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ER
: dr. Gede
Consultant : dr. Betsy
Stroke unit : dr. Putri
Ward
: dr. Nining-dr. Sari
PATIENTS IDENTITY
Name
: Mrs. C
Age
: 51 yo
Gender
: Male
Occupation
: Minner Employer
Hospital admission : 1 July 2015
HISTORY (autoanamnesis)
Chief complaint
her bottom
Onset
admission
Quality
Quantity
family
HISTORY
Chronology :
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
HISTORY
HISTORY
CLINICAL FINDINGS
Present States
GCS
: E4M6V5
Vital signs
:
BP 130/80 mmHg
HR
80x/min
RR 20x/min
Temp 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 FINDINGS
Movement +/+
+/+
Strength
555/555
Tonus N/N N/N
TrophyE/E E/E
FR
++/++
++/++
PR -/--/Clonus -/-
555/555
CLINICAL FINDINGS
LABORATORY FINDINGS
LABORATORY
EXAMINATION
1 june 2015
Hb
14.1
12.00 15.00
Ht
43,0
35 47
4.5
4.4 5.9
MCH
29.5
27 32
MCV
87.3
76 96
MCHC
35.4
29 36
9.7
3.6 11 x103
268.1
Blood glucose
79
80 140
Ureum
21
15 39
LABORATORY FINDINGS
LABORATORY
EXAMINATION
Magnesium
0.74
0,74-0.99
Calcium
2.14
2.12-2.52
Sodium
139
136-145
Potassium
4,0
3.5-5.1
Chloride
106
98-107
Electrolyte
MRI
DIAGNOSIS
I. Clinical Diagnosis
Ischialgia bilateral
Hypesthesia from toes to L2-3 dermatome
Topical Diagnosis
Radix of the Spinal nerve VL4-5, L5-S1
Etiologic Diagnosis :
Hernia Nucleus Pulpous Lumbosacral
MONITORING :
GCS, vital signs, neurologic deficits, fluid
balance
EDUCATION :
diagnosis, management, complications,
prognosis