)
dr. T. Ronasky
(Jaga III)
dr. Sumrahadi
(Jaga III)
dr. Bobby Hermi
(Jaga IV)
dr. Kas Mulyadi
(Jaga IV)
dr. Herdi Gunanta
(Jaga V)
dr. M. Taqwa
(Jaga VI)
dr. Syahmardani Ibnu
(Jaga
VI)

No

Distribution of surgery
patient

Room

1 /961912
Emergency room patient

15 Patients

2 Hospitalize

9 Patients

3 Out of clinic

5 Patients

4 Refuse medical advice

1 Patient

5 Passed away
6 Hospitalize room

Jeumpa 1

28/28 bed

Jeumpa 2

28/28 bed

Jeumpa 3

28/28 bed

Jeumpa 4

26/26 bed

ICU

2 Patients

ICUC

1 Patients

PICU

1 Patients

NICU

2 Patients

ICU
Usman/M/51 yo/Post VP shunt ai Stroke
ADULT
Haemoraghic + IVH/POD 28
Farhan Andika/M/17 yo/Poost Craniectomy ai
evakuasi ICH/POD 17
NICU

By Assifa Najwa Salsabila/F/12 do/Post Eksisi

Higroma Coli/POD 3
By Ahmad Alfaya/M/13 do/Susp. Hirschsprungs
disease/AD 3

ICU
Nurjannah/F/5 yo/Effusi pleura bilateral ec Ca
Cardia
Mamae post VATS/POD 5
c
PICU

Kaisa Azisa/M/5 yo/Post Laparotomy explorasi +

reseksi kolon sigmoid+ end stoma ai perforasi
sigmoid/POD 9

Patient identity
Name

: Yandika

Age

: 34 years old

Sex
Address
Simeuleu

: Male
: Ds. Tran Meutiara, Kab

MR

: 1082207

HP

: 082370587868

Driving licence

: (+)

Admission time

: at 1:55 PM

Time Response
Date/ Exam Laborator Radiology
hour inati
y
Examinati
patie
on
Examinati
on
nt
hour
on
came
Sen Res Send Res
to ER
d
ult
ult

28-22016
01.55
PM

Hour Date/ Superv

of
hour
isor
Diag patie
nosti nt out
cs
from
ER

02.03 02.1 03.3 02.30 03.0 03.00

PM
0 PM 0 PM
PM
0 PM
PM

28-22016
04.00
PM
OR

dr.
Bustami
SpBS

Chief complaint
Decrease of consciousness
Patient illnes History
The patient reffered from Simeuleu
distric hospital
to Zainoel Abidin
emergency room with chief complaint
decrease of consciousness for 3 days.
The complaint started when the
patient was riding motorcycle without
helmet, suddenly strucked a cow. He
felt down to the street and his head hit

Physical examination
Primary survey
A : Clear, C-spine control
B : Spontaneous, RR : 22 breaths/min
C : BP : 146/86 mmHg, Pulse : 78
beats/min
D : GCS : 9 : E2 M5 V2 , pupil 3mm/3mm,
light reflex (+/+), no lateralization
E:

L/S at the right parietal region

I : hematome (+), wound (-)

Secondary survey
Head region :
L/S at the right parietal region
I : hematome (+), wound (-)
Neck region
: in normal limit
Thorax region
: in normal limit
Abdominal region : in normal limit
Pelvic region
: in normal limit
Upper extremity
: in normal limit
Lower extremity
: in normal limit

Assessments:
Moderate head injury

Management
Stop oral intake
Head up 30
Urine catheter clear (initial 50 cc)
O2 8 L/minutes via facemask
IVFD NaCl 0,9% 20 drips/minutes
Inj. Ceftriaxone 1 gram
Inj. Ketorolac 30 mg
Laboratory examination
Radiology examination

Laboratory result
Hb

: 13,8 gr/dl

White blood count

Platelet

: 12.400 /ul

: 112.000 /ul

CT

: 9 minute

BT

: 3 minute

Ht

: 42 %

Radiology Examination result

Head CT-Scan:
SCALP hematoma at the left parietal and the
right fronto-temporo-parietal region
There was no fracture at the bone window
There were hyperdens area at the right frontotemporo-parietal region SDH, SAH and ICH
Sulcus and gyrus was narrow
Ventricle and cysterna system was narrow
There was midline shift to the left > 0,5 cm

Cervical Lateral in normal limit

Diagnose
1. Moderate head injury (ICD 10 CM S06.0)
2. SDH at the right fronto-temporo-parietal
region (ICD 10 CM I62.1)
3. ICH at the right fronto-temporo-parietal
region (ICD 10 CM I61.1)
4. SAH at the right fronto-temporo-parietal
region (ICD 10 CM I60.0)

Consult to Neurosurgery Division

.Craniotomy decompression emergency

Operative report :
Performed temporo-frontal extended incision
layer by layer
Made 5 burr holes, the skull was sawed and
pull out.
The dura looked bluewish and tension
Performed dura stiches
Duramater was incision sharply.
Evacuated SDH with thick about 1 cm
Bleeding control and perform duraplasty
Bone flap to subgaleal
Performed one tube drain

Post Operative Diagnosed :

1. Moderate head injury (ICD 10 CM S06.0)
2. SDH at the right fronto-temporo-parietal
region (ICD 10 CM I62.1)
3. ICH at the right fronto-temporo-parietal
region (ICD 10 CM I61.1)
4. SAH at the right fronto-temporo-parietal
region (ICD 10 CM I60.0)

Follow up
Dat
S
O
e
29/2/ Decreas Vital Sign :
2016
BP : 140/90
e of
POD conscio mmhg
1
usness HR : 67
beats/min
RR: 20
breaths/min
with ventilator
IPPV
TV : 450
PEEP : 5
Temp : 37,2 0 C

Post craniotomy
decompression
(SDH evacuation)

Head Up 30o
IVFD NaCl
0,9% 20
drips/min
Inj.Ceftriaxon
2 gr/24 hours
Inj.Metamizol
e Sodium 1 gr
/ 8 hours
Inj.Ranitidin
50 mg/12
hours
Inj. Phenitoin
100 mg/ 8
hours
Piracetam 1
gr/8 hours

1.Moderate head
injury (ICD 10 CM
S06.0)
2.SDH at the right
fronto-temporoparietal region
(ICD 10 CM I62.1)
3.ICH at the right
fronto-temporoGCS : on
parietal region
ventilator
(ICD 10 CM I61.1)
4.SAH at the right
S/L at the
fronto-tempororight temporoparietal region
parietal :
(ICD 10 CM I60.0)
I : wound

Liquid diet
6x100