Reyhan Janitra Farandi

Mrs. Haryati, 33 y.o/ 14.8.1985/ 0001778374

Consultant dr. Ali Sundoro., SpBP-RE (K)
Fresia 2 11.4

Diagnosis:
• Pressure Ulcer grade 2-3 a.r sacrum
• Multiple SOL ec Toxoplasmosis Cerebrii
• HIV St 4 with Wasting Syndrome

Surgical History :
-

General Status:
Compos Mentis, inadequate
BP 110/70 mmHg HR 78 x/min RR 20 x/min Temp 36,9 oC
Clinical Picture
1/8/2019
Clinical Picture
5/8/2019
Clinical Picture
8/8/2019
Clinical Picture
12/8/2019
 Laboratory
Blood Gas Analysis
N Parameter 26/7/19 29/7/19 9/8/19
PH -
1 Hemoglobin 13.2 9.9

2 Hematokrit 39.6 29.3 pCO2 -

3 Leukocyte 10.44 9.78
4 Trombocyte 322 296 p02 -
5 Ureum 68.8 17 33.3
6 Creatinin 0.97 1.07 1.11 HCO3 -

7 Blood Glucose 101 -

tCO2 -
8 Sodium - 139
9 Potasium - 4.2 Standar BE-b -

10 Protein Total - -
Saturasi 02 -
11 Albumin - -

12 CD4 - 8

13 Na / K 131 / 4.3
Management
Plastic surgery :
• Wound care with hydroactive gel zalp ( every 3 days )

• Passive mobilization every 2 hours

• Maintain moisture and hygiene surround wound area

• Use decubitus bed

Neurology :
• Cotrimoxazole 2x1920 mg
• Dexametason 4 x 20 mg
• Ranitidin 2 x 50 mg iv
• Paracetamol 3 x 1 gr iv
• Plan to CT Scan w/ contrast
• Plan to ARV Medication after the infection therapy
 Tn. Anang Miftahul, 51 y.o/ 15.5.1968/ 0001734394
Consultant Dr.dr. Hardi Siswo., SpBP-RE (K)
Kemuning 2 10.5

Diagnosis:
• Pressure Sore grade IV a.r sacrum
• Post Repair shunt due to shunt malfunction due to acute communicating
hydrocephalus due to post IVH + Post craniectomy decompression due to
spontaneous ICH

Surgical History :
- Post repair shunt ( May 29, 2019)
- Post craniectomy decompression ( January 1, 2019)

General Status:
GCS E4M6Vtc = 10Tc
BP 110/80 mmHg HR 78 x/min RR 20 x/min Temp 36,9 oC
Clinical Picture
6/8/2019
Clinical Picture
9/8/2019
Clinical Picture
12/8/2019
Thorax X Ray at Hasan Sadikin Hosptal, Bandung
August 04th 2019
Within normal limit
Non Contrast Head CT Scan at Siloam Hospital, Purwakarta
July 31st, 2019
• Bone Defect at Left
Frontotemporoparietal
• Sulci and gyri are not compressed
• Sylvian fissures are compressed
• Cysterns are compressed
• Enlargement of all ventricle system
• TH > 2 mm
• FH/ID: 40%
• Evans ratio: 0, 32
• Shunt tip (+) at right lateral ventricle
• Isodense area at left frontotemporal
• Midline shift (-)
 Laboratory
Blood Gas Analysis
N Parameter 4/8/19 8/8/19
PH -
1 Hemoglobin 11.0 11.6

2 Hematokrit 32.4 34.1 pCO2 -

3 Leukocyte 10.21 11.22
4 Trombocyte 321 363 p02 -
5 Ureum 17.0 17
6 Creatinin 0.49 1.07 HCO3 -

7 Blood Glucose 76 -
tCO2 -
8 Natrium 129 -
9 Kalium 3.6 - Standar BE-b -

10 Protein Total - -
Saturasi 02 -
11 Albumin - 2.52
Management
Plastic surgery :
• Wound care with duoderm gel zalp ( every 3 days )

• Passive mobilization every 2 hours

• Maintain moisture and hygiene surround wound area

• Use decubitus bed

Neuro Surgery :
Plan to DSA Elective