Professional Documents
Culture Documents
ER
: dr. Marcus
Consultant : dr. Iin
Stroke unit : dr. Sumarji
Ward
: dr. Niken-dr.Daniel
Tandem : dr. Runi-dr.Fathul
PATIENTS IDENTITY
Name
: Mrs. T
Age
: 51 years old
Gender
: Female
Occupation
: housewife
MR Number
: B071612
Hospital admission : 29th September
2015
HISTORY (autoanamnesis)
Chief complaint
Onset
admission
Location
: Lower Back
Quality
continous
Quantity
: ADL independent
HISTORY
Chronology :
HISTORY
HISTORY
extremity
- Hot And Tingling
sensation
HISTORY
CLINICAL FINDINGS
Present States
GCS
: E4M6V5
Vital signs
:
BP 140/80 mmHg
HR
80x/min
RR 20x/min
Temp 36.5 (axilla)
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
MotoricSup
Inf
Movement + / +
Strength
Tonus N/N N/N
Trophy E/E A/A
FR
+2/+2
PR -/- -/Clonus -/-
/
555/555
+1/+1
4+4+4+/444(pain)
CLINICAL FINDINGS
Laboratorium
Laboratorium
Nilai
Nilai normal
Hb
13.8
13-16
Ht
41.8%
40-54
4.71 juta/mmk
4,4-5,9 juta
MCH
30,8 pg
27-32
MCV
89.8 fl
76-96
34.3 g/dl
29-36
9.700/mmk
3600-11000
356.000/mmk
150-400ribu
14,5
11.6-14.8
Eritrosit
MCHC
Leukosit
Trombosit
RDW
MPV
10.2
4-11
Nilai
Nilai normal
Ur
30 mg/dl
15-39
Cr
0.7 mg/dl
0,6-1,3
145 mg/dl
80-160
Natrium
141 mmol/L
135-145
Kalium
3,9 mmol/L
3,5-5,1
Chlorida
109 mmol/L
98-107
GDS
Impression
Ro Thorax AP (28-092015)
No Tuberculosis
imaging,
Cor is normal
DIAGNOSIS
I.
Clinical Diagnosis
Low Back Pain
Ischialgia Bilateral
Paraparese Inferior Flaccid
Parethesia Inferior
Topical Diagnosis
Cauda Equina
Etiologic Diagnosis :
HNP ec susp trauma Medula Spinalis
Spondilolisthesis Lumbal 3-4
Consult to RM
Planning : MRI Lumbosakral
Therapy :
IVFD : RL 20 drop per minutes
Inj Ranitidine 50 mg/12 ho IV
Ketorolac 30 mg/12 h.o IV
B1B6B12 1 tab/ 8 h.o P.O
Amitriptilin 12.5 mg/24 h.o P.O
MONITORING :
GCS, vital signs,VAS, neurologic deficits
EDUCATION :
diagnosis, management, complications,
prognosis
THANK YOU