MORNING

REPORT
January 19th, 2015
EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
HO/PU

IDENTITY
Name

: F.A.

Age

: 54 years old / Female

Admission : January 19th, 2015 at 21:34

Registratio : 69 77 59
n
Status

: BPJS

AUTOANAMNESIS
(at 21.35)

Chief Complain : Low back Pain

Suffered since 2 weeks before admitted to Wahidin General Hospital

Patient had felt pain on and off, throbbing pain, intermittent,
duration 5 10 minutes, worsen when activity and better when
rest, and referred to both of leg. She has difficulty in walking due to
pain.
Patient has not any bowel and bladder symptom. She has weight
loss 3 kgs since 3 months ago.
Three months ago, patient admitted to University Hasanuddin
Teaching Hospital due to Pulmonary Tuberculosis and still controlled
with Anti-tuberculosis drugs until now.
One week ago, patient went to Dr. Karya Triko Biakto, SpOT Clinic
and underwent MRI Lumbosacral examination and the result
revealed Spondylitis Tuberculosis vertebrae Lumbal 4 5.

GENERAL STATUS
(at 21.37)

Conscious / Well-nourished
Vital Signs:
Blood pressure
: 130/90 mmHg
Pulse rate
: 88 x/min
Respiratory rate
: 20 x/min
Temperature
: 3 7 0C
VAS : 4/10

LOCAL STATUS
(at 21.39)

Thorax Region
Inspection : Symmetrical in expansion of chest,
wound (-) , scar (-)
Palpation

: Stem fremitus +/+

Percussion : Sonor +/+

Auscultati
on

: Vesiculer +/+. Rales at superior part

of right lung, Wheezing (-)

LOCAL STATUS
(at 21.39)

Vertebra Region
Look : Deformity (+) : Gibbus, swelling (-),
hematoma (-), wound (-)
Feel

: Tenderness (+) as level as Vertebrae

Lumbal IV V, Step Off (-)

5
5
5
5
5

5
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5
5

5
NT
5
5
5
NT
5
NT
5

5
5
5
5

yes

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2

Any anal sensation

N

0 Absent
1 Impaired
2 Normal
NT Not testable

REFLEX
Physiologic
Reflex

Biceps
Triceps
Achilles
Patellar

R
(+)
(+)
(+)
(+)

L
(+)
(+)
(+)
(+)

Pathologic Reflex

Babinski
Chadock
Openheim
Hoffman
Trommer

R
(-)
(-)
(-)
(-)

L
(-)
(-)
(-)
(-)

CLINICAL FINDINGS

RADIOLOGY FINDINGS
(22.10)

LABORATORY FINDINGS
(at 22.30)

WBC
: 7.300/ul
RBC
:
4.630.000/ul
HBG
: 12,5 g/dl
HCT
: 37,0 %
PLT
:
420.000/ul
CT
: 700
BT
: 200

Albumin
: 3,4
g/dL
SGOT : 26 U/dL
SGPT : 14 U/dL
Ureum : 21
Creatinine : 0,50
RBG
: 99 g/dL
HBsAg : Nonreactive

DIAGNOSIS

Spondylitis Tuberculosis
Vertebrae Lumbal IV V
Pulmonary Tuberculosis Under
Treatment

MANAGEMENT

IVFD RL
Analgesics
Report to Orthopaedic senior, advice:
Report

to
Sp.OT(K)Spine

Dr.

dr.

Karya

Triko

Biakto