PATIENT’S IDENTITY

Name : Markus Minggu Popang

Medical Record : 866238
Sex : Male
Date of Birth : March 17th 1953
Admitted on : December 16th 2018
Room : Lontara 3 Bawah Depan
Supervisor : dr. Andi Ihwan, Sp. BS
 History Taking

• Chief Complaint : Weakness at upper and lower limb

• Suffered since 2 days ago before admitted to Wahidin Sudirohusodo General
Hospital after hit by house log. Pain at neck and back with difficult to moved
his neck after accident. Patient can’t defecate and urinate loss of control
after accident. There was no history of loss of consciousness. There once
history of nausea and vomiting. There was no history of seizure. There was
no history of dyspnea. There was no history of Diabetes Mellitus. There was
no history of hypertension.
• Trauma Mechanism:
Patient was hit by house log when avoiding the ruins of the house. After hit
by the log patient stand up and walked until 5 meters. And then patient cant
moved his limb.
 PRIMARY SURVEY

• AIRWAY : Clear, C-spine control with rigid collar neck

• BREATHING : RR 20x/minute, regular, spontaneous
• CIRCULATION : BP 130/70 mmHg; HR 64 x/minute, regular
• DISABILITY : GCS 15, pupils isochoric, light reflex +/+
• EXPOSURE : T 36,6oC
Head
Scalp : There’s no deformity
Eyes : Pallor (-), icteric (-), pupil round isochoric 2,5 mm/2,5 mm
Nose : within normal limit, bloody rhinorrhea (-)
Ear : within normal limit, battle sign (-), bloody otorrhea (-)

Neck Region
Inspection : Symmetric, Hematoma (-)
Palpation : Can’t evaluate
Thorax:
Inspection : Normal thorax shape, right and left symmetrical movements, ictus cordis can’t see
Palpation : tenderness (-), right and left symmetrical movement, ictus cordis can’t fell
Percussion : Sonor at both lung field, the heart’s border not widen
Auscultation : Vesicular breath sound, rhonchi and wheezing (-/-), S1 and S2 pure regular, murmur (-),
gallop (-)
Abdomen:
Inspection : flat, lesion (-)
Auscultation: peristaltic (+) normal impression
Palpation : tenderness (-), mass (-), liver and spleen can’t palpate
Percussion : Timpani

Extremities : warm (+), oedema (-)

NVD : Hipostesi at upper limb and anestesi at lower limb.
Pulsation of radial and tibialis anterior are palpable, CRT < 2 second
 NEUROLOGICAL STATUS

GCS 15 (E4M6V5)
Neck Stiffness : Can’t to evaluate
Cranial nerve:
N. I : Within normal limits
N. II : Within normal limits
N. III, IV, VI :
Ptosis : (-)
Strabismus : (-)
Nystagmus : (-)
Eye Movement : Within normal limits
Pupil : Round, isochoric, 2.5 mm/2.5 mm
Direct Light Reflex : (+) / (+)
Indirect Light reflex : (+) / (+)
 NEUROLOGICAL STATUS

N.V
Open and close mouth : Within normal limits
Biting : Within normal limits

N.VII :
Frowned : Within normal limits
Close Eyes : Within normal limits
Nasolabialis folds : Within normal limits

N.VIII
Hearing : Within normal limits
Balance : Difficult to evaluated
 NEUROLOGICAL STATUS
N.IX, X
Dysphagia : (-)
Dysphonia : (-)
Pharynx arc : Within normal limits
Uvula : Within normal limits

N.XI
Turn the head : Can’t to evaluate
Shrug : Within normal limits

N.XII
Tongue deviation : Within normal limits
Atrophy of tongue’s papillae : (-)
 NEUROLOGICAL STATUS

- Glasgow coma scale 15 (E4M6V5) , pupil isochoric, diameter 2.5

mm/2.5 mm, light reflex +/+
- Motoric :
Power 3 2 Tonus N N
0 0

Physiologic Reflex Pathologic Reflex

R L R L
Biceps N N Babinski - -
Triceps N N Chadock - -
Achiles - - Hoffman - -
tromner
Patellar - -
- Sensoric :
Anesthesia (+) Dermatome T4 - S5
Hipesthesia (+) Dermatome C6 – T3
- Otonom :
Urinate : Use catheter (Inkontinence urine)
Defecate : Can’t to defecate
 LABORATORY EXAMINATION
Parameter Results Reference Value Unit
WBC 16.6 4-10 103 / ul
RBC 3.97 4-6 106 / ul
HGB 12.4 12-16 g/dL
MCV 86.9 80-97 fL
MCH 31.2 26.5-33.5 pg
MCHC 35.9 31.5-35 g/dL
PLT 159 150-400 103 / ul
HCT 34.5 37-48 %
PT/APTT 10.6/23.2 10-14/22-30 detik
SGOT/SGPT 66/12 <38/<41 U/L
Ureum/ Kreatinin 69/1.13 10-50/1.3 U/L
Na/K/CL 131/4.0/99 136-145/3.5- mmol/L
5.1/97-111
X-ray Neck AP+Lateral
Expertise :
- Spondylolisthesis CV C5
from C6 grade III with
stenosis discus
intervertebralis and
soft tissue swelling at
the level.
- Osteoporosis Senilis
X-ray Thorakal AP+Lateral

Expertise :
- Spondylosis thoracalis
- Osteoporosis senilis
 DIAGNOSIS

• Tetraparese ec Spinal Cord Injury

• Spondilolysthesis CV C5-C6
 PLANNING

• Rigid Collar Neck

• MRI Vertebra Cervical
• Posterior Stabilization
THANK YOU