Sie sind auf Seite 1von 20

Morning Report

Departement of Surgery
G24
Sept 19th 2016

Identity
Name : Mr N
Age
: 18 y.o
Sex
: Male
Address : Maduran, Lamongan
Date :Sept 12nd 2016 at 15:34

Chief complain: cant walk


Present illness history
Patient came to emergency room because he cant walk. He felt it
since 5 days before hospital admission. At first he felt pain around
waist area and having parasthesia. It happened around a month ago.
He felt numbness in his lower leg. He never had an accident around
waist area. 5 days before hospital admission suddenly he cannot walk
and cannot bear his body so he fell. The numbness is getting worse
and now he felt in from his stomach to his feet.
headache - , nausea and vomiting -, dizziness
Patient is having a hard time to defecate since 5 days befor hospital
admission
Patient is bedwetting in emergency room.

Past illness history


DM and Hypertension is denied, injury around waist area is
denied

Family illness history


DM and hypertension is denied

Vital sign
Blood pressure
145/87 mmHg

Pulse Rate
118 bpm

Temperature
36.3 oC

Respiratory Rate
18 x/minute

Physical examination
Airway
clear, gargling -, snoring -, speak fluently +, potential obstruction -

Breathing
spontaneous breath 18 x/minute, vesicular/vesicular, rh -/-, wh -/-, SaO2 100 %
without O2 support

Circulation
Warm, dry and red acral, CRT < 2, Pulse rate 118 bpm, blood pressure 145/87
mmHg

Disability
GCS 456, lateralization - , round pupil 3 mm/3 mm, light perception +/+

Exposure
-

Secondary Survey
Head and Neck
Anemis -/ icterus -/ cyanosis -/ dyspnea -/ lesion -

Thorax
I: Symmetrical, retraction -/ P: stem fremitus normal/normal, thrill
P:
Cor : normal
Pulmo : sonor/sonor

A:
Cor :Single Split Regular S1 S2 sound, heart murmur -, gallop
Pulmo :vesicular/vesicular breath sound, rhonchi -/-, wheezing -/-

Abdomen

I: Flat, injury A: bowel sound within normal limit


P: liver and spleen unpalpable, tenderness -/P: tympany

Extremity
Warm, dry, red acral

Neurological status
GCS 456
Meningeal sign :

Nuchal rigidity
Kernig sign
Brudzinski sign 1
Brudzinski sign 2

Cranial nerve : within normal limit


Motoric : 5/5
3/3

Sensory : parahipoestesia
Physiological Reflex

BPR +2/+2
TPR +2/+2
APR +2/+2
KPR +2/+2

Pathological reflex

Hoffman -/Tromner -/Babinsky -/Chaddock-/-

Assessment
Myelopathy

Planning diagnosis
Chest X-ray
Thoracolumbal x ray AP Lateral
Complete blood count
Electrolyte serum

Laboratory value
Erythrocyte 6.04
Haemoglobin 14.1
Erythrocyte Sedimentation Rate 1 28
Erythrocyte Sedimentation Rate 1 56
Leukocyte12.0
Eosinophil2.8
Basophil 2.7
Neutrophil 72.2
Lymphocyte 15.1
Monocyte 7.2
Thrombosit 460

Plasma Glucose
101
Potassium serum
3.9
Sodium serum
135
Chloride serum 103
Urea
27
Creatinine serum 0.8
SGOT
30
SGPT
23

Radiology

Radiology

Re Assessment
Close Fracture thoracal vertebrae XI-XII

Planning therapy
Insertion of urinary catheter
IVFD Ringer Asetate 1500 cc/24 hrs
Na Metamizole 3x1 gr
Ranitidin 2x50 mg
Mecobalamin 1x500 ug
B complex vitamin drip 1x1 amp
Consult to neurologist and neurosurgeon

Planning monitoring
Vital sign
Patients complain

Education
Explain to the family about the disease, about its
treatment and intervention, and also about complication
and prognosis.