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M.Irsyad, Male, 15 y.

o
Chief Complain
Crooked spine

History of Present Illness

Since 10 years ago patient complains for crooked spine. The patient was troubled with this
complaint. Patient cannot run and walking unbalanced. Pain at spine (-). Deformitty (+) .
Patient have abnormality congenital.

History of Past Disease


Diabetes (-), hypertension(-), no history of allergy or asthma
Physical Examination
Compos mentis, BP : 100/70 mmHg, HR : 80x /min, RR :
17x/min
Eye : No anemic conjunctiva, No icteric sclerae
Thorax : No bruises, symmetric on both sides when
inspiration and expiration
Lungs : Vesicular on both sides, No Rhales nor Wheezing
Heart : Normal Heart sounds, no murmur nor gallop
Abdomen : flat, No pain on palpation, liver and spleen wasnt
enlarged, no muscular defense, normal bowel sounds
Extremity : Warm, CRT <2
Local State of Spine
Look
Deformity (+), gibus (-), no sinus

Feel
No Tenderness, muscle spasm (-),

Move
Spinal ROM N
Physical Examination
Reflexes Right Lef

Patellar tendon (L4) ++ ++

Autonom
Achilles tendon (S1) ++ ++
Urinary incontinence (-)
Fecal incontinence (-)
Babinsky group - -

Clonus - -

Right Lef Right Lef

C5 5 5 C5 5 5
C6 5 5 C6 5 5
C7 5 5 C7 5 5

C8 5 5 C8 5 5

T1 5 5 T1 5 5
Physical Examination
Right Lef Right Lef

L2 5 5 L2 5 5

L3 5 5 L3 5 5

L4 5 5 L4 5 5

L5 5 5 L5 5 5

S1 5 5 S1 5 5
MRI
Pre Op, 2016
X Ray
X-RAY THORAX
Laboratory

CBC : 13.2/32.2/5700/325000
PT : 9.6
aPTT : 21.5
AST / ALT : 14/33
Ur / Cr : 17/1.0
Fasting blood glucose/2HPP BG : 100/194
Electrolyte :145/4.7/115
Assessment

Diagnosis Performed
Scoliosis Scoliosis Reconstruction

List of Problems
Deformity
Socioeconomic
Eko Budianto, Male, 36 y.o
Chief Complain
pain at spain
History of Present Illness
2 weeks ago ,patient complains for spain without history of trauma. Patient working in the oil
palm plantation. While working, the spain patients hit sack contain 15 kiogram.
Patient direct can not move until now.
Pain at spine (+). Then he started the treatment at Neurology and Orthopaedi unit at Ulin
Hospital, she had a problem pain at spain. The patient then hospitalized in Tulip ward.

History of Past Disease


Hypertension (-) No history of diabetes, allergy or asthma
Physical Examination
Compos mentis, BP : 120/70 mmHg, HR : 95x /min, RR :
19x/min
Eye : No anemic conjunctiva, No icteric sclerae
Thorax : No bruises, symmetric on both sides when
inspiration and expiration
Lungs : Vesicular on both sides, No Rhales nor Wheezing
Heart : Normal Heart sounds, no murmur nor gallop
Abdomen : flat, No pain on palpation, liver and spleen wasnt
enlarged, no muscular defense, normal bowel sounds
Extremity : Warm, CRT <2
Local State of Spine
Look
No deformity, no gibus, no sinus
drain

Feel
Tenderness, muscle spasm (-), step
off (-)

Move
Spinal ROM limited due to pain
Physical Examination
Reflexes Right Lef

Patellar tendon (L4) + +

Autonom
Achilles tendon (S1) + +
Urinary incontinence (catheter)
Fecal incontinence (-)
Babinsky group - -

Clonus - -

Right Lef Right Lef

C5 5 5 C5 5 5
C6 5 5 C6 5 5

C7 5 5 C7 5 5
C8 5 5 C8 5 5

T1 5 5 T1 5 5
X-RAYMRI
Sagittal Sept 2016
April 2014
X-RAY sept 2016
Axial MRI
X-RAY THORAX
Laboratory

CBC : 11.1/35.0/8200/200.000
PT : 10.7
aPTT : 23.4
AST / ALT : 27/16
Ur / Cr : 22/0,19
Fasting blood glucose : 111
Electrolyte :146/4,7/115
Assessment

Diagnosis Performed
Fracture dislocationV. L4- Surgical:
L5 + cauda equina Stabilization
syndrome Pro laminectomy

List of Problems
Instability
Deformity