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  • Ronde Ortho

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    erdikasatria
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    This document summarizes the medical history and physical examination of a 59-year-old male patient, Markus Saleha, who presented with low back pain that had been occurring for one month. The physical examination revealed decreased sensation on the left side from thoracic vertebrae 12 down and normal motor function. The diagnosis was lumbar canal stenosis from L4 to S1, and the recommended treatment was decompression surgery and posterior stabilization.

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    laporan status pasien orthopedi

    Original Title

    Ronde ortho

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    This document summarizes the medical history and physical examination of a 59-year-old male patient, Markus Saleha, who presented with low back pain that had been occurring for one month. The physical examination revealed decreased sensation on the left side from thoracic vertebrae 12 down and normal motor function. The diagnosis was lumbar canal stenosis from L4 to S1, and the recommended treatment was decompression surgery and posterior stabilization.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    9 views21 pages

    Ronde Ortho

    Uploaded by

    erdikasatria
    This document summarizes the medical history and physical examination of a 59-year-old male patient, Markus Saleha, who presented with low back pain that had been occurring for one month. The physical examination revealed decreased sensation on the left side from thoracic vertebrae 12 down and normal motor function. The diagnosis was lumbar canal stenosis from L4 to S1, and the recommended treatment was decompression surgery and posterior stabilization.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 21

    Markus Saleha

    Male, 59 y.o
    PRE OP
    PRE OP
    PRE OP
    PRE OP
    PRE OP
    PRE OP
    Chief complaint : Low Back Pain
    Suffered since 1 month before admitted to
    Wahidin general hospital
    History of trauma (-)
    History of lifting heavy objects (+)

    11
    PHYSICAL EXAMINATION

    Conscious / Well-nourished Motoric Right Lef


    Vital Signs: L2 5/5 5/5
    Blood pressure : 120/70 mmHg L3 5/5 5/5
    Pulse rate : 86 x/min L4 5/5 5/5
    Respiratory rate : 18 x/min L5 5/5 5/5
    Temperature : 36,7 0C S1 5/5 5/5
    NRS : 4
    Regio vertebra thoracal: Sensibilitas Hipoestesi Th.XII ke
    Look : Deformity (-), Gibbus(-), bawah sisi kiri
    hematoma (-) , wound (-) Swelling (-)
    Feel : Tenderness (-), Step off (-)

    12
    Reflex Fisiologis
    BPR normo/normo
    TPR normo/normo
    KPR normo/normo
    APR normo/normo
    Klonus -/-
    Reflex Patologis
    Hoffman Trommer-/-
    Babinsky -/-
    Chaddock -/-

    13
    PRE OP
    PRE OP
    PRE OP
    PRE OP
    PRE OP
    PRE OP
    Diagnosis Management
    Lumbal Canal Stenosis Decompression and
    L.IV-S.I Posterior Stabilization
    THANK YOU

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