Case Report

Herniated Disc
Senida Ayu Rahmadika
030.09.230
Neurology
RSAL dr.Mintohardjo

Patient Id

MR No
Name
Gender
Age
Address

: 14.60
: Ny. H
: Female
: 48 y.o
: Jl. KPBB II
RT 017/007
Cengkareng
Religion : Moslem

Marital status: Married

Occupation : Housewive
Educational : High
School
Date of hospital
admission:
31 December 2015
Room
: P. Numfoor

Chief
complaint
Also currently
complains of:

Prolonged pain her low back for the past 2

years before admission to hospital

Pain in her right groin

Continous headache
Uncomfortable sensation in her stomach
Weakness in her extremity

History of Present illness

Prolonged pain her low back for the past 2 years

-She felt pain in her lower back to the right groin worsened after her
upper arm broken two months ago
-Numbness in her left leg and foot
-She cant move her right leg because of the pain
-No complaint of Loss of bladder or bowel control
History:
Had miomektomy in 2012
Had mastectomy on her left breast in 2013.
After the surgery, she recieved Chemotherapy 3 times and stop. Patient didnt
want to continue treatment
Two months before getting into the hospital, she fell and broke her upper arms.
She went into alternative therapy but patient still couldnt move her arm
So she went into the doctor and been dignosed as malunion

Past Medical History:

Hypertension (-), Diabetes Mellitus (-), Asthma
(+), Allergies (-),Upper respiratory infection (-)
Family Medical History:
Hypertension (-), DM (-), Asthma (-), Allergies
(-)Upper respiratory infection (-)

Personal life History:

No tobacco, drug, or alcohol use

Physical Exam
Compos Mentis
Moderate pain
GCS
:15
Vital signs
BP
Pulse
RR
Temp

: 160/100 mmHg
: 84x/min
: 18x/min
: 36,9 C

Status Generalis: Normal

 Neurological
examination
Meningeal
sign

Head

normal

Neck

normal

Aphasia/disart ria

Cranial nerve

Result

N.I

Not checked

N.II

Not checked

N.III

Opening of eyelids: symmetric, good eye

movement, pupil isocoria, direct light reflex +/+,
indirect rightreflex +/+, nistagmus (-)

N.IV

Eye movement: good, diplopia (-)

N.V

Mouth opening;good, biting;good, cornea reflex

(+)

N.VI

Eye movement: good, diplopia (-)

N.VII

Fascial: Asymmetric weaknes on the left side, eye

opening +/+

N.VIII

Auditory:not checked. Balance: finger to nose +/-,

finger to finger normal, dysdiadokinesia: normal.

N.IX

Not checked

N.X

Arcus pharynx symmetric

N.XI

normal

N.XII

normal

Neurological Examination:
Upper extremity
Motoric

Right

Left

Muscle strength

5555

Not checked

Reflex
Biceps

++

Triceps

Pathological Reflex
Hoffman-Tromer

Sensoric
Pin-Prick Test

Neurological Examination:
Lower extremity
Motoric

Right

Left

Muscle strength

Not checked

3333

Patella

++

Achilles

++

Babinsky

Chadock

Reflex

Pathological Reflex

Sensoric
Pin-Prick Test

Lab
Result

Normal

Leukocyte

18.100 /uL

5000-10.000

Eritrocyte

2.060.000 /dL

4.000.000-5.4000.000

Hb

6.7 g/dL

12 -14

Ht

23 %

37-42

LED

73 mm/hour

<20

Trigliserid

319 mg/dL

60 - 170

Total Choresterol

248 mg/dL

<200

AST

128 U/I

<34

Albumin

3.1 g/dL

3.5 - 5.2

Uric Acid

16.1 g/dL

2.6 - 6

Kalium

2.40 mmol/L

3.4 - 4.3

Ax1 K: Low back pain

Lesion n.VII central sinistra
E: Hernia Nucleus Pulposus
T: Lumbal

Diagnosis

Ax2 : Tummor Mammae sinistra

Ax3 : Dyslipidemia
Ax4 : Hipokalemi
Ax5 : Anemia
Ax6 : Hiper uricemia

Treatment

Ketorolac
Gabapentin
Amitriptilin
Diazepam
Simvastatin
Gemfibrosil
Allopurinol
Omeprazole
Transfusion PRC

3 x 1amp
3 x 300mg
2 x 12,5mg
3 x 1 tab
1 x 10mg
2 x 1 tab
3 x 100mg
1 x 1 vial
300cc

Thankyou