Canal Stenosis Lumbal

COASS :
1. Ida
2. Paramitha
3. Sovian
4. Fredik

Consulant : dr. Tommy Jack Numberi, Sp.BS

Ms. I. J./26 year old )

Chief complaint :
Leg muscle weaknes and back pain

Present illness :
A 26-year-old man was hospitalised for back pain
and leg muscle weaknes so the patient have
difficulty walking since January 2019. the patient
climed that initially the legs ware tingling then
followed by muscle spasm. The patient had a
motorcycle accident about two years ago.

History of illness :
HT (-)
• Primary Survey
o Airway & C-spine control : cyanotic (-), snoring (-),
gurgling (-), stridor (-), crowing sound (-), speaks clearly (-)
→ clear
o Breathing & ventilation: spontaneous, symetrical,
retraction(-), vesicular(+/+), RR 20 x/min, SpO2 99%
o Circulation & hemorrhage control: BP 110/70 mmHg,
HR 72x/min, warm peripheries, CRT less than 2 sec →
clear
o Disabillity: GCS E4V5M6 , isochoric pupil 3mm/3mm
o Exposure/Environtment: T: 37,2◦C

Initial Assessment: No life threatening

 Secondary Survey:
• GCS: E4V5M6
• VS: BP=110/70 mmHg, HR=72 x/min, RR=20x/min,
T=37,2◦C, SpO2=99%
• Head: isochoric pupil 3mm/3mm, anemic conjunctive (-/-),
sklera jaundice (-/-), bloody rinorrhea (-/-), foreign object
inside the nasal cavity (-/-)
• Neck: Edema (-) , enlarged lymph nodes (-)
• Chest: symetrical, flat, involved in breathing, vesicular
breath +/+, rhonki -/-, wheezing -/-
• Abdomen: within normal limit
• Extremities: within normal limit
• St. Neurologis
Meningeal sign : kaku kuduk (+) brudzinski (-)
Patology reflex : Babinski -/-, chaddock -/-, oppenheim -/-,
Fisiologi reflex : BPR +/+, TPR +/+, KPR +/+
Motoric : 5 5
4 4
Diagnosis
 Canal Stenosis Lumbal

Further examination :
• Laboratory examination
• CT-Scan Lumbosacral
 LABORATORY ( 28-09-2019)

Parameter Value
HB 16,9 g/dL
HCT 51,9 %
PLT 352 10^3/Ul
RBC 6,73 10^6/uL
WBC 13,27 10^3/uL
PT 11,4 detik
APTT 35,1 detik
Glucose 69 mg/dL
BUN 17,1 mg/dL
Creatinin 0,97 mg/dL
HBs Ag Non Reaktif
CT-SCAN LUMBO SAKRAL
Planning
 IVFD D5 ½ NS 20 tpm macro
 Inj. Antrain 3x1 amp
 Inj. Ceftriaxone 2x 1gr
 Inj. Mecobalamin 3 X 500 mg

 Pro Laminectomy
Thank you