CASE REPORT

TUEDAY, 6 MARET 2021

Spv : dr. Yovita Andhitara, Sp.S, Msi.Med, FINS

 NIGHT SHIFT TEAM

 ED : dr. Amel
 ICU : dr. Faishol
 Stroke Unit Team : dr. Herman
 Consultant Team : dr. Adinda dan dr. Hairu
 Consultant Team (intern) : dr. Amrul
 Wards Team : dr. Ardi, dr. Mayang, dr. Arif, dan dr. Sany
PATIENT’S IDENTITY

Name : Ny. S
Medical Record : C853411
Age : 52 y.o
Gender : Female
Addres : Ngesrep, Semarang
Occupation : Food Seller
Date of Admission : 06/04/2021
ANAMNESIS

 Main complain : low back pain

 Onset : 6 months ago
 Location : lower back spread to right foot
 Quantity : continuous all day long
 Quality : ADL by herself
CHRONOLOGY

-+ 7 months before admission ago patient fell down with sitting

position. Pain at lower back (-), pain at foot (-), numbness (-).
Miction and defecation are normal. After accident, she still
lifting the heavy goods like gallons of water, rice or LPG.

-+ 6 month before admission, patient felt pain only at lower

back. Her pain is up and down especially when she lift the heavy
goods. To release her pain, she slept with her foot in bent
position. Sometime, she drank a drug for release her pain. She
felt numbness at the right foot. She still do daily activity by
herself. Miction and defecation are normal
 -+ 3 months before admission, she felt pain from lower back until her right
leg. Pain worse when she bent over and lifting the heavy goods. Pain better
when she rest. Numbness (+) at the right foot. The miction and defecation are
normal. She came to Diponegoro National Hospital and she got pain killer then
she could do her daily activity again.

 -+ 1 week before admission, pain got worse at her right leg and continuous all
day long. She couldn’t do her daily activity. She couldn’t lifting heavy goods
anymore. She could do her daily activity only when using corset. Numbness
(+) from tip of toe until the inguinal
 Precipitating factors : do activity, lifting heavy goods
 Relieving factors : get rest, use a corset
 Accompanying symptom : numbness from the tip of the toe until to the
inguinal
HISTORY OF MEDICAL CONDITIONS

Hypertension history (+)

Dyslipidemia history (+)
Trauma (+) 7 months before admission, fell down with sitting position, lifting the
heavy goods
Diabetic Mellitus(-)
Stroke history(-)
TBC(-) trauma (+)
autoimun (-)
cancer (-)
 HISTORY OF FAMILIAL DISEASE

No family members of the patient suffered a similar condition.

SOCIOECONOMY STATUS
Patient was a food seller, She has 4 children, 3 children are not
financially independent. She use BPJS.
the patient has a low economy status
GENERAL PHYSICAL EXAMINATION
 GCS : E4M6V5
 BP 157/ 80
 HR 80
 RR 20
 T 36,5
 SpO2 : 98 % room air
 NPRS : 4-5
STATUS NEUROLOGIS
 eye : PBI 3mm/ 3mm RC +/+
 neck : kaku kuduk (-)
Motoric Sup Inf
strength 555/555 555/555
Tonus N/N N/N
Trophy E/E E/E
RF ++/++ ++/++
RP -/- -/-
clonus -/-
Sensibility :
Numbness from foot until dermatome of S1
Vegetativ : Defecation and urination are normal
ADDITIONAL EXAMINATIONS

 laseq <70 / > 70

 bragard +/-
 sicard +/-
 valsava : +
LABORATORY EXAMINATIONS (6 APRIL 2021)
LABORATORY EXAMINATIONS (6 APRIL 2021)

Osm : 304,27
FD : 1.44
X – Foto Vertebra Lumbosacral AP Lat
RSND
(29/1/2021)

 straight lumbal
spondilolistesis gr 1 at L4-5
narrowing of foramen neuralis L4-
5, L5-S1
osteofit : suggesting of spondilosis
X – Foto Thorax
(06/04/2021)
 Cardiomegaly (LV, susp LA)
 No infiltrate at the lung
ASSESMENT

1. Clinical diagnosis :
- ichialgia dekstra
- hipesthesia similar appropriate to dermatom L5-S1 dextra
Topical Diagnosis : radiks nn spinalis segmen lumbal
Etiology Diagnosis : susp HNP posterolateral lumbal dd spondilosis lumbal
spinal kanal stenosis ec spondilolistsis

2. hipertensi

3. dislipidemia

4. hiperurisemia
Therapy
 IVFD RL 20 tpm
 inf RL 20 tpm
 inj ketorolac 30 mg / 12 hr iv
 inj ranitidin 50 mg / 12 hr iv
 gabapentin 300 mg / 12 hr po
 diazepam 2 mg / 12 hr po
Routine medication:
 amlodipin 10 mg / 24 hr po
 candesartan 16 mg / 24 hr po
 alupurinol 100 mg / 24 hr
 simvastatin 20 mg / 24 hr po
 vitamin B12 1 tab / 12 hr po
PLAN

 Monitoring for general condition, vital signs, pain, and neurological

deficit
 EMG ekstremity inferior
 MRI lumbosacral non contrast
 Consult to Neurosurgery
 TERIMA KASIH
MOHON ARAHAN
DAN BIMBINGANNYA