CASE REPORT Friday, May 31st 2013 Team On Duty: dr. Maria M dr. Hendra K dr. Tugam UB dr.

Rynaldi A dr. A Ahmad D dr. H.I. Pinim I. Patient identity Name : Husaini Age : 50 years old Sex : Male Address : Ds Juli Meunasah Teugoh, Kec Juli, Bireuen MR : 954921 Phone : 085260630056 Chief complaint Decrease of consciousness Presenting history of illness The patient came to emergency room with chief complaint decrease of consciousness since 1 day ago. Initially, he got severe headache. There was no history of stroke hemorrhage before. There was history of hypertension (+). Physical examination General condition : General condition : moderate GCS : E1 M3 V2 = 6, isochoric pupil 3 mm (R/L), reflex of light (+/+) Blood Pressure : 170/100 mmHg Heart rate : 89 beats/minutes Repiratory rate : 24 breaths/minutes Neurologic examination: Motoric (R/L) : 0 5 0 5

II. III.

IV.

Right hemiparesis

V.

Assessments: Stroke haemorrhagic due to ICH at the right ganglia basalis + hypertension stage II Management Head up 30 Stop oral intake O2 8 L/minute (mask) NGT Kateter urine IVFD NaCl 20 drips/minute Inj Ceftriaxone 1 gr Inj Ranitidin 50 mg Inj Tramadol 50 mg Laboratory examination Radiology examination Laboratory examination Hb White blood count Platelet Ht CT BT Blood glucose Ureum Creatinin : 14,0gr/dl : 22.100 /ul : 257.000 /ul : 38 % : 7 minute : 2 minute : 158 mg/dl : 98 mg/dl : 2,7 mg/dl

VI.

VII.

VIII. Radiology examination Head CT-Scan: Periventricle edema Hiperdens abnormal at the right ganglia basalis Temporal horn (+) There was no midline shift IX. Diagnose: Stroke haemorrhagic due to ICH at the right ganglia basalis + hypertension stage II Consult to Neurosergery division Craniectomy ICH evacuation

X.

XI.

XII.

Intra operative Patient supine position, extended to the left side, head up 300 , with general anesthesia. Perform aseptic and antiseptic procedure Perform question mark incision at the right temporoparietal layer by layer until bone Perform 5 Burrhole, the Bone was sawed and than bone segment pulled out Duramater was tension and bluewish Perform duramater hit stiches When duramater was opened identified haematom ICH Evacuation of ICH with volume 25 cc Bleeding control Performed dura facial graft Bone was return Wound operation closed by primary sutured with one tube drain . Post operative diagnose : Stroke haemorrhagic due to ICH at the right ganglia basalis (ICD 10 CM S06.363A) + hypertension stage II

XIII. Follow up
Date 04/6/ 2013 POD III S O - GCS E M V Blood pressure : 190 / 100 mmhg Pulse : 94beats/minute Respiratory : 28 breaths/minute/ T : 38,0 0 C A Stroke haemorrhagic due to ICH at the right ganglia basalis (ICD 10 CM S06.363A) + hypertension stage II P Head Up 30 Oxygen 8 Litres via face mask IVFD NaCl 20 drips/minute Ceftriaxone 2 gr/24 hr Ketorolac 3% /8 hr Ranitidin 50 mg/ 12 hr