MORNING REPORT

SUNDAY, JUNE 1ST 2015

ER
: dr. Gede
Consultant : dr. Betsy
Stroke unit : dr. Putri
Ward
: dr. Nining-dr. Sari

PATIENTS IDENTITY
Name
: Mrs. C
Age
: 51 yo
Gender
: Male
Occupation
: Minner Employer
Hospital admission : 1 July 2015

HISTORY (autoanamnesis)

Chief complaint

: Pain at her low back to

her bottom

Onset

: 7 days before hospital

admission

Quality

: pain radiating two the leg

Quantity

: ADL partly assisted by

family

HISTORY

Chronology :

7 years before hospital admission Pt fell down with backward

position, her back hit the stairs but he didnt experience any
complaint, and was still able to do her work. But the pt
complained for numbness and tingling at the leg from toes to the
groin area. The patient had history of heavy lifting
2 years before hospital admission the pain is worsening when
he was coughing, straining, bowing and it gets better when he
was resting, then pt went to see a doctor but there is no
change. And then she was sent to see a neurologist and had a
spine x-ray. The result from the spine x-ray was HNP.

7 days before hospital admission the painful that radiating two the leg.The paint more
severe while coughing or straining. Because the pain get worse, pt went to check
herself to RSDK and was suggested to had an MRI for her back.
When the result came up patient was submitted to RSDK

HISTORY

Aggravated Factors : coughing, straining

Extenuated Factors : resting

Concomitant Symptoms : numbness

and tingling at the leg from toes to

the groin area.

HISTORY

Past Medical History

- patient fell down 7 years ago, but no complaint
- Tumor (-)
- heavy lifting (+)
Family Disease History : no family history of
tumor, no family history had the same illness
Social Economic-Status And Personal History :
pt is an single and used National insurance for her
treatment

CLINICAL FINDINGS
Present States
GCS
: E4M6V5
Vital signs
:

BP 130/80 mmHg
HR
80x/min
RR 20x/min
Temp 36.5 (axilla) VAS 6-7
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

Motoric Sup Inf

Movement +/+
+/+
Strength
555/555
Tonus N/N N/N
TrophyE/E E/E
FR
++/++
++/++
PR -/--/Clonus -/-

555/555

CLINICAL FINDINGS

Sensibility : Hypesthesia from toes to L23 dermatome

Vegetative :normal
Laseq : <70/<70
Kernig : >135/>135
Bragard : +/+
Sicard : +/+
Patrick : +/+
Contra patrick: +/+

LABORATORY FINDINGS
LABORATORY
EXAMINATION

1 june 2015

Hb

14.1

12.00 15.00

Ht

43,0

35 47

4.5

4.4 5.9

MCH

29.5

27 32

MCV

87.3

76 96

MCHC

35.4

29 36

Red blood cell

White blood cells

Platelet

9.7

3.6 11 x103

268.1

150 400 x103

Blood glucose

79

80 140

Ureum

21

15 39

LABORATORY FINDINGS
LABORATORY
EXAMINATION

22nd November 2014

Magnesium

0.74

0,74-0.99

Calcium

2.14

2.12-2.52

Sodium

139

136-145

Potassium

4,0

3.5-5.1

Chloride

106

98-107

Electrolyte

Thoracolumbar MRI with contras

MRI

Degenerative at the VL2 corpus

Spondilosis torakolumbalis
Anular bulging on the intervertebral disc
VL2-3 and Vl3-4 with the constriction of
the neuralis foramen VL4-5 both left
right and VL5-S1
Protusio posterosentral on the
intervertebral disc VL4-5 and VL5-SI
Sklerotik end plate superior vertebra
sacrum 1

DIAGNOSIS
I. Clinical Diagnosis
Ischialgia bilateral
Hypesthesia from toes to L2-3 dermatome
Topical Diagnosis
Radix of the Spinal nerve VL4-5, L5-S1
Etiologic Diagnosis :
Hernia Nucleus Pulpous Lumbosacral

INITIAL PLANS &

THERAPY
1.
2.

Consult to Physical Medicine and Rehabilitation

Therapy :
IVFD : RL 20 drop per minutes

Inj Ranitidine 50 mg/12 ho IV

Inj ketorolac 1 amp/12 ho iv
Vitamin B1 B6 B12 1 tab/8 ho (orally)

MONITORING :
GCS, vital signs, neurologic deficits, fluid
balance

EDUCATION :
diagnosis, management, complications,
prognosis