NEUROSURGICAL DIVISION

ACTIVITY REPORT
16 September– 22 September 2019
Coass : 1. Yehuda Simbiak
2. Wa Juliani Djampaka
3. Sarah Samori
4. Eva Siregar
5. Martha Kabagaimu
Consultant : dr. Tommy, Sp.BS
Cognita Manu Melia Cultu Neurosurgery Division
Mr.Yohanis Pallo/Male/ 18 y.o/ 451793

 Chief complaint : Penurunan Kesadaran (loss of

consciousness)
 Present illness :
Patient came to the emergency care unit with headache after
falling from a motorcycle 2 months ago. Previously the patient
had been treated at another hospital but there was no
improvement. Fainted (+) Fever (-), nausea (+) vomitting (+),
defecation/urination: minimal, Seizures (-).
 History of ilness : -

Cognita Manu Melia Cultu Neurosurgery Division

 RPS : Pasien merupakan rujukan dari RSUD Nabire
datang ke IGD RSUD Jayapura dengan keluhan
penurunan kesadaran sejak 4 hari yang lalu.
Sebelumnya pasien mengeluhkan nyeri kepala hebat
yang mendadak ketika sedang mandi, nyeri
dirasakan terus menerus, keluhan disertai dengan
mual, muntah 1x berisi makanan sebanyak kira-kira
300 cc, kejang disangkal, kemudian tiba-tiba pasien
tidak sadar dan dibawa ke RSUD Nabire dilakukan
pemeriksaan CT Scan kepala lalu di rujuk ke RSUD
Jayapura.
Cognita Manu Melia Cultu Neurosurgery Division
 RPD :
 Riwayat Stroke Perdarahan tahun 2016
 Riwayat Hipertensi grade II tidak terkontrol
 Riwayat DM (-)
 Riwayat Displidemia (-)

Cognita Manu Melia Cultu Neurosurgery Division

Mr.Yohanis Pallo/Male/ 18 y.o/ 457093
 Physical examination :
• General state: limp/ GCS 15: E4V5M6
• Motorik 5 VAS:
5 7-8

5 5

• Sensorik: Normal
• VS, BP:120/80 : HR : 100 bpm, RR : 24 x/m, T: 37,0˚C, SpO2: 99% spontan
• Normocephal, anemic conjuctiva -/-, light reflex +/+, corneal reflex +/+, blurred
vision: +/+, Parese N.VI sinistra
• Thorax: cor and pulmo within normal limit
• Abdomen: within normal limit
• Extremities: within normal limit

Cognita Manu Melia Cultu Neurosurgery Division

 Physical Examination :
General state :

Cognita Manu Melia Cultu Neurosurgery Division

Mr.Yohanis Pallo/Male/ 18 y.o/ 451793
 Clinical Diagnosis : headache
 Topical Diagnosis : regio frontotemporoparietal sinistra
 Etiological Diagnosis : Subduralhemorragic cronic

Further examination :
• Laboratory examination
• Chest X-ray, Thoracolumbal MSCT.

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Laboratorium Examination
Lab Result Lab Result
HB 13,5 Albumin -
HCT 42,8 SGOT 55,1
SGPT 124,2
RBC 6,11
WBC 8,39
PLT 321 PT 10,5

DDR Neg APTT 25,9

GDS 116
BUN 9,7
Creatinin 0,44
Kalium darah 4,79
Natrium darah 139,10
Cl darah -
Calcium darah -

Cognita Manu Melia Cultu Neurosurgery Division

Plan
 Apply II line infusion
- IVFD RL 500cc / 8 hour
 IVFD Manitol Loading 200-150-150, maintanance manitol 4x125cc
 Injection Receptor H 2 blocker 50 mg/12 hours
 Injection Antagonis serotonin 5-HT3 4mg/ 8 hours
 Injection analgesic opiate 100mg /8 hour
 Injection Phenytoin 100mg/ 8 jam
 Pro Burrhole drainage

Cognita Manu Melia Cultu Neurosurgery Division

Mr.Yohanis Pallo/Male/ 18 y.o/ 451793
MSCT skull

Cognita Manu Melia Cultu Neurosurgery Division

 Thank You

Cognita Manu Melia Cultu Neurosurgery Division