MORNING REPORT

FRIDAY 18TH JANUARY 2019

ER : dr. Yanti
ICU : dr. Selly
Stroke Unit : dr. Gerard
Consult : dr. Ranu-dr.Ninda
Stroke unit’s Tandem : dr. Josep
Ward : dr. Aji – dr. Firman
Tandem : dr. Tami – dr.Melly
 PATIENT’S IDENTITY

Name : Mr. S
Age : 71 yo
Gender : Male
Occupation : Porter
MR Number : C624071
Hospital admission : 18th January 2019
 HISTORY (autoanamnesis)

 Chief complaint : Pain at her low back to his leg

 Onset : a week before hospital admission

 Quality : stiffness and tight at her low back

 Quantity : ADL partly assisted by family

 HISTORY
 Chronology :

± a week before hospital admission pt felt stiffness on his low

back to his leg, throbbing pain, the pain is worsening when he
was coughing, straining, bowing and it gets better when he
was resting.
± 5 days before hospital admission pt went to see a doctor and
was submitted to Telogorejo hospital
± 3 days before hospital admission, the pain was getting
worsen, pt felt pins and needles on both of her legs, but the
right side is worse. When he walked he had to lean on to
someone because he couldn’t felt his feet, but pt deny
weakness on his legs. Pt was submitted to Kariadi Hospital
HISTORY

 Aggravated Factors : coughing, straining, bowing

 Extenuated Factors : resting

 Concomitant Symptoms : pins and needles,

weakness at both legs
 HISTORY
 Past Medical History
- 6 years ago, pt had diagnosed with HNP
- coughing history in a long period of time, loss body weight,
sweating at night (-)
- Tumor (-)
- heavy lifting (+) for about 100 kgs
 Family Disease History : no family history of tumor, coughing in a
long period of time, no family history had the same illness
 Social Economic-Status And Personal History : pt was a porter, Pt has
5 married children. Pt used National insurance for his treatment
 CLINICAL FINDINGS
Present States
 GCS : E4M6V5
 Vital signs :
BP 140/80 mmHg HR 62x/min
RR 20x/min Temp 36.5 (axilla)
VAS 7
 Eye : pupil round, isocor 3/3 mm,light reflex +/+
 Thorax : normal breathing, Rh-/-, Wh -/-
normal heart sound, murmur (-),gallop (-)
 Abdomen : unpalpable liver and spleen, ascites (-)
 CLINICAL FINDINGS
 Cranial Nerves : normal

 Motoric Sup Inf

Movement +/+ /
Strength 555/555 444/444
Tonus N/N N/N
Trophy E/E E/E
FR ++/++ ++/++
PR -/- -/-
Clonus -/-
CLINICAL FINDINGS
 Sensibility : normal
 Vegetative :normal
 Laseq : <70/>70
 Bragard : +/-
 Siccard : +/-
 Patrick : -/-
 Contra patrick: -/-
 Nafziger +
 Valsava +
 LABORATORY FINDINGS
LABORATORY EXAMINATION January 18th 2019
Hb 14 12.00 – 15.00
Ht 39,5 35 – 47
Red blood cell 4.47 4.4 – 5.9
MCH 31.7 27 – 32
MCV 88.4 76 – 96
MCHC 35.4 29 – 36
White blood cells 6.8 3.6 – 11 x103
Platelet 263 150 – 400 x103
Blood glucose 113 80 – 140
Ureum 19 15 – 39
Creatinin 0.9 0.6 – 1.3
 LABORATORY FINDINGS

LABORATORY EXAMINATION 18th January 2019

Magnesium 0.8 0,74-0.99
Calcium 2.0 2.12-2.52
Electrolyte
Sodium 142 136-145
Potassium 3.6 3.5-5.1
Chloride 106 98-107
Osmolaritas 300,5
Fluid Deficit 0,71 liters
ECG 18th January 2019
Thorax X-ray

COR : Normal
PULMO: Normal
Lumbar MRI without contras -
spondilolisthesis
January 28th 2013 L5-S1 (grade 1)
with L5 posterior
compression
- Spondilosis
lumbal with
L2 L3 L4
endplate
degeneration
(modic 2)
- HNP multipel
( L4-5 and L5-
S1 protrution,
L2-3 and L3-4
bulging)
- L2-3, L3-4
dan L4-5
bilateral
efussion facet
joint.
- hipertrofi
ligamentum
flavum L5-S1.
Lumbar MRI without contras - spondilolisthesis
L5-S1 (grade 1)
January 28th 2013 with L5 posterior
compression
- Spondilosis
lumbal with L2
L3 L4 endplate
degeneration
(modic 2)
- HNP multipel (
L4-5 and L5-
S1 protrution,
L2-3 and L3-4
bulging)
- L2-3, L3-4 dan
L4-5 bilateral
efussion facet
joint.
- hipertrofi
ligamentum
flavum L5-S1.
 DIAGNOSIS
I. Clinical Diagnosis
Spastic Inferior paraparesis
Bilateral ischialgia, the right side is worse
Low back pain
Topical Diagnosis
Lumbal Spinal Nerve roots
Etiologic Diagnosis :
Herniated Nucleus Pulposus DD MS tumor
 INITIAL PLANS & THERAPY
Therapy :
IVFD RL 20 drops per minutes
Ketorolac inj 30 mg/8 ho IV
Ranitidine Inj 50 mg/12 ho IV
Vitamin B1 B6 B12 1 tab/8 ho (orally)
Gabapenttin 100mg/8 ho (orally)
Program :
Consult to Medical Rehabilitation
MRI lumbosacral with contrast
 MONITORING :
GCS, vital signs, neurologic deficits, fluid balance

 EDUCATION :
diagnosis, management, complications, prognosis
Thankyou