Laporan Jaga Hening 1 Juli 2015

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Morning reportSunday, june 1st 2015

ER: dr. GedeConsultant: dr. BetsyStroke unit: dr. PutriWard: dr. Nining-dr. SariPATIENTS IDENTITYName: Mrs. CAge: 51 yoGender: MaleOccupation: Minner EmployerHospital admission: 1 July 2015

HISTORY (autoanamnesis)Chief complaint : Pain at her low back to her bottomOnset : 7 days before hospital admissionQuality: pain radiating two the legQuantity: ADL partly assisted by family

3HISTORYChronology :

7 years before hospital admission Pt fell down with backward position, her back hit the stairs but he didnt experience any complaint, and was still able to do her work. But the pt complained for numbness and tingling at the leg from toes to the groin area. The patient had history of heavy lifting 2 years before hospital admission the pain is worsening when he was coughing, straining, bowing and it gets better when he was resting, then pt went to see a doctor but there is no change. And then she was sent to see a neurologist and had a spine x-ray. The result from the spine x-ray was HNP.

7 days before hospital admission the painful that radiating two the leg.The paint more severe while coughing or straining. Because the pain get worse, pt went to check herself to RSDK and was suggested to had an MRI for her back. When the result came up patient was submitted to RSDK

HISTORYAggravated Factors : coughing, strainingExtenuated Factors : restingConcomitant Symptoms : numbness and tingling at the leg from toes to the groin area. HISTORYPast Medical History- patient fell down 7 years ago, but no complaint- Tumor (-)- heavy lifting (+)Family Disease History : no family history of tumor, no family history had the same illnessSocial Economic-Status And Personal History : pt is an single and used National insurance for her treatment

CLINICAL FINDINGSPresent StatesGCS : E4M6V5Vital signs :BP 130/80 mmHgHR 80x/min RR 20x/minTemp 36.5 (axilla) VAS 6-7 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 FINDINGSCranial Nerves: normal

MotoricSup InfMovement+/+ +/+Strength 555/555 555/555TonusN/NN/NTrophyE/EE/EFR ++/++ ++/++PR-/--/-Clonus-/-

CLINICAL FINDINGSSensibility : Hypesthesia from toes to L2-3 dermatomeVegetative :normalLaseq : 135Bragard : +/+Sicard : +/+Patrick : +/+Contra patrick: +/+LABORATORY FINDINGSLABORATORY EXAMINATION1 june 2015Hb14.112.00 15.00Ht43,035 47Red blood cell4.54.4 5.9MCH29.527 32MCV87.376 96MCHC35.429 36White blood cells9.7 3.6 11 x103Platelet268.1 150 400 x103Blood glucose7980 140Ureum2115 39Creatinin 0,80.6 1.3LABORATORY FINDINGSLABORATORY EXAMINATION22nd November 2014Magnesium0.740,74-0.99Calcium2.142.12-2.52ElectrolyteSodium139136-145Potassium4,03.5-5.1Chloride10698-107Thoracolumbar MRI with contras

MRIDegenerative at the VL2 corpus Spondilosis torakolumbalisAnular bulging on the intervertebral disc VL2-3 and Vl3-4 with the constriction of the neuralis foramen VL4-5 both left right and VL5-S1Protusio posterosentral on the intervertebral disc VL4-5 and VL5-SISklerotik end plate superior vertebra sacrum 1Imaging degenerative spine DIAGNOSISI. Clinical DiagnosisIschialgia bilateral Hypesthesia from toes to L2-3 dermatomeTopical Diagnosis Radix of the Spinal nerve VL4-5, L5-S1Etiologic Diagnosis : Hernia Nucleus Pulpous Lumbosacral

INITIAL PLANS & THERAPYConsult to Physical Medicine and RehabilitationTherapy : IVFD : RL 20 drop per minutesInj Ranitidine 50 mg/12 ho IVInj ketorolac 1 amp/12 ho iv Vitamin B1 B6 B12 1 tab/8 ho (orally)

MONITORING : GCS, vital signs, neurologic deficits, fluid balance

EDUCATION : diagnosis, management, complications, prognosis