On Duty:

Rivan
Aprillia
Merry
Yasinta
Bima
Dennis

DPJP:
Dr. Arthur Mawuntu, SpS
1. Mrs. JG/ 45 yo/ Dx : BPPV
2. Mr. ME / 59 yo / Dx : Migraine + Hypertensi
gr.2
3. Mr. LD/ 47 yo/ Dx : Tetraparese UMN ec SCI ASIA
IMSOP Gr. C
4. Mrs. SJ / 54 yo / Dx :Vertigo post trauma
5. Mrs. MP / 34 yo/ Dx : Reattack CVD SI onset
day 3rd
6. Mr. DH/ 49 yo/ Dx : Unconsiousesness ec
Sepsis
7. Mr. TR /24 yo / Dx : comotio cerebri
8. Mr. KG /16 yo / Dx : comotio cerebri
9. Mr. RA /38 yo / Dx : Moderate Head Injury +
Susp. Fr Basis Cranii
10. Ms. MK / 1 yo / Dx: Mild Head Injury
 Male 47 yo admitted to hospital with weakness in all
extremity since 10 hour before admission
10 hour BEFORE ADMISSION HOSPITAL ADMISSION

• Patient got accident while he was • Crampt in all extremity and

down and his face bumped a ground following weakness in all extremity
• Crampt in all extremity and (+)
following weakness in all extremity • Headache (+)
(+) 30 minute after accident
•Consciousness and complained of
headaches (+)
•History of vomiting(_)
•Blood from nose and ears(-)
•Seizure (-),Fever(-)
•Alcohol (+)
 Historyof trauma (+) 1 year ago
 Hypertensi(+) not take medicane
regulary, DM (+),cholesterol (+) , urid
acid (+)
 General examination:
• General condition: moderate, Consciousness : compos mentis
• BP: 130/80 HR: 78 x/m reg, RR: 20x/m , T: 36,5 °C VAS 6
• Conjunctiva : pale (-/-), sclera ikteric (-/-)
• Thorax : Rale -/-, Wh -/-, heart sound I/II normal, gallop -,
murmur –
• Back : gibbus (-)
• Abdomen : flat, normal turgor, peristaltic normal
• Extremities : warm acral
• GCS E4M6V5(15) PERRL +/+ ø 3mm / 3mm
• Meningeal Sign: Nuchal rigidity (not evaluated),
Laseque (-/-) , Kerniq(-/-)
• Cranial Nerves: NII – N.XII paresis (-)
• FODS: colour orange, Cupping (+), a:v = 2:3
• Motoric State : tetraparesis UMN
• MS : 3333/3333 MT : ↓ ↓ FR : ++ ++ PR : - -
3322/2233 ↓ ↓ ++ ++ --

Sensoric State : hipestesi at C-5 dermatoma

• Autonomic State : incontinentia urine et alvi (-)
 In Normal Range
 Hb : 14,2
 MCV : 92
 MCH : 30
 Ht : 42,2
 WBC : 10.200
 PLT : 276.000
 RBC : 4,25x106
 GDS : 89
 Cr : 0,8
 Ur : 30
 Na :139
 K : 3,3
 Cl :107
 Tetraparesis ec compressed fracture C2-
3, C5
 Hipokalemia mild
 Bed rest
 Collar Neck Rigid
 IVFD NaCl 0,9% 500cc 14tpm
 Inj Methylprednisolone 3x500mg iv
 Inj Ranidine 2x50mg iv
 Inj Ketorolac 1amp if severe pain iv
 Paracetamol 3x500mg po
 Gabapentin 2x300mg po
 Lactulax syr 0-0-CII
 Consult to Orthopaedic department
 Consult to Rehabilitation department
 MRI Cervical + contrast