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Short Case Non Trauma
Short Case
Non Trauma
Name : Mr. D Age : 46 Years old Sex : Male Address : Pasi Kolaga,
Name
:
Mr. D
Age
: 46 Years old
Sex
:
Male
Address
: Pasi Kolaga, Muna
Occupation
:
Farmer
Admission
: July, 23 th 2018
Doctor in charge : dr. Benny Murtaza, Sp.OT
History Taking Chief complain : Can not move both of lower limbs Anamnesis : • Suffered
History Taking
Chief complain :
Can not move both of lower limbs
Anamnesis :
• Suffered since 4 months before admitted to the hospital.
• Patient began to complain cramp sensation at both legs 5 months ago
and in the last 4 months patient felt numb and then can not move his
legs anymore.
 History of diagnosed with TB and only got analgetic and kortikosteroid treatment 1 week ago
History of diagnosed with TB and only got analgetic and kortikosteroid
treatment 1 week ago at Siloam Hospital
History of disease in the family (-), DM (+), HT (-), fever (-), trauma
(-).
• History of trauma (-), history of surgery (-)
Patient didn’t noticed when defecate and urinate.
Moderate illness/ Consciouss/ Well nuorished Generalized State Vital sign BP = 140/90 mmHg RR = 24x/min.
Moderate illness/ Consciouss/ Well nuorished
Generalized State
Vital sign
BP = 140/90 mmHg
RR = 24x/min.
HR =84x/min, reguler, strong
T
= 37 0 C (axillaries)
Present State Head Face Eye Nose Mouth Ear Neck Chest Abdomen : Within Normal Limit :
Present State
Head
Face
Eye
Nose
Mouth
Ear
Neck
Chest
Abdomen
: Within Normal Limit
: Within Normal Limit
: Within Normal Limit
: Within Normal Limit
: Within Normal Limit
: Within Normal Limit
: Within Normal Limit
: Within Normal Limit
: Within Normal Limit
Upper limb : Within Normal Limit
C.Vertebra : Localized
Lower limb : Localized
Localized Status Vertebra Region I : wound (-), swelling (-), hematoma (-), gibus (-), deformity (-)
Localized Status
Vertebra Region
I
: wound (-), swelling (-), hematoma (-), gibus (-),
deformity (-)
P : tenderness (-)
 
 

5

 

5

 

5

5

5

5

5

5

5

5

 
 

0

 

0

 

0

0

0

0

0

0

0

0

 
 

No

 
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
1
2
0
2
0
2
0
2
0
2
2
2
0
0
0
2
0
2
2
2
2
2
0
2
0
2
0
2
2
0
2
2
0
2
0
2
0
2
0
2
2
2
2
2
0
0
2
2
2
2
0
0
2
2
0
2
0
2
0
2
2
0
2
2
0
2
0
2
0
2
2
0
2
2
2
2
0
2
2
2
0
2
2
2
2
0
2
2
0
2
Any anal sensation
N
2
2
2
0
2
2
0
2
2
2
2
0
2
2
0
2
1
1
2
2
0
1
0
1
0
0
2
2
0
0
0
0
0
0
2
2
0
→ Absent
0
0
0
0
1
→ Impaired
0
0
2
2
0
0
0
0
0
0
0
0
2
→ Normal
0
0
0
0
2
0
2 0
0
0
0
0
NT → Not testable
0
0
0
2
0
2
0
0
0
0
0
0
0
0
0
2
0
2 1
0
0
0
0
0
0
0
2
2
0
0
0
0
0
0
2
0
2
0
0
0
0
0
0
0
2
0
2 0
0
0
2
0
0
0
0
2
0
2
0
0
0
2
0
2
0
 
   

REFLEX

 

Physiologic reflex

Pathologic Reflex R

L

 

R

L

  • Babinski

(-)

(-)

  • (+)

Biceps

(+)

  • Chadock

(-)

(-)

  • (+)

Triceps

(+)

  • Openheim

(-)

(-)

  • Achilles

(-)

(-)

  • Hoffman

(-)

(-)

  • Patellar

(-)

(-)

tromner

 
Complete blood count Toracholumbal x-ray ap/lat X-ray lumbosacral ap/lat Thorax X-Ray AP
Complete blood count
Toracholumbal x-ray
ap/lat
X-ray lumbosacral
ap/lat
Thorax X-Ray AP
LABORATORIUM FINDING Rontin Blood 7/4/2018 hemistry Blood Test 7/4/2018 Parameter result Unit Reference Parameter result Unit
LABORATORIUM FINDING
Rontin Blood 7/4/2018
hemistry Blood Test 7/4/2018
Parameter
result
Unit
Reference
Parameter
result
Unit
Reference
value
value
WBC
9,11
10^3/uL
4.00-10.00
GDS
162 Mg/dl
70-180
HGB
14,8
g/dL
12-16
PLT
255 10^3/uL
150-400
Radiological Finding
Radiological Finding
DIAGNOSE Compressi C.Vertebra L II ec Suspect Spondylitis TB DD : spondilitis piogenik
DIAGNOSE
Compressi C.Vertebra L II
ec
Suspect Spondylitis TB
DD : spondilitis piogenik
pharmacology : Non-pharmacology : IVFD Rest Education Analgetic IV H 2 R Antagonis IV Neuroprotector IV
pharmacology :
Non-pharmacology :
IVFD
Rest
Education
Analgetic IV
H 2 R Antagonis IV
Neuroprotector IV
Diet high calory high protein
CONSULT ORTHOPEDIC
SURGERY
Thank You
Thank You