KENANGA

1. Identity of patient
Name : Sandy Bere
Sex : Male
Age : 11 years old
No MR :
Chief complain : Headache
History of disease : The patient came to the hospital complaining of right-sided headache
since 3 hours before being admitted to the hospital. The patient had a history of being shot by
an air gun to the right side of his head. The pain that is felt is getting worse and did not
spread. At the time of the incident the patient remained conscious, nausea (-), vomiting (-),
rhinorhea (-), othhorhea (-)
Phisycal Examination
General state : moderate illness
GCS : E4V5M6
Blood Pressure : 110/60 mmHg
Pulse : 60x/minute
RR : 21x/minute
Temperature : 36,7 C
Secondary Survey
Head : Normocephal, wound in the right frontal (+), bleeding (-), swelling (-)
Eye : anemic conjungtive(-/-), icteric sclera(-/-), bruise (-/-)
Ear : otorhagia (-/-)
Nose : Rhinorea (-/-), blood (-/-)
Mouth : pale (-) ,cyanosis (-)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : symmetrical chest expansion , lesion (-) bruise (-) wound (-)
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultasi : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)
Abdomen:
 Inspection : flat, symetric
 Ausculation : bowel sound (+) normal
 Palpation : Supel, organomegaly (-)
  Percussion : Tympanic
Extremities:
 Warm
 edema (-/-)
 CRT < 2 sec

CT Scan

Assesment
Vulnus sclopetorum at regio frontal dextra

Planning therapy
Pro craniotomy exploration (25/08/2020)
Current condition : post craniotomy POD-2, GCS E4V5M6, dizziness (+) when trying to
mobilization. Nausea (-), vomiting (-).

2. Identity of Patient
Name : Eman Maubanu
Sex : Male
Age : 7 years old
No MR :
Chief complain : Headache
Anamnesis
Chief complain : unconsciousness
The referral patient from Kefa Hospital with diagnosis of severe head injury. The patient
come with complaints of decreased consciousness since 1 day before being admitted to the
hospital. The patient has a history of falling from a tamarind tree with a height of about 4
meters. After falling, the patient immediately fell unconscious, vomiting 2 times. Seizures (-),
rhinorre (-), othhorhea (-)
Phisycal Examination (24/08/2020)
General state : Severe illness
GCS : E2V1M5
Blood Pressure : 100/70 mmHg
Pulse : 120x/minute
RR : 22x/minute
Temperature : 37 C
Phisycal Examination (28/08/2020)
General state : Moderate illness
GCS : E4V5M6
Blood Pressure : 110/70 mmHg
Pulse : 82x/minute
RR : 20x/minute
Secondary Survey
Head : hematom on regio temporooccipital sinistra
Eye : anemic conjungtive(-/-), icteric sclera(-/-), bruise (-/-), anisokor pupil 3mm/5mm
light reflects +/+ minimal
Ear : otorhea (-/-)
Nose : Rhinorea (-/-), blood (-/-)
Mouth : pale (-) ,cyanosis (-)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : symmetrical chest expansion , lesion (-) bruise (-) wound (-)
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultasi : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)
Abdomen:
 Inspection : flat, symetric
 Ausculation : bowel sound (+) normal
 Palpation : Supel, organomegaly (-)
 Percussion : Tympanic
Extremities:
 Warm
 edema (-/-)
 CRT < 2 sec
CT Scan
Assestment
Pre-OP : severe HI + EDH at regio TP sinistra, pro craniotomy evacuation
Post OP (28/08/2020) : Post craniotomy evacuation Severe HI + EDH at regio TP
sinistra POD-4
Planning Therapy
Pre-OP : pro craniotomy evacuation
Post-OP :
Obs GCS , vital sign
Head up 300
Diet cair 6x100 cc/NGT
Rawat luka / hari
 IVFD D5 ½ NS 750 cc/24 jam
 Inj. Terfacef 1x500 gram
 Inj. Ketorolac 2 x 10 mg
 Inj. Ranitidin 2x25 mg
 Inj. Vit K 3x5 mg iv
 Inj. Plasminex 3x250 mg iv
 Sucralfate 4x5 cc PO

3. Identity of Patient
Name :Yusri Liu
Sex : Male
Age : 7 years old
No MR : 535586
Chief complain : Headache
Anamnesis
S : Pasien rujukan dari rumah sakit so'e dengan penurunan kesadaran setelah ditabrak motor
1 hari yg lalu sebelum masuk rumah sakit. Pasien ditabrak dari samping dan kepala pasien
terkena setir motor. Setelah kejadian pasien mengalami penurunan kesadaran. Sakit kepala
(+), Muntah (+), Seizures (-), rhinorre (-), othhorhea (-)

Chief complain : unconsciousness

The referral patient from So'e Hospital with a decrease in consciousness after being hit by a
motorbike 1 day ago before being admitted to the hospital. The patient was hit from the side
and the patient hit the head of the motorbike. After the incident the patient experienced a
decrease in consciousness. Headache (+), Vomiting (+), Seizures (-), rhinorre (-), othhorhea
(-)

Phisycal Examination (26/08/2020)

General state : Severe illness
GCS : E3V4M5
Blood Pressure : 110/70 mmHg
Pulse : 120x/minute
RR : 22x/minute
Temperature : 37 C
Phisycal Examination (28/08/2020)
General state : Moderate illness
GCS : E4V5M6
Blood Pressure : 110/70 mmHg
Pulse : 82x/minute
RR : 20x/minute
Secondary Survey
Head : Vulnus laseratum at regio parietal
Eye : anemic conjungtive(-/-), icteric sclera(-/-), bruise (-/-), light reflects +/+ minimal
Ear : otorhea (-/-)
Nose : Rhinorea (-/-), blood (-/-)
Mouth : pale (-) ,cyanosis (-)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : symmetrical chest expansion , lesion (-) bruise (-) wound (-)
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultasi : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)
Abdomen:
 Inspection : flat, symetric
 Ausculation : bowel sound (+) normal
 Palpation : Supel, organomegaly (-)
 Percussion : Tympanic
Extremities:
 Warm
 edema (-/-)
 CRT < 2 sec
CT Scan
Assestment
Pre-OP : mild HI + open fracture depressed Depressed Parietal
Post OP (28/08/2020) : post op craniotomy debridement e. c mild HI + open fracture
depressed Depressed Parietal
Planning Therapy
Pre-OP : pro craniotomy debridement
Post-OP :
Obs GCS , vital sign
Head up 300
Diet cair 6x100 cc/NGT
Rawat luka / hari
 IVFD D5 ½ NS 750 cc/24 jam
 Ceftriaxon 2x500 mg
 Inj. Ketorolac 2 x 10 mg
 Inj. Ranitidin 2x25 mg
 Inj. Vit K 3x5 mg iv
 Inj. Plasminex 3x250 mg iv

4. Identity of Patient
Name : Farida
Sex : Male
Age : 7 years old
No MR : 535586
Chief complain : Headache
Anamnesis
4. Ny. Farida/
S : Pasien rujukan dari RS naibonat dengan diagnosa DOC HT emergensi ec susp SNH dd
SH. Pasien datang dengan keluhan penurunan kesadaran sejak 1 hari sebelum masuk rumah
sakit. Awalnya Pasien kemarin mengeluhkan pusing saat pasien sedang mandi. Pasien lalu
dibawa oleh suami ke tempat tidur. Dan saat di tempat tidur pasien tidak sadarkan diri dan
pasien sempat buang air besar tidak sadar. Pasien muntah 3x saat di RSUD naibonat.
Riwayat Penyakit Dahulu HT (+)
Referral patient from naibonat hospital with diagnosis of emergency HT DOC ec susp SNH
dd SH. The patient presented with complaints of decreased consciousness since 1 day before
admission to the hospital. One day before, the patienr felt dizziness while she was taking
shower. Because of the complaint of dizziness, her husband took her to bed. While in the bed,
she defecate unconsciously. The patient vomited 3 times while at the naibonat hospital. Past
Medical History HT (+)

Phisycal Examination (26/08/2020)

General state : Severe illness
GCS : E3V4M5
Blood Pressure : 110/70 mmHg
Pulse : 120x/minute
RR : 22x/minute
Temperature : 37 C
Phisycal Examination (28/08/2020)
General state : Moderate illness
GCS : E4V5M6
Blood Pressure : 110/70 mmHg
Pulse : 82x/minute
RR : 20x/minute
Secondary Survey
Head : Vulnus laseratum pada regio parietal
Eye : anemic conjungtive(-/-), icteric sclera(-/-), bruise (-/-), light reflects +/+ minimal
Ear : otorhea (-/-)
Nose : Rhinorea (-/-), blood (-/-)
Mouth : pale (-) ,cyanosis (-)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : symmetrical chest expansion , lesion (-) bruise (-) wound (-)
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultasi : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)
Abdomen:
 Inspection : flat, symetric
 Ausculation : bowel sound (+) normal
 Palpation : Supel, organomegaly (-)
 Percussion : Tympanic
Extremities:
 Warm
 edema (-/-)
 CRT < 2 sec
CT Scan
Assestment
Pre-OP : mild HI + open fracture depressed Depressed Parietal
Post OP (28/08/2020) : post op craniotomy debridement e. c mild HI + open fracture
depressed Depressed Parietal
Planning Therapy
Pre-OP : pro craniotomy debridement
Post-OP :
Obs GCS , vital sign
Head up 300
Diet cair 6x100 cc/NGT
Rawat luka / hari
 IVFD D5 ½ NS 750 cc/24 jam
 Ceftriaxon 2x500 mg
 Inj. Ketorolac 2 x 10 mg
 Inj. Ranitidin 2x25 mg
 Inj. Vit K 3x5 mg iv
 Inj. Plasminex 3x250 mg iv
Identity of patient
Name : Jamres Subu
Sex : Male
Age : 29 years old
No MR :
Chief complain : Headache
History of disease : The patient was brought by his family because of the traffic accident. The
mechanism of the accident: the motorcycle hit a rock, and then the patient fall with head hit
the asphalt. Blood from the right ear (+) After the accident, the patient remain unconscious,
and he doesnt remember about the accident. The patient is under alcohol when he was driving
the motorcycle. The patient doesn’t wear helmet.
Phisycal Examination
General state : moderate illness
GCS : E4V5M6
Blood Pressure : 110/70 mmHg
Pulse : 85x/minute
RR : 21x/minute
Temperature : 36,7 C
Secondary Survey
Head :hematom (+), vulnus excoriasi , vulnus laceratum and krepitasi at regio temporal
dextra.
Eye : anemic conjungtive(-/-), icteric sclera(-/-), bruise (-/-)
Ear : otorhea (+/-)
Nose : Rhinorea (-/-), blood (-/-)
Mouth : pale (-) ,cyanosis (-)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : symmetrical chest expansion , lesion (-) bruise (-) wound (-)
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultasi : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)
Abdomen:
 Inspection : flat, symetric
 Ausculation : bowel sound (+) normal
 Palpation : Supel, organomegaly (-)
  Percussion : Tympanic
Extremities:
 Warm
 edema (-/-)
 CRT < 2 sec

CT Scan

Assesment
EDH + depressed fracture at os temporal dextra
Planning therapy
 IVFD Futrolit 1500 cc/24 jam
 Inj. Terfacef 1x1 gr
 Inj. Ketorolac 2 x 40 mg
 Inj. Ranitidin 2x50 mg
 Inj. Vit K 3x10 mg iv
 Inj. Plasminex 3x500 mg iv
 Patient refused the craniotomy
Identity of patient
Name : Yohanes Mau
Sex : Male
Age : 22 years old
No MR :
Chief complain : paralysis on both legs
History of disease : Referral patient from Bajawa hosptal diagnosed with SCI Frankle type A
as high as 3,4 lumbar + multiple decubitus ulcer + urethral rupture + anemia. Patient post car
traffic accidents on March 18, 2020. After the incident the patient was unconscious for 4
hours. Then immediately the patient complained of numbness in both legs and could not
move them. The Patient also cannot feel and control defecating and bloating.
Phisycal Examination (06/08/2020)
General state : moderate illness
GCS : E4V5M6
Blood Pressure : 110/70 mmHg
Pulse : 85x/minute
RR : 21x/minute
Temperature : 36,7 C
Secondary Survey
Head : wound (-), hematom (-)
Eye : anemic conjungtive(-/-), icteric sclera(-/-), bruise (-/-)
Ear : otorhea (+/-)
Nose : Rhinorea (-/-), blood (-/-)
Mouth : pale (-) ,cyanosis (-)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : symmetrical chest expansion , lesion (-) bruise (-) wound (-)
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultasi : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)
Abdomen:
 Inspection : flat, symetric
 Ausculation : bowel sound (+) normal
 Palpation : Supel, organomegaly (-)
 Percussion : Tympanic
Extremities:
 Warm
 edema (-/-)
 CRT < 2 sec
Esktremities inferior
Motoric : 0000/0000

CT Scan

Assesment
Pre op : parese inferior ec SCI + Multiple ulkus decubitus
Post op (28/08/2020) : post laminectomy with stabilization posterior ec SCI POD-2

Planning therapy (28/08/2020)

 Observation GCS, vital sign
 Inline position
 02 2 lpm via NK
 IVFD Futrolit 1500 cc/24 jam
 Inj. Ceftriaxon 2x1 gr
 Inj. Ketorolac 2x30 mg
 Inj. Omeprazole 2x20 mg
 Inj. Kalnex 3x500 mg
 Inj. Methylprednison 3x120mg
Identity of patient
Name : Syamsudin
Sex : Male
Age : 64 years old
No MR :
Chief complain : decreased of conciousness
History of disease : Patient had decreased of consciousness since 2 days before admission to
the hospital. Previously, patient was found in the bedroom with unconscious. Nausea (-)
vomiting (-) fever (-) mechanism of falling is denied.
Phisycal Examination (28/08/2020)
General state : moderate illness
GCS : E4VxM5
Blood Pressure : 140/90 mmHg
Pulse : 81x/minute
RR : 24x/minute
Temperature : 37 C
SpO2 : 98%
Secondary Survey
Head : wound (-), hematom (-), adanya luka operasi
Eye : anemic conjungtive(-/-), icteric sclera(-/-), bruise (-/-)
Ear : otorhea (+/-)
Nose : Rhinorea (-/-), blood (-/-)
Mouth : pale (-) ,cyanosis (-)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : symmetrical chest expansion , lesion (-) bruise (-) wound (-)
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultasi : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)
Abdomen:
 Inspection : flat, symetric
 Ausculation : bowel sound (+) normal
 Palpation : Supel, organomegaly (-)
 Percussion : Tympanic
Extremities:
 Warm
 edema (-/-)
 CRT < 2 sec

CT Scan

Assesment
(28/08/2020) : post VP Shunt ec Hydrocephalus POD-5

Planning therapy (28/08/2020)

 Observation GCS, vital sign
 Head up 300
 Rawat luka/hari
 02 4-6 lpm via NK
 Diet bubur saring 6x200 cc
 IVFD Futrolit 1500 cc/24 jam
 Inj. Tramadol 2x100 mg
 Inj. Omeprazole 2x40 mg
 Inj. Plasminex 3x500 mg
 Inj. Vit K 3x10mg
 Sucralfat syrup 4x10 cc/NGT
 Inj. Metocloperamid Hcl 3x1 amp IV
 1. Identity of Patient
Name : Halimah
Sex : Female
Age : 37 years old
No MR :
Anamnesis
S : Pasien rujukan Siloam Dengan SAH + Hidrocephalus communicans + edema cerebri + ht
+ hipokalemia +pro vp shunt cito. Awalnya pasien mengeluhkan nyeri kepala yg sangat
berat, sekitar 1 jam kemudian pasien mulai gelisah dan mengalami penurunan kesadaran. (+),
Muntah (-). Seizures (-).
Chief complain : Decreased of of consciousness
Siloam referral patient With SAH + Hydrocephalus communicans + cerebral edema + ht +
hypokalemia + pro vp shunt cito. Initially the patient complained of a very severe headache,
about 1 hour later the patient began to be restless and experienced a decrease in
consciousness. (+), Vomiting (-). Seizures (-).

Phisycal Examination (25/08/2020)

General state : Severe illness
GCS : E3V1M5
Blood Pressure : 140/90 mmHg
Pulse : 120x/minute
RR : 22x/minute
Temperature : 36.5 C
Phisycal Examination (28/08/2020)
General state : Moderate illness
GCS :EVM
Blood Pressure : 110/70 mmHg
Pulse : 82x/minute
RR : 20x/minute
Secondary Survey
Head : Normocephal
Eye : anemic conjungtive(-/-), icteric sclera(-/-), bruise (-/-), light reflects +/+
Ear : otorhea (-/-)
Nose : Rhinorea (-/-), blood (-/-)
Mouth : pale (-) ,cyanosis (-)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
 – Inspection : symmetrical chest expansion , lesion (-) bruise (-) wound (-)
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultasi : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)
Abdomen:
 Inspection : flat, symetric
 Ausculation : bowel sound (+) normal
 Palpation : Supel, organomegaly (-)
 Percussion : Tympanic
Extremities:
 Warm
 edema (-/-)
 CRT < 2 sec
CT Scan
Assestment
Pre-OP : Hidrocephalus Komunikan + SAB + Ruptur aneurisme
Post OP (28/08/2020) : post vp shunt POD 2
Planning Therapy
Pre-OP : pro EVD
Post-OP :
Obs GCS , vital sign
Head up 300
Puasa- Diet cair 6x200 cc/NGT
Rawat luka / hari
 IVFD 1000 cc/24 jam
 Ceftriaxon 1x1 gr
 OMZ 2x40 mg
 Inj. Vit K 3x10 mg iv
 Inj. Plasminex 3x250 mg iv
 Pertahankan tekanan darah < 140
 Current condition : post craniotomy POD2, G C S , dizziness (+) Nausea (-), vomiting
(-).

2. Identity of Patient
Name : Marthen Here
 Sex : male
Age : 24 years old
No MR :
Anamnesis
S : Pasien datang dengan keluhan penurunan kesadaran sejak 1 jam yg lalu sebelum masuk
rumah sakit. Pasien mengalami kecelakaan lalu lintas, pasien menbrak mobil dan pasien
terjatuh ke sebalah kiri. setelah itu pasien cenderung tidur, nyeri kepala ( +), muntah (-).
Seizures (-), rhinorre (-), othhorhea (-)
Decreased of of consciousness
The patient presented with complaints of decreased consciousness since 1 hour ago before
admission to the hospital. The patient had a traffic accident, the patient hit the car and the
patient fell to the left. after that the patient tends to sleep, headache (+), vomiting (-). Seizures
(-), rhinorre (-), othhorhea (-)

Phisycal Examination (25/08/2020)

General state : Severe illness
GCS : E3V4M5
Blood Pressure : 120/80 mmHg
Pulse : 120x/minute
RR : 22x/minute
Temperature : 36.5 C
Phisycal Examination (28/08/2020)
General state : Moderate illness
GCS :EVM
Blood Pressure : 110/70 mmHg
Pulse : 82x/minute
RR : 20x/minute
Secondary Survey
Head : Normocephal
Eye : anemic conjungtive(-/-), icteric sclera(-/-), bruise (-/-), light reflects +/+
Ear : otorhea (-/-)
Nose : Rhinorea (-/-), blood (-/-)
Mouth : pale (-) ,cyanosis (-)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : symmetrical chest expansion , lesion (-) bruise (-) wound (-)
 – Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultasi : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)
Abdomen:
 Inspection : flat, symetric
 Ausculation : bowel sound (+) normal
 Palpation : Supel, organomegaly (-)
 Percussion : Tympanic
Extremities:
 Warm
 edema (-/-)
 CRT < 2 sec
CT Scan
Assestment
Pre-OP : Mild HI

Obs GCS , vital sign

 IVFD Furtrolit 1500 cc/24 jam
 Terfacef 1x1 g
 Ranitidine 1x1 gr
 Ketorolac 2x30 mg