Morning Report

Tuesday, June 22 th, 2015

Team on duty
dr. Andria Saputra
( Jaga
dr. Aa Ahmad Dimyati
( Jaga
dr. Aswad Affandi
( Jaga
dr. Andri Feisal N
( Jaga 4 )
dr. Bobby Fermi S
( Jaga
dr. Avicenna Gatot
( Jaga
dr. Herdi Gunanta S
( Jaga
I.

Patient identity
Name
Age
Sex
Address
CM
Phone
Admission time

II.

:
:
:
:
:
:

1)
2)
3)
4)
5)
5)

Alifa Fitria
3 years old
Girl
Jl. Medan banda Aceh, Desa Payameuneng
10 46 613
085260551499
: 19.53 WIB

TIME RESPONE

Date/ho
ur
patient
came to
ER

Examina
tion hour

22/06/20
15
19.53

19.53

III.

Laboratory
Examinatio
n

Radiology
Examinatio
n

Sen
d

Res
ult

Sen
d

Res
ult

20.1
5

20.3
0

21.0
0

21.3
0

Hour of
Diagnos
tics

Date/h
our
patient
out
from
ER

21.30

23/6/20
15
07.30

Chief complaint
Headache and Vomite
Patient illnes History
The patient came to Zainoel Abidin Hospital with chieft complaint
headache and vomite for 2 days ago. Firstly, patient have hospilized at 1
April 2015 with a same complaint. After he going home, the complaint
become worst. Head CT-Scan (+) 3 April 2015.

IV.

Physical examination

Consciousness
HR
RR

: GCS = 15 (E4M6V5), isochoric pupil 3mm/3mm

: 96 beats/ minute
: 24 breaths/ minute

V.

Radiology Result
Head Ct-Scan
Sulcus and gyrus was narrow
Hypodens abnormal at the occipital region cerebri abses
Ventricular system normal
No midline shift

VI.

VII.

VIII.

IX.

X.

XI.

XII.

Diagnose:
1. Cerebri abses
2. Susp. Hydrocepalus
Management
Head up 30o
IVFD NaCl 0,9% 20 drips /minutes
Inj. Chloranfenicol 150 mg
Inj. Metronidazole 150 mg
Laboratory examination
Review Radiology examination
Laboratory result
Hb
White blood count
Platelet
Ht
CT
BT
Blood glucose ad random

: 12,3 gr/dl
: 23.600/ul
: 377.000 /ul
: 35 %
: 8 minute
: 2 minute
: 135 gr/dl

Radiology result
Head Ct-Scan
Sulcus and gyrus was narrow
Hypodens abnormal at the occipital region cerebri abses
Ventricular system was dilated
Temporal horn (+)
Periventricular edema (+)
No midline shift
Diagnose
Hydrocepalus Non communicant due to Abcess cerebri
Consult to Neurosurgery Division
1. VP Shunt Urgency
2. Craniotomy Abcess Evacuation (elective)

Operation report
Semilunar incision at the right of frontoparietal
Performed one burr hole, Dura mater was opened sharply

Insertion the tube to the left lateral ventricular

Pulled out LCS serenely

XIII.

Post Operative Diagnose

Hydrocepalus Non communicant due to Abcess cerebri (ICD X CM G91.1)

XIV.

Follow Up

Date

22/6/201
5
POD II

Pain
(+)
decreas
e

HR : 86x/minute
RR : 22x/minute
GCS : E4 M6 V5 :
15
L/S. at the left
frontal region:
L: Wound
operation close
by gauze (+) dry
F: pain (+)

Hydrocepalus Non
communicant due
to Abcess cerebri
(ICD X CM G91.1)

Head up 30o
IVFD NaCl 0,9%
20 drips /minutes
Inj.
Chloranfenicol
150 mg
Inj.
Metronidazole
150 mg
Novalgin 300 mg
Ranitidin 15 mg
Phenotoin 30 mg