NEUROSURGERY REPORT Saturday, August 31 st 2019 Chief on Call:dr. Centery Chief on Site:dr. M. Rainda Farhan Jaga 2:dr. Ayu Iswandari Raharjo Jaga 3:dr. Mustafa Afif Jaga 5:dr. Faisal Akbar Jaga Stase: dr. Agustina (B. Umum)

New Patient: Emergency Patient : Urgent Consult: Emergency Operation: 4 Pre Operative: - Post Operative: - Death Case: - Outpatient Clinic: - NCCU/ICU/PICU/NICU/HCU-RIK/HCU-KMG: 2 / 3 /2 / - / 1 / 3

NEW PATIENT

The patient Directly referred to Dr. dr. A. Imron, Sp.BS (K), Mkes. CC: Headache History: Since ± 1 year prior to admission, the patient complained intermittent headache that getting worst over 5 days ago. The complaint was accompanied with vomiting (+). History of fever (-) trauma (-) and seizure (-). Because of the complaint she was brought to Emergency unit of Al Islam Hospital, hospitalized for 5 days by neurologist, underwent contrast head CT scan and consulted to neurosurgeon at Al Islam Hospital, diagnosed with brain tumor then referred to Emergency Unit of Hasan Sadikin Hospital. History of behavioral changes (-). History of smelling disturbance (-), hearing disturbance (-), double vision (-), facial asymetri (-), slurred speech (- ), weakness of extremities (-). History of lump on other parts of the body (-). NP 1. Mrs. Iis Ayoe / ♀ / 54 yo / / Skullbase / IM

General State: BP: 130/80 mmHgP: 98 x/mntRR: 18 x/mnt Temp: 36,7 0 Local State: At thorax: VBS right = left, rh-/-, wh -/- Neurological State: GCS 15, nuchal rigidity (-) Pupils: round equal, RLO Ø 5 mm/5 mm, LR -/- Visus: RLO: >6/60 Funduscopy: RLO: papil defined borders Eye ball movement: good to all directions Other cranial nerve: within normal limit Motoric: no paresis Sensoric: within normal limits Physiologic Reflex : +/+ Pathologic Reflex : -/- Physical Examination

LabsResult Hb14 Ht40,9 L Tr Laboratory Finding LabsResult PT10,5 aPTT22,6 INR0,93 LabsResult Ot/Pt26/50 Ur/Cr24/0,76 Na/K140/4,7

Thorax X- Ray at Al Islam Hospital, Bandung August 28 th, 2019 Within Normal Limit

Contrast Head CT Scan at Al Islam Hospital, Bandung August 28 th 2019

Contrast Head CT Scan at Al Islam Hospital, Bandung August 28 th 2019 Sulcus and gyrus are compressed Sylvian fissures are compressed Ventricle are compressed Cisterns are not compressed Isodense mass at left sphenoid and right parietal that enhance homogenously with contrast administration Perifocal Edema (+) Hyperostosis (+) Midline shift (-)

WD/Mutiple SOL Supratentorial at Left Temporal and Right Parietal due to suspect Meningioma ICD 10:Benign neoplasm of meninges (D32.9) Th/ Plan for Craniotomy Tumor Removal Elective GCS this morning 15RIK Ward

EMERGENCY PATIENT

URGENT CONSULT

UC 1. Boy. Irfan Fikri / ♂ / 10 yo / / Pediatric / MS The patient was consulted from Pediatric Department CC: Blurred Vision History: Since + 2 weeks prior to admission, the patient complained of blurred vision of both eyes, accompanied with double vision. The complaint was preceded with intermittent headache since 1 year ago, that getting worst over 2 weeks. The complaint was accompanied with vomiting 12x. History of seizure (-), trauma (-), fever(-). Because of the complaint, he was brought to Pediatric Emergency Unit of Hasan Sadikin Hospital, underwent contrast head Ct scan, then consulted to Neurosurgery department. History of weakness extremities (-). Loss of body weight (-). Lump of the other parts of the body (-).

Physical Examination General state : BP: 110/70 mmHg HR: 100x/m RR : 22 x/mnt T : 36,5 C Local State : At Thorax: Symmetrical shape and movement, VBS right = left, rh -/- wh-/-

Physical Examination Neurological States : GCS 15, Nuchal rigidity (-) Pupil: RLO round, equal, 3mm/3mm, LR +/+ Visus: RLO: 4/60 Funduscopy: RLO: papil edema (+) Eye ball movement: Paresis Left CN VI Other cranial nerve: Within normal limit Motoric: parese -/- Sensoric: response to pain (+) Physiologic Reflex: +/+ Pathologic Reflex: Babinsky -/-

LabsResult Hb13,2 Ht36,6 L9.740 Tr LabsResult Na/K135/3,8 Ur/Cr26/0,49 RBG98 PT/APTT/ INR 10,9/18,5/ 0,97 Laboratory Finding at Hasan Sadikin Hospital Bandung August 31 st, 2019

Thorax X- Ray at Hasan Sadikin Hospital, Bandung August 31 st, 2019 Within Normal Limit

Contrast Head CT Scan at Hasan Sadikin Hospital, Bandung August 31 st 2019

Contrast Head CT Scan at Hasan Sadikin Hospital, Bandung August 31 st 2019 Sulcus and gyrus are compressed Sylvian fissure are compressed Cisterns are not compressed Enlargment of all ventricle system TH >2mm FH/ID 57,5% Evans ratio 0,45 Hyperdense mixdensity mass at pineal region that enhance inhomogen with contrast administration Calcification (+) Midline shift (-)

WD/Acute Non Communicating Hydrocephalus due to Supratentorial SOL at pineal region due to susp. Germ cell tumor dd/ Pineal cell tumor ICD 10: Npn Communicating hydrocephalus (G91.0); Benign Neoplasm of Pineal Glan (D35.4) Th/ NC : Vp Shunt Cito Pediatric (leader) : Improve general condition GCS this morning 15EMG Ward

The patient was consulted from Pediatric Department CC: Decrease of consciousness History: ± 4 days prior to admission, his family noticed that the patient looked drowsy and difficult to be awakened. The complaint was preceded with seizure 3x, whole body, duration >5 min, during and after seizure patient was unconscious. History of trauma (-). Because of the complaint, he was brought to Soreang Hospital, hospitalized for 2 days by pediatrician, diagnosed with Tuberculous meningitis then reffered to Pediatric Emergency Unit of Hasan Sadikin Hospital, underwent contrast head CT Scan and consulted to Neurosurgery Department. History of the same complaint (+) 3 weeks ago (07/08/2019), the patient was hospitalized at Kenanga 2 nd Ward for 12 days, underrwent contrast head CT scan then consulted to neurosurgery department and diagnosed with Acute communicating hydrocephalus due to Meningitis serous + Lung TB on OAT, planned for VP shunt but the family was refused. The patient sent home with improvement. UC 2. Boy Rendi / ♂ / 8 yo / / Pediatric / MS

The patient was diagnosed with active lung TB since 4 months prior to admission, and get OAT therapy. History of progressive loss of body weight (-) prolonged cough (+) since 6 month with night sweating (+). History of TB contact (+), his mother, didn’t seek any medication.

General State: P: 112 x/mntRR: 20 x/mnt Temp: 37 º C Local State: At Thorax: Symmetrical shape and movement, VBS right = left, rh -/- wh-/- Neurological State: GCS E4M6V4=14, nuchal rigidity (+) Pupils: round equal, RLO Ø 3 mm/3 mm, LR +/+ Visus: difficult to be examined Funduscopy: RLO: papil edema bilateral Eye ball movement: doll’s eyes (+) Other cranial nerve: difficult to be examine Motoric: Paresis (-) Sensoric: response to pain (+) Physiological reflex: +/+ Pathological reflex: babinski -/- Physical Examination (07/08/2019)

Thorax X-Ray at Hasan Sadikin Hospital, Bandung July 30 th, 2019 Active Lung TB (+)

Contrast Head CT Scan at Hasan Sadikin Hospital, Bandung August 6 th, 2019

Sulci and gyri are compressed Sylvian fissure are compressed Cistern are not compressed Enlargment of all ventricle system TH >2mm FH/ID 40% Evans ratio 0,35 Periventricular edema (+) Meningeal Enhancement(+) Midline shift (-)

General State: P: 116 x/mntRR: 24 x/mnt Temp: 37,8 º C Local State: At Thorax: Symmetrical shape and movement, VBS right = left, rh -/- wh-/- Neurological State: GCS E3M6V4=13, nuchal rigidity (+) Pupils: round equal, RLO Ø 3 mm/3 mm, LR +/+ Visus: difficult to be examined Funduscopy: RLO: papil edema bilateral Eye ball movement: good to all direction Other cranial nerve: difficult to be examine Motoric: Paresis (-) Sensoric: response to pain (+) Physiological reflex: +/+ Pathological reflex: babinski -/- Physical Examination

LabsResult Hb14,8 Ht42,8 L Tr LabsResult Ur/Cr14,6/0,63 Na/K132/3,7 RGB105 Laboratory Finding at Hasan Sadikin Hospital Bandung August 30 th, 2019 Labs (LP)Results Cell Count28 MN64 PMN36 Glucose16 Protein164 ColorYellowish ClarityCloudy

Thorax X-Ray at Hasan Sadikin Hospital, Bandung August 31 st, 2019 Active Lung TB (+)

Contrast Head CT Scan at Hasan Sadikin Hospital, Bandung August 31 st, 2019

Sulci and gyri are compressed Sylvian fissure are compressed Cistern are not compressed Enlargment of all ventricle system TH >2mm FH/ID 55% Evans ratio 0,47 Periventricular edema (+) Meningeal Enhancement(+) Midline shift (-)

WD/ Acute communicating Hydrocephalus due to Serous meningitis + Active Lung TB + Hyponatremia ICD 10:Communicating hydrocephalus (G91.0); Serous meningitis (A87.9); tuberculosis of lung (A15.0); Hyponatremia (87.1) Th/CTR elective GCS this morning: E3M6V4=13EMG Ward

UC 3. Mrs. Diyar / ♀ / 30 yo / / Infection/ IM The patient was consulted from Neurology Department CC: Decrease of consciousness History: ± 12 days prior to admission, her family noticed that the patient looked drowsy and difficult to be awaken. The complaint was preceded with intermittent headache that relieved with oral medication. History of Seizure (-), vomiting (-), trauma (-) Because of the complaint, she was brought to Psychiatry outpatient clinic of Hasan Sadikin Hospital, hospitalized for 10 days with diagnosed depression. Then consulted to Neurology department, underwent non contrast head ct scan, chest X-Rayd, and lumbar puncture then cosulted to Neurosurgery department. History of loss of body weight (+) 4 kg since 1 month ago, History of prolonged cough (+) and fever (+) that not relieved with oral medication since 2 months ago. History of night sweating (+), History TB contact is unknown.

General State: BP : 80/50 mmHg, P : 40x/min, RR : 12 x/min Temp: 37,5 C Local State: At thorax: Shape and movement symmetrical, VBS right=left, Rh +/+, Wh -/- Neurological State: GCS E1M1V1 = 3, nuchal rigidity (+) Pupils round equal RLO Ø 5mm/5mm, LR -/- Visus : Difficult to examined Funduscopy: RLO Bilateral papil edema Eye ball movement: Doll’s eyes (-) Other cranial nerve: Difficult to examined Motoric : Difficult to examined Sensoric: Difficult to examined Physiologic Reflex : -/- Pathologic Reflex : -/- Physical examination

LabsResult Hb13,3 Ht40 L9.270 Tr LabsResult Ur/Cr61/0,93 Na/K133/3,8 RGB183 Laboratory Finding at Hasan Sadikin Hospital Bandung August 30 th, 2019 Labs (LP)Results Cell Count178 MN71 PMN29 Glucose48 Protein490 ColorColorless ClarityCloudy

Thorax X- Ray at Hasan Sadikin Hospital, Bandung Not Examined

Non Contrast Head CT Scan at Hasan Sadikin Hospital, Bandung August 31 st, 2019 Sulcus and gyrus are compressed Sylvian fissure are compressed Cistern are not compressed Enlargement all system ventricle TH > 2mm FH/ID: 0.35 Evans ratio: 28% Perventricular edema (+) Meningeal enhancement (+) Midline shift (-)

WD/ Acute communicating Hydrocephalus due to Serous meningitis + Active Lung TB + Hyponatremia ICD 10:Communicating hydrocephalus (G91.0); Serous meningitis (A87.9); tuberculosis of lung (A15.0); Hyponatremia (87.1) Th/NC : Plan for Intubation, Intensive Care Unit, Closed Observation Neurology (Leader) : Improve general condition Passed Away

EMERGENCY OPERATION

PRE OPERATIVE

POST OPERATIVE

INTENSIVE PATIENT

OUTPATIENT CLINIC

THANK YOU Chief on Call:dr. Centery Chief on Site:dr. M. Rainda Farhan Jaga 2:dr. Ayu Iswandari Raharjo Jaga 3:dr. Mustafa Afif Jaga 5:dr. Faisal Akbar Jaga Stase: dr. Agustina (B. Umum)