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    Morning Report, Tuesday November 2015: On Duty: Rivan Aprillia Merry Yasinta Bima Dennis DPJP: Dr. Arthur Mawuntu, Sps

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    Rivan Ho
    The morning report summarizes a 47-year-old male patient admitted for weakness in all extremities. He was involved in an accident 10 hours prior where he fell and hit his face on the ground. Since then he has experienced cramping and weakness in his extremities. On examination, he has tetraparesis and hypesthesia consistent with a compressed fracture of C2-3 and C5 vertebrae. His treatment plan includes bed rest, cervical collar, IV fluids, steroids, pain medications, consultations, and an MRI of the cervical spine.

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    Morning Report, Tuesday November 2015: On Duty: Rivan Aprillia Merry Yasinta Bima Dennis DPJP: Dr. Arthur Mawuntu, Sps

    Uploaded by

    Rivan Ho
    20 views14 pages
    The morning report summarizes a 47-year-old male patient admitted for weakness in all extremities. He was involved in an accident 10 hours prior where he fell and hit his face on the ground. Since then he has experienced cramping and weakness in his extremities. On examination, he has tetraparesis and hypesthesia consistent with a compressed fracture of C2-3 and C5 vertebrae. His treatment plan includes bed rest, cervical collar, IV fluids, steroids, pain medications, consultations, and an MRI of the cervical spine.

    Original Description:

    Tetraparesis Umn

    Original Title

    Tetraparesis UMN

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    The morning report summarizes a 47-year-old male patient admitted for weakness in all extremities. He was involved in an accident 10 hours prior where he fell and hit his face on the ground. Since then he has experienced cramping and weakness in his extremities. On examination, he has tetraparesis and hypesthesia consistent with a compressed fracture of C2-3 and C5 vertebrae. His treatment plan includes bed rest, cervical collar, IV fluids, steroids, pain medications, consultations, and an MRI of the cervical spine.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    20 views14 pages

    Morning Report, Tuesday November 2015: On Duty: Rivan Aprillia Merry Yasinta Bima Dennis DPJP: Dr. Arthur Mawuntu, Sps

    Uploaded by

    Rivan Ho
    The morning report summarizes a 47-year-old male patient admitted for weakness in all extremities. He was involved in an accident 10 hours prior where he fell and hit his face on the ground. Since then he has experienced cramping and weakness in his extremities. On examination, he has tetraparesis and hypesthesia consistent with a compressed fracture of C2-3 and C5 vertebrae. His treatment plan includes bed rest, cervical collar, IV fluids, steroids, pain medications, consultations, and an MRI of the cervical spine.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 14

    Morning Report ,

    Tuesday th November 2015

    On Duty:
    Rivan
    Aprillia
    Merry
    Yasinta
    Bima
    Dennis

    DPJP:
    Dr. Arthur Mawuntu, SpS
    Statistic
    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
    History Taking
    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 Crampt in all extremity and


    was down and his face bumped a following weakness in all
    ground extremity (+)
    Crampt in all extremity and Headache (+)
    following weakness in all
    extremity (+) 30 minute after
    accident
    Consciousness and complained
    of headaches (+)
    History of vomiting(_)
    Blood from nose and ears(-)
    Seizure (-),Fever(-)
    Alcohol (+)
    History of Past Illness
    History of trauma (+) 1 year ago
    Hypertensi(+) not take medicane
    regulary, DM (+),cholesterol (+) , urid
    acid (+)
    Physical Examination
    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
    Neurologic examination
    GCS E4M6V5(15) PERRL +/+ 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
    (-)
    ECG expertise
    In Normal Range
    Laboratory Examination
    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
    X-Ray Chest
    Dx
    Tetraparesis ec compressed fracture
    C2-3, C5
    Hipokalemia mild
    Planning
    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

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