MORNING REPORT

TUESDAY 29 SEPTEMBER 2015

ER
: dr. Marcus
Consultant : dr. Iin
Stroke unit : dr. Sumarji
Ward
: dr. Niken-dr.Daniel
Tandem : dr. Runi-dr.Fathul

PATIENTS IDENTITY
Name
: Mrs. T
Age
: 51 years old
Gender
: Female
Occupation
: housewife
MR Number
: B071612
Hospital admission : 29th September
2015

HISTORY (autoanamnesis)

Chief complaint

Onset

: Low Back Pain

: 3 months before hospital

admission

Location

: Lower Back

Quality

:Pain Radiating to both toes,

continous

Quantity

: ADL independent

HISTORY

Chronology :

3 years before hospital admission, patient complaint she

had a back pain. She didnt always felt the paint, only
happened when she lift heavy things, She can do all daily
activity normally, weakness in lower extremity(-) Not radiated
to toes, Urination and defecation normal.The pain relieves
when she took a rest.She didnt ask help to any medical
center.
3 months before hospital admission, she said the pain got
worsen not only in lower back, but radiating to her buttock
and to both of her toes, she said pain didnt relieve with any
effort, continuously she felt the pain, when she walked she
felt the pain, and when shalat or bending her back, the pain
got worsen. Weakness in lower extremity (-), Urination and
defecation normal. And then she ask help to Purwodadi

HISTORY

3 week before hospital admission, she said she

felt the pain got worsen again, she said she
started to felt weakness in lower part of
extremity, left lower extremity more weaker than
the right lower extremity, the pain got worsen,
she felt hot and tingling sensastion too, radiating
from her back, to both of her toes. She said that
hot and tingling sensation is worse in the left
lower side rather than the right sides. Fever(-),
cough(-) Urination and defecation normal. And
then she asked for help to Kutilang Hospital and
suggested that she have to transferred to Kariadi
Hospital for further diagnosis and treatment.

HISTORY

Aggravated Factors : - cough, sneeze,

Extenuated Factors : - analgetic, resting

Concomitant Symptoms : - weakness in

lower

extremity
- Hot And Tingling
sensation

HISTORY

Past Medical History

- same complaint denied
- Chronic Cough denied(-)
- Trauma denied
- Hipertension denied
- DM denied

Family Disease History : no family history

had the same illness
Social Economic-Status And Personal
History : patient is a house wife, with 2
kid,1st one normal, the 2nd has physical
defect,the 2nd child can manage his daily
activity indepedently. Social Economy Good

CLINICAL FINDINGS
Present States
GCS
: E4M6V5
Vital signs
:

BP 140/80 mmHg
HR
80x/min
RR 20x/min
Temp 36.5 (axilla)
Eye : pupil round, isocor 3/3 mm,light reflex +/+
Thorax : normal breathing, Rh-/-, Wh -/normal heart sound, murmur (-),gallop (-)
Abdomen : unpalpable liver and spleen, ascites (-)

CLINICAL FINDINGS

Cranial Nerves:normal

MotoricSup

Inf

Movement + / +
Strength
Tonus N/N N/N
Trophy E/E A/A
FR
+2/+2
PR -/- -/Clonus -/-

/
555/555

+1/+1

4+4+4+/444(pain)

CLINICAL FINDINGS

Sensibility : Parasthesia inferior

Vegetative : normal

Laboratorium
Laboratorium

Nilai

Nilai normal

Hb

13.8

13-16

Ht

41.8%

40-54

4.71 juta/mmk

4,4-5,9 juta

MCH

30,8 pg

27-32

MCV

89.8 fl

76-96

34.3 g/dl

29-36

9.700/mmk

3600-11000

356.000/mmk

150-400ribu

14,5

11.6-14.8

Eritrosit

MCHC
Leukosit
Trombosit
RDW
MPV

10.2

4-11

Nilai

Nilai normal

Ur

30 mg/dl

15-39

Cr

0.7 mg/dl

0,6-1,3

145 mg/dl

80-160

Natrium

141 mmol/L

135-145

Kalium

3,9 mmol/L

3,5-5,1

Chlorida

109 mmol/L

98-107

GDS

0sm : 2(141+3.9)+ 145/18+ 30/6: 302.8

Fluid Deficit : 0.9 L

Ro Thorakolumbal AP/L 28-092015

Impression

Spondilolisthesis Lumbal 3-4

Spondilosis Lumbal
Straight Lumbar

Ro Thorax AP (28-092015)

No Tuberculosis
imaging,
Cor is normal

DIAGNOSIS
I.

Clinical Diagnosis
Low Back Pain
Ischialgia Bilateral
Paraparese Inferior Flaccid
Parethesia Inferior
Topical Diagnosis
Cauda Equina
Etiologic Diagnosis :
HNP ec susp trauma Medula Spinalis
Spondilolisthesis Lumbal 3-4

INITIAL PLANS &

THERAPY
1.
2.
3.

Consult to RM
Planning : MRI Lumbosakral
Therapy :
IVFD : RL 20 drop per minutes
Inj Ranitidine 50 mg/12 ho IV
Ketorolac 30 mg/12 h.o IV
B1B6B12 1 tab/ 8 h.o P.O
Amitriptilin 12.5 mg/24 h.o P.O

MONITORING :
GCS, vital signs,VAS, neurologic deficits

EDUCATION :
diagnosis, management, complications,
prognosis

THANK YOU