Mr Yana/ M / 41 yo / MR : 0001737570 / National Health Insurance

Admission : 14-01-2019 At : 14.26 WIB

INA CBG : M-4-17-III
Consultant : Dr. Ghuna Arioharjo Utouo., Sp.OT

CC : Weakness on the both of upper and lower extremities

HT :
Ten hours prior to admission, when the patient repaired the rooftop at
Cimahi, suddenly the patient lost his balance and fell down from 3 meters in height
with the his back hit the ground. After that, the patient feel a weakness from both of
his upper and lower extremities. History of disturbance of micturition (-) and
defecation (-). History of unconsciousness (-), vomiting (-), bleeding for ear (-), mouth
(-) and nose (-).
After that, the patient was bought to Mitra Kasih Hospital and then referred
to Hasan Sadikin Hospital for further treatment.
 PHYSICAL EXAMINATION
Primary Survey :
A : Clear with C-spine control
B : RR : 20 x/min, symmetrical chest expansion, equal VBS, Rh -/-, Wh -/-
C : PR : 90 x/min, BP : 120/80 mmHg
D : GCS = 15 (E4M6V5), pupil round equal Ø 3/3 mm, light reflex +/+, motoric: no paresis

Secondary survey :

At Cervical :

L : wound (-), deformity (+) gibbus, swelling (-), bruising (-)

F : Terderness (+), distal sensibility was decreased

M: ROM limited
 PHYSICAL EXAMINATION
Secondary survey :
Motoric :
• Shoulder Elevation 5/5 • Hip Flexion 0/1
• Shoulder Abduction 0/1 • Knee Flexion 0/1
• Elbow Flexion 0/1 • Knee Extension 0/1
• Elbow Extension 0/1 • Ankle dorsiflexion 0/1
• Wrist Felxion 0/1 • Ankle plantarflexion 0/1
• Wrist Extension 0/1 • Great toe extension 0/1
• Finger adduction abduction 0/1 • Great toe flexion 0/1

Sensory : hypoesthesia at level C5

• Propioceptive +/+
• Light touch +/+
• Deep touch +/+
• Temperature +/+
• Vibration +/+
• Two point discrimination+/+
 PHYSICAL EXAMINATION

Physiological Reflex : Vegetative

Biceps : -/+ • BAK normal

Triceps : -/+ • BAB normal

BCR +
Pathological Reflex :
Hoffman Trommer -/- Sacral Sparing
Babinski -/- • Great toe flexion
Chaddok -/- • Anal Wing +

Clonus -/- • Perianal sensation +

CLINICAL PICTURE
CLINICAL PICTURE
Cervical X-Ray, Hasan Sadikin Hospital January 14th 2019
 Neck, Chest, and Hip X-Ray
Hasan Sadikin Hospital January 14th 2019
Spine X-Ray, Hasan Sadikin Hospital January 14th 2019
 Laboratory Findings
Laboratorium 14/01/19
PT 10.9
APTT 22.6
INR 0.97
Haemoglobin 15.9

Haematocrit 45.7

Leukosit 11.980

Trombosit 306.000
Sod / Pot 138/4.0
Ur/Cr 17/0.76

AST/ALT 34/29

Random blood glucose 115

Working Diagnosis :
Spinal cord injury at level C3 incomplete lesion anterior cord syndrome due to closed fracture at V. C3-C4
frankel C

Therapy :
• Oxygenation
• Analgetic
• Immbolization with hard collar brace
• Plan to
• Further investigation with cervical CT-Scan
• Decompression + posterior stabilization

M-4-17-III COMPLEX VERTEBRAE PROCEDURES 9.251.372

ISS: 25 RTS: 7,841 TRISS: 97,8%