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RF Edit SN
Survei Primer
A : gurgling suctioning intubation with C-spine control
B : RR: 24 x/min, Symmetrical shape and movement, VBS right = left
C : P: 117 x/min, BP: 137/80 mmHg
D : GCS: E2M4V2 = 8 E2M4VT = 6T
Pupil round equal Ø RLO 3 mm/3 mm, LR +/+
Motoric: left hemiparesis
Secondary Survey:
At Left MAE: Otorrhagia (+), Halo test (-)
At Left Clavicle : Deformity (+), Crepitation (+)
Cervical and Thorax X-Ray at Hasan Sadikin Hospital, Bandung
November 5th, 2018
DO at right frontotemporoparietal :
• Tidak ditemukan garis fraktur pada tulang
• Ditemukan duramater kebiruan, intak dan
tegang.
• Ditemukan SDH clot 5 cc, lisis 5 cc
• Ditemukan ICH clot 15 cc, lisis 10 cc
• Dilakukan duroplasty menggunakan graft
pericranial
• Left bone defect 12x10 cm
• GCS pre op E1M4VT = 5T
• Interval op 16 jam
Physical Examination
General State:
BP: 110/70 mmHg HR: 72 x/min RR: 18 x/min T: 37,3ºC
Local State:
At Right Frontotemporoparietal: bone defect size 12 x 10 cm, scar post op (+)
At Mid Frontoparietal: bone flap (+)
Neurological State:
GCS: 15, nuchal rigidity (-)
Pupils: round, equal, Ø RLO 3 mm/3 mm, LR +/+
Visus: RLO > 6/60
Funduscopy: papil defined border
Eye ball movement: good to all direction
Other cranial nerves: within normal limit
Motoric: left hemiparesis 5 1
Sensoric: within normal limit 5 1
Physiologic reflex: +/+
Pathologic reflex: babinski -/+
Laboratory Findings
General States:
BP: 100/70 mmHg P: 98 x/min RR: 22 x/min T: 36,9C
Local States:
At Right Parietal: hematoma (+),
Lacerated wound 4x0.5 cm, based on fascia
Lacerated wound 2x0.5 cm, based on fascia
Neurological States:
GCS: 15
Pupils: round, equal, Ø RLO 3 mm/3 mm, LR +/+
Motoric paresis: -/-
Laboratory Findings
Labs Result
Hb 10.3
Ht 31.3
L 8.640
Tr 364.000
Head CT Scan at Slamet General Hospital, Garut
March 15th, 2019
Head CT Scan at Slamet General Hospital, Garut
March 15th, 2019
• Soft tissue swelling at right
parietal
• Bone discontinuity > 1 table at
right parietal
• Sulci and gyri are not
compressed
• Sylvian fissure and ventricles
are not compressed
• Cistern are not compressed
• Midline shift (-)
WD/ Mild Head Injury + Closed Depressed Fracture > 1 table at Right
Parietal + Lacerated Wound at Right Parietal
ICD 10: Concussion (S06.0); Fracture of vault of skull (S02.0); Open wound of
scalp (S01.0)
General States:
BP: 90/60 mmHg P: 102 x/min RR: 24 x/min T: 36,5C
Local States:
At Mid Paritooccipital: hematoma (+)
Neurological States:
GCS: 15
Pupils: round, equal, Ø RLO 3 mm/3 mm, LR +/+
Motoric paresis: -/-
Laboratory Findings
Labs Result
Hb 11.6
Ht 32.0
L 9.770
Tr 254.000
Skull X-Ray at Hasan Sadikin Hospital, Bandung
March 15th, 2019
No Fracture Line
WD/ Mild Head Injury
Th/ Conservative
General States:
BP: 90/50 mmHg P: 108 x/min RR: 26 x/min T: 36,8C
Local States:
At Mid Occipital: hematoma (+)
Neurological States:
GCS: 15
Pupils: round, equal, Ø RLO 3 mm/3 mm, LR +/+
Motoric paresis: -/-
Laboratory Findings
Labs Result
Hb 12.4
Ht 35.2
L 10.200
Tr 286.000
Skull X-Ray at Hasan Sadikin Hospital, Bandung
March 15th, 2019
No Fracture Line
WD/ Mild Head Injury
Th/ Conservative
General States:
BP: 120/70 mmHg P: 76 x/min RR: 16 x/min T: 36,9C
Local States:
At Left Frontal: excoriated wound (+), hematoma (+)
At Left Zygoma: lacerated wound 2 x 0.5 cm
based on subcutaneous
At Left Periorbital: lacerated wound (+) 1 x 0.5 cm
based on subcutaneous
Neurological States:
GCS: E3M6V5 = 14
Pupils: round, equal, Ø RLO 3 mm/3 mm, LR +/+
Motoric paresis: -/-
Laboratory Findings
Labs Result
Hb 16.1
Ht 46.5
L 13.190
Tr 234.000
Skull X-Ray at Hasan Sadikin Hospital, Bandung
March 15th, 2019
No Fracture Line
WD/ Mild Head Injury + Multiple Lacerated Wound at Left Zygoma and
Left Periorbital
Local State:
At Cervical: tenderness (+), deformity (-)
At Right Hemithorax: CTT (+), WSD (+), air bubble (+)
Neurological State:
GCS 15, nuchal rigidity (-)
Pupils : Round equal, RLO Ø 3 mm/3 mm, LR +/+
Sensoric : Hypesthesia at level C6 below
Propioseptif : Disrupted
Vegetative : Urinary catheter (+)
Motoric :
Elbow flex 4/4 Hip flexion 1/1
Sacral Sparing :
Wrist 1/1 Knee extension 1/1
• Perianal sensation (+), hypesthesia (+) extension
• Voluntary anal contraction (+)
Extend elbow 1/1 Ankle 1/1
• Great toe extension (-) dorsoflexion
Physiological Reflex : +/+ Flexion middle 1/1 Great toe 1/1
Pathological Reflex : Babinsky +/+ distal phalanx extension
Finger abduct 1/1 Ankle plantar 1/1
flexion
Laboratory Findings
Local States :
Ar Thorax: VBS right < left, rh -/- wh -/-, Scar post op (+) at right hemithorax
Neurological State :
GCS E3M5V2 = 10, Nuchal rigidity (-)
Pupil : Round equal, Ø ODS 3 mm/ 3 mm, LR : +/+
Visus : difficult to be examined
Funduscopy : bilateral papil edema
Eye ball movement : Doll’s eyes (+)
Other cranial nerves : difficult to be examined
Motoric : no paresis
Sensoric : response to pain (+)
Physiologi reflex : +/+
Babinski : -/-
Laboratory Findings
Local State:
-
Neurological State:
GCS 15, nuchal rigidity (-)
Pupils : Round equal, RLO Ø 3 mm/3 mm, LR +/+
Sensoric : Paresthesia at level Th 4 below, bilateral symmetric
Vegetative : Within normal limit
Motoric : Elbow flex 5/5 Hip flexion 0/0
Sacral Sparing : Wrist 0/0 Knee extension 0/0
extension
• Perianal sensation (+)
Extend elbow 0/0 Ankle 0/0
• Voluntary anal contraction (+) dorsoflexion
• Great toe extension (+) Flexion middle 0/0 Great toe 0/0
Physiological Reflex : ++/++ distal phalanx extension
Pathological Reflex : Babinski +/+ Finger abduct 0/0 Ankle plantar 0/0
flexion
Laboratory Findings
Syringomyelia at level
vertebrae Th 1 - Th 9
WD/ Myelopathy at level Vertebra Th 4 below due to suspect Transverse
Myelitis and Syringomyelia at Level Vertebrae Th 1 – Th 9 + Sjogren’s
Syndrome
Local States :
Ar Thorax: VBS right = left, rh -/- wh -/-, slem -/-
Head Circumference: 45.5 cm (N: 41- 46 cm)
Anterior Fontanelle: Open, size 1x1 cm, flat, not tense
At Right Palpebral: Ptosis (+)
Neurological State :
CCS E3M3V2 = 8, Nuchal rigidity (-)
Pupil : Round unequal, Ø ODS 4 mm / 2 mm, LR : +↓/+
Visus : difficult to be examined
Funduscopy : difficult to be examined
Eye ball movement : difficult to be examined, doll’s eyes (+)
Other cranial nerves : paresis of right CN III
Motoric : no paresis
Sensoric : response to pain (+)
Physiologi reflex : +/+
Babinski : +/+
Laboratory Findings
The patient was born from P1A0 mother, preterm (36 weeks), Spontaneous
delivery by Obstetrician at Hasan Sadikin Hospital. BBW 2030 grams, and
directly crying. History of USG Fetomaternal with suspect Ventriculomegaly.
History of ANC (+) regularly to midwife. History of mother’s infection during
prenatal care (-). History of drug consumption during pregnancy (-). History
Folat acid consumption (+).
Physical Examination (18/02/2019)
General States:
HR: 140 x/min RR: 38 x/min T: 37° C
Local States:
Head circumference: 33 cm (N: 31 - 35 cm)
Anterior fontanelle: open, flat, not tense, size 3 x 4 cm
Frontal bossing (-)
At lumbosacral: lump size 4 x 3 x 3 cm, soft, defined border, transilumination
(+), discharge (+), pus (-).
At bilateral foot: Bilateral Congenital Talipes Equinovarus
Physical Examination
Neurological States:
CCS 11, nuchal rigidity (-)
Pupils: round equal, Ø RLO 3 mm/3 mm, LR +/+
Visus: RLO: difficult to be examined
Funduscopy: RLO: difficult to be examined
Eye ball’s movement: difficult to be examined
Other cranial nerves: difficult to be examined
Motoric: no paresis
Sensoric: response to pain
Vegetatif: within normal limit
Physiological reflex: +/+
Babinski reflex +/+
Laboratory Finding at Hasan Sadikin Hospital Bandung
January 14th, 2019
Local States :
Head circumference: 35 cm (N: 35 - 39 cm)
Anterior fontanelle: open, flat, not tense, size 4 x 4 cm
Frontal bossing (-)
At lumbosacral: lump size 4 x 3 x 3 cm, soft, defined border, transilumination
(+), discharge (+), pus (-).
At bilateral foot: Bilateral Congenital Talipes Equinovarus
Physical Examination
Neurological State :
CCS E3M4V2 = 9, Nuchal rigidity (-)
Pupil : Round equal, Ø ODS 3 mm/ 3 mm, LR : +/+
Visus : difficult to be examined
Funduscopy : difficult to be examined
Eye ball movement : difficult to be examined, Doll’s eyes (+)
Other cranial nerves : difficult to be examined
Motoric : paraparesis inferior
Sensoric : respond to pain
Physiologi reflex : +/+
Babinski reflex: +/+
Laboratory Findings
GICU 2
GICU 1
Ventilator Mode
Spontaneous ICH at left Parietooccipital due to PS 6 PEEP 5 FiO2
Craniectomy
suspect Amyloid Angiopaty DD/ Hypertension + 40%)
Decompression and
Emergency Hypertension + Bronchopneumonia Antibiotic
7 Yulianti P 59 yo POD 28 E3M5V2 = 10 E3M5Vtc = 8tc Evacuation (01.24) Breathing AD
Therapy
ICD 10: Non traumatic ICH (I61.5); Primary
Tracheostomy (31.1)
hypertension (I10); Bronchopneumonia(J18.0); Advice :
Thorax xray
GCS/CCS GCS/CCS
BED NAME SEX AGE POD / PH DIAGNOSIS PROCEDURE PROBLEM THERAPY KS
INITIAL TODAY
NICU
Mode Ventilator
Microcephaly + Spontaneous IVH at Lateral Ventricle
SIMV PC (IPL 14
due to Suspect Germinal Matrix Hemorhage Grade III
RR 24 PS 9 PEEP
+ Suspect Hydrocephalus + Preterm Infant (30 week)
6 FIO2 30%)
+ LBBW (Low Birth Body Weight) + Respiratory
By. Irnawati P 1 mo PH 3 CCS E4M4VT=8T CCS E4M4VT=8T Distress Syndrome + Bronchopneumonia - Breathing MS
Advice :
Head
ICD 10: Other intracranial (nontraumatic)
circumferrence
hemorrhages of newborn (P52.8);
observation
BRONCHOPNEUMONIA (J18.0)
Head USG Serial
OUTPATIENT CLINIC
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