IDENTITY

Name : Mr.F
Age : 20 years old
Address : konsel
Admission Date : December, 7th 2017
DPJP : dr.Tri Tuti Hendarwati, Sp.OT
 HISTORY TAKING
Main Complaint : Pain at the Back bone

Anamnesis : (Autoanamnesis)
Referred from the Konsel hospital with complaint paint at back bone since 3 days ago caused by
traffic accident.

MOT
The patient was ride the motorcycle. He was not using helmet and suddenly another rider crashed him
from behind and maked the patient fall down

History :
there were no history of Alcohol consumption (+), drugs (-), vomiting (-), nausea (-), headache (-)
PHYSICAL EXAMINATION
General State :
Moderate ill, conscious
Vital Sign :
BP : 110/70mmHg
RR : 20x/m regular, spontaneus thoracoabdominal type
HR : 80x/m regukar, strong lift
T : 36,70c /axillary
VAS: 6/10
 GENERALIZED STATUS

Head : Normally Chest : Normally

Face : Normally Abdomen : Normaly
Eyes : Normally Lower limb : Normally
Nose : Normally
Mouth : Normally
Ears : Normally
Neck : Normally
LOCALIZED STATE
Lumbal Region

Inspection : Deformity (-), swelling (-), hematome (-), wound (-), elongasi (-),
Shortening (-), Rotation (-), eritema (-)
Palpation : Tenderness (+)
ROM : Passive and active movement of vertebra lumbalis was limited
due to of pain.
PLANNING

Plain photo Lumbosacral dextra

AP/Lat
Blood routine
 LABORATORY
FINDINGS
ROUTINE BLOOD TEST PARAMETER RESULT

December 7th 2017 WBC 13,62x 103/Ul

RBC 5,06x 106/uL
HB 12,8 g/dL
PLT 405 x 103/uL
RADIOLOGY FINDINGS
DIAGNOSE

Spinal cord Injury

 MANAGEMENT
Non Pharmacology Pharmacology

Bed rest IVFD

Antibiotics

Analgetics

H2 reseptor antagonis

Consult to orthopaedic surgeon