MORNING REPORT

Patient Identity
Name : MR. L.D
Sex : Male
Date of Birth : 31-12-1973
Age : 44 Years Old
Religion : Muslim
Address : Jalikko
Room : IC 2nd Floor Room 5
MR : 802274
Date of Admission : 04-05-2018
 Anamnesis
Chief Complain : Low back pain
Low back pain is felt continuously for the last 4 months Worsening since 1 month ago. Pain increases if
the patient changes position. At this time the patient is difficult to move both extremitas up and down.
Cough is accompanied by white mucus since last 2 weeks. Fever is occasional, night sweats do not exist.
Weight loss exists but it is not known how many kilograms.

No history of consumption Tuberculosis drug

No history of people with lung Tuberculosis
Smoking history is denied
History of Diabetes melitus and Hipertention is denied
 History of Illnes
January 2018
Mei 2018
treatment of
hospitalized in
neurology wards
Enrekang Hospital
for 1 month or
and send to RS.
more, forced home
Wahidin
for refusing for
Sudirohusodo
neurosurgery Mei 2018
Hospitalized in
Infection
Centre

2014 left foot April 2018, all

shrink, limp, foot can’t move
medication in and followed by
the Hometownn all hand
 Physical Examination
General Status
• Moderate-ill/ Compos mentis (E4M6V5) / good nourish
• Weight: 55 kg
• Height : 160 cm
• BMI : 21.7 kg/m2 normal weight
• VAS :6

Vital Sign
• Blood Pressure : 140/80 mmHg
• Pulse : 88 x/minutes
• Respiratory Rate : 22x/minutes,
• Temperature : 36.9oC
• SPO2 : 98% with no oxygen
 Physical Examination
• Head : Normocephal
• Eyes : anemis (-), icteric (-), isokor pupil 2,5mm/2,5mm
• Neck : JVP R +2 cmH2O, enlargement lymph nodes in left and right
neck. Neck stiffnes

• Thorax :
I: Symmetrically in dynamic and static
P: Vocal Fremitus Symmetrically Sonor in right and left hemithorax.
P: Sonor in right and left hemithorax.
A: vesicular breath sounds, crackles (-) and wheezing (-).

• Abdomen : Pristaltic normal impression

Hepar no palpable
Lien no Palpable
 Physical Examination
• Extremity : pitting edem (+)
P K T BPM
2 0

TPM
2 2 2 2

KPR
N N

APM
 Laboratory Finding
(04/05/2018)

Examination Result Real Value Examination Result Real Value

RBC 3.53 3.8 – 5.8 10^6/uL PLT 357 150 - 500 10^3/ul

HGB 10.0 11.5 - 16.0 gr/dl Ureum 63 10 – 50 mg/dl

MCV 83.9 80.0 - 100.0 fL Kreatinin 1.76 L(<1.3);P(<1.1) mg/dl

MCH 28.3 27 - 32 pg GDS 101 140 mg/dl

WBC 8.39 4.00 - 10.0 10^3/ul SGOT 13 <38 U/L

HCT 29.6 37.0 - 47.0 % SGPT 15 <41 U/L

NEUT 71.8 52 – 75 % Albumin 3.3 3.5-5.0 gr/dl
LYMP 15.9 20 – 40 % Natrium 137 136 – 145 mmol/l
MONO 9.4 2 – 8 10^3/ul Kalium 3.6 3.5 – 5.1 mmol/l
EOS 2.4 1 – 3 10^3/ul Klorida 99 97 – 111 mmol/l
BASO 0.5 0 – 0.1 10^3/ul
 Laboratory Finding
(15/05/2018)

Examination Result Real Value Examination Result Real Value

RBC 3.28 3.8 – 5.8 10^6/uL PLT 304 150 - 500 10^3/ul

HGB 9.4 11.5 - 16.0 gr/dl Ureum 64 10 – 50 mg/dl

MCV 82.9 80.0 - 100.0 fL Kreatinin 0.70 L(<1.3);P(<1.1) mg/dl

MCH 28.7 27 - 32 pg Calcium 10.4 6.8-10.2 mg/dl

WBC 17.67 4.00 - 10.0 10^3/ul SGOT 15 <38 U/L

HCT 27.2 37.0 - 47.0 % SGPT 26 <41 U/L

NEUT 90.9 52 – 75 % Albumin 2.8 3.5-5.0 gr/dl
LYMP 4.8 20 – 40 % Natrium 139 136 – 145 mmol/l
MONO 3.2 2 – 8 10^3/ul Kalium 3.9 3.5 – 5.1 mmol/l
EOS 1.0 1 – 3 10^3/ul Klorida 102 97 – 111 mmol/l
BASO 0.1 0 – 0.1 10^3/ul
 Fast Molecular Test (TCM)
date Result
14/2/2018 MTB Detected Low Rifampicin Resistance Not Detected
 Anti HIV
date Result
7/5/2018 Non Reactive Non Reactive
 Smear BTA
date Result
8/5/2018 BTA 1 Negative

BTA 2 Negative

BTA 3 Negative
 Tumor Marker
date Result Real Value

9/5/2018 CEA 1.40 0 - 4.70

PSA 0.74 0 - 4.00

4.24 0.00 – 39.00

 ADT
date Result
15/5/2018 Anemia Normositik normokrom suspek kausa penyakit
kronik disertai leukositosis dengan tanda-tanda infeksi
Chest X-Ray
(19/01/2018)
MRI (18/01/2018)
• Alignment vertebra lumbosacral baik
• Tampak lesi isointens di T1W1 yang menyangat
homogen, heterogen dominan hipointens di T2W1
batas tegas tepi irregular kesan berasal dari
m.multified kiri pada level CV L3-L4 yang meluas ke
m.psoas mayor kiri serta mendestruksi pedikel kiri proc
articularis dan CV L4 menyebabkan penekanan pada
kanalis spinalis.
• Tidak tampak lesi intradural, intra/extramedular
• Conus medularis berakhir pada level CV L1
• Intensitas diskus menurun pada level CV L3-L4, L4-L5,
L5-S1

KESAN:
Massa berasal dari m.multified kiri pada level CV L3-L4
yang meluas ke m.psoas mayor pada kanalis spinalis
suspek rhabdomyosarcoma dd/ neuroblastoma
Degeneratif disc disease
MR-myelografi: Severe stenosis canalis spinalis pada level
CV L3-L5
MS CT SCAN
with Contrast (18/05/2018)
Cervical AP/Lateral
with Contrast (8/05/2018)
 ASSESMENT

1. Clinical Lung Bacteriologist, new case. HIV non reactive

2. Tetraparese ec rhabdomyosarcoma dd/ neuroblastoma
3. Rhabdomyosarcoma metastase ke paru, hepar , Tulang
4. Hipoalbuminemia
 Therapy

1. Natrium clorida 0,9% 20 drops/minute

2. N. Acetyl sistein 200mg/8hours/oral
3. 4FDC 3 tab/24hours/oral
4. Vip albumin 2 tab/8hours/oral
5. Duragesic patch 25mcg/72hours/transdermal
6. Ceftazidime 2gr/8hours
7. Levofloxacine 750mg/24hours
 Problem

1. Paraparese
2. Cancer pain
3. Leukositosis
 Planing

1. Sputum Sitology
2. Bronchoscopy
Assesment Subjektif Objektif Planning Therapy

Tetraparese ec Low back pain is felt - Konsul Ts/ R/

Power
Rhabdomiosarcoma continuously for the Neurology Mecobalamin 1
dd/ neuroblastoma last 4 months BPM amp/24hours/intravena
Worsening since 1 2 2
month ago Methyl Prednisolon
TPM 125mg/24hours/intravena
2 2
P Ranitidin
50mg/12hours?intravea

Gabapentin
100mg/12house/intravena
K
2 0

2 2
Assesment Subjective Objective Planning Therapy

Clinical Lung Shortness of breath, TCM : MTB Detected OAT 4FDC 3 tab/24hours
Tuberculosis , new History of smoking Very low
case since 30 years ago,
16 packs per day,
quit since 1 years
ago

Cancer Pain Low back pain is felt Vas : 6 analgetic Duragesic Patch
continuously for the 25mcg/72
last 4 months hours/transdermal
Worsening since 1
month ago. Pain
increases if the
patient changes
position
Assesment Subjective Objective Planning Therapy

Bacteriological Lung Shortness of breath, TCM : MTB Detected OAT 4FDC 3 tab/24hours
Tuberculosis , new History of smoking Very low
case since 30 years ago,
16 packs per day,
quit since 1 years
ago

Hospitalized Fever is occasional Wbc : 17.67 Blood Culture Ceftazidime

aquaired Pneumonia Neutrofil: 90.44 2gr/8hours

Levofloxacine
750mg/24hours
Assesment Subjective Objective Planning Therapy

Hipoalbuminemia Pitting edema Albumin 2.8 Albumin control Vip Albumin 2

positive tab/8hours/oral
Thakyou