MORNING REPORT

13th DECEMBER 2021

1 Supervisor : dr. Gloria Rondonuwu, Sp.KFR

Resident : dr. Kiki Stefanus
 2 Identity
 Name : Mr. W.J
 Age : 26 yo
 Sex : Male
 Religion : Christian
 Occupation : Unemployed
 Address : Manado
 Date of examination : December 2nd 2021
 Anamnesis
3
• Chief complaint : Weakness at his both legs
• History of Present illness:
 Weakness at his both legs since 1 month ago, progressive, begun
from his right leg, and then he felt weakness at his both legs
 Loss of body weight (-), history of trauma (-), fever (-)
 Bowel and bladder using diapers but still continence
 For his ADL, he is helped by his parents.
 Decubitus (-), shortness of breath (-)
 4

History of past illness

Lung Tuberculosis 5 years ago, treated properly until the end of the
regimen (6 months)
Social & economics:
5

 He is unemployed
 Live in 1 floor permanent house, with his parents
 Live expenses managed by his parents who work as a seller
 To go to Kandou Hospital he must rent a car and spend a lot
of money
 Medical expenses using BPJS
Physical Examination
6
ALERT
BP 121/86 HR 81 x/mnt RR 20 x/mnt Temp. 36.4
Head : normocephali,
conj. Anemis -/-,
Thorax : cor murmur -, pulmo ronchi -/-, whezing -/-
Abdomen : hepar/lien not palpable, peristaltic normal
Extremity : warm
BW and BH difficult to evaluate because he is on brancard
 Motoric Status
7 Upper Ekstremity Lower Ekstremity
Right Left Right Left
Movement Normal Normal Decreased Decreased

Muscle strength 5/5/5/5 5/5/5/5 1/1/1/1 1/1/1/1

Muscle Tone Normal Normal Decreased Decreased

Muscle atrophy - - + -
Physiological Reflex ++ ++ +++ +++

Patological Reflex - - - -

Sensibility Normal Normal Decreased Decreased

 Status SCI
Pin Prick Light Touch MMT MMT Light Touch Pin Prick
8

2 2 C2-C4 2 2
2 2 5 C5 5 2 2
2 2 5 C6 5 2 2
2 2 5 C7 5 2 2
2 2 5 C8 5 2 2
2 2 5 T1 5 2 2
2 2 T2-T12 2 2
1 1 L1 1 1
1 1 1 L2-L5 1 1 1
1 1 1 S1 1 1 1
1 1 S2-S5 1 1
 RECTAL TUSSUE:
9
Sfincter ani refleks: -
Feces +
VAC: No
DAP: No
10 Laboratory result (May 2, 2019)
 Complete blood test, blood glucose, liver function,
electrolyte are all normal
 HbsAg negative, Anti HCV and HIV non reactive
 Radiologic Result

11

 XRAY Torakolumbal tanggal 19 November 2021

Tampak pemipihan dengan destruksi CV Th 5-7 disertai bayangan
massa paravertebral pada level tersebut. Sugestif spondylitis TB +
abses
 DIAGNOSIS
12

Clinical diagnosis : SCI AIS A NL Th.5 ec Lesi medulla

spinalis setinggi Th VI ec tuberculosis spondylitis +
paravertebral abcess
 Topical diagnosis : Spinal Cord
 Etiology diagnosis : Infection
 13 Functional Diagnosis:
 Body function :
b730 Muscle power functions
b735 Muscle Tone
b740 Muscle endurance functions
b749 Muscle functions

913
  Body structure :
14
s120 Spinal cord and related structures

 Activity and participation:

d469 Walking and moving, other specified and
unspecified
d129 Purposeful sensory experiences, other specified
and unspecified
d998 Community, social and civic life, other specified
 Environment :
15
e110 Products or substances for personal consumption
e310 Immediate family
e320 Friends
e580 Health services, systems and policies
 Problem and Program
16
Problem Program
Weakness at both legs NMES at quadriceps, anterior tibial and
gastrocnemius muscle
Prevent spasticity Passive ROM exercise at both lower extremities
Long immobilization Education: breathing exercise

Vertebral movement TLSO

stabilization
He worries about his Psychology: support mental
condition
Transportation cost to Sosiomedic
hospital is covered by
his parents
17

THANK YOU