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1. MORNING REPORT
Monday, Februari 23 2020
Department of Neurology, Dr. Sardjito Hospital
Gadjah Mada University
dr. Adhi Hermawan

2. Neurology In-Patients
Name Age MR Diagnosis Sub
division
Doctor
Mrs S 55 y.o 01.90.xx.xx Vertigo Mixed Type at patient Leukemia Vertigo Prof SS

3. Consulted to Neurology
Name Age MR Diagnosis Sub
division
Docto
r
Mrs. R 64 Hemiarese sequele post Stroke with STEMI CV PA
Mrs N 22
Sopor cum headache progressive ec encephalitis bacteria
dd TB
Infection SK
Mrs S 56
LBP mixed type chronic progressive cum paraparese
spastic ec spondylitis TB
Pain YD
Mr K 60
Secundery Epilepsy with History of stoke patient CHF
Epilepsy TY
Mr J 57 Right Hemiparese cum PN VII susp stroke recurent CV AG
Mr S 51 Without neurologis deficit at patient post stoke with STEMI CV PA
Mr J 50 Stroke non hemoragik CV AG
Mr Y 20 Headache patient with CML CV AG
Mr W 51
Somnolen cum without lateralitation ec metabolic
intensif IS

4. Patient Identity
Name : Mrs. P
Age : 77 years old
Marital Status : Married
Religion : Islam
Address : Sleman
Job : unemployee
Education : Senior high school
Admitted : 21 February, 2020
MR : 01.92.xx.xx

5. Chief Complaint
Weakness of Lower extremity

6. Present Illness
2 months before admission desember 2019
Patient complained of back pain. Pain reffered to lower extremity (both of the leg),
intermitent, mild intensity, duration more than 5 minutes. improved with rest (relieved
with?)and pain medication ( apa aja obatnya?) from the hospital. Worsening with
activity. complaints accompanied by numbness (numbness dimana? karakteristik?)
Denied: Unilateral Sensory Loss, weakness extremity (udah difficult to walk mestinya mulai ada
weaknes of extremity), Trauma, Fever, Urinary or Bladder retention, double vision, Decreased of
sensibility.
1 months before admission January 2020
Back pain get worse from mild to moderate intensity, accompanied by burning , pin
and neddles sensation. Improved (maksudnya berkurang apa bertambah?) with pain
medication and rehabilitation at hospital. And later on patient become difficult to walk.

7. Present Illness
2 days before admission
The pain is still at moderate intensity and even become persistent during the day.
Worsened during any movement and accompanied by lower extremity weakness.
Difficult to wearing sandals especialy on the right leg.
Denied: Trauma, Vomitus, Tumor, Urinary or Bladder retention, Decreased sensibility, Fever
The pain is getting worse and the intensity become severe . The pain medication
that patient take didn’t help at all. Weakness of lower extremity complaint becoming
persistent and so the patient reffered to the Emergency Room of RSS immediatelly.
Admission day February 21st 2020

8. Past Medical History
History of trauma from traffic accident 10 years ago but the weakness
of extremity wasn’t found back then.
Denied:
• History of similar complaint in the past
• History of Fever
• History of chronic illnesses
• History of prolonged cough
• History of hormonal Contrateption
• History of drug abuse
• History of tumor

9. Family Medical History
Denied:
• History of similar symptom or illnesses
• History of prolonged cough
• History of tumor
• History of chronic illnesses

10. Pyschososial History
• Live with her children
• History of job store seller
• Moderate to high economy level
• Insurance status is Provided by the JKN

11. Systemic Anamnesis
 Cerebrospinal system : weakness of lower extremity, low back
pain,(yang mana duluan ??) burning ,pin and needles sensation
 Cardiovascular system : no complaint
 Respiratory system : No complaint
 Musculoskeletal system : no complaint
 Genitourinary system : no complaint
 Gastrointestinal system : no complaint
 Integumental system : no complaint

12. Summary of Anamnesis
Patient 55-years-old Female with the chief complaint of acute
weakness of lower extremity. Complaint accompanied by sub-acute
progresive low back pain with severe intensity, intermittent (apa
persistent?), with the duration more than 5 minutes,(membaik dan
memberat dengan?) pain reffered to both of the legs, numbness,
burning, pins and needles sensation,worsened during activity.

13. Low back pain mixed type onset subacute
progressive cum weakness of lower extremity
Radix spinalis In the level of Vertebra lumbal
susp of Lumbal HNP
Topical Diagnosis
Ethiological Diagnosis
Clinical Diagnosis
Temporary Diagnosis

14. General Status (February, 22th 2020)- anggrek 1
General condition : moderate, GCS: E4V5M6
W= 50 kg, H= 164 cm
BMI: 18.6 kg/m2 (normowight)
NPS = 5
WB = 4
id Pain = 3
Vital Sign :
BP : 125/70 mmHg
HR : 96 bpm, regular Temp : 36.6°C
RR : 20 x/minute, regular SpO2 : 99%
Physical Examination

15. Physical Examination
 Head : Normocephalic
 Neck : JVP normal, Lymph gland not palpable
 Thorax : symmetrical, retraction (-)
 Pulmo : ves +/+, crackle -/-, wheezing -/-
 Cor : S1-S2 singular, regular, murmur (-)
 Abdomen : peristaltic (+) Normal, tympanic
 Hepar/lien/ren not palpable
 Extremities : drop foot of the right leg
 Vertebrae : Gibbus (-) Inflamation (-)

16. Neurology Examination
 Consciousness : Compos mentis GCS: E4V5M6
 Head : isochoric pupils, ∅ 3 mm/3 mm, light reflex (+/+),
corneal reflex (+/+)
 Cranial Nerves : Normal
 Neck : meningeal sign (-), nuchal rigidity (-)
Kernig’s Sign (-), Brudzinski’s Sign(-)
 Movement and strength:
 Sensibility :Dermatomal hypoestesia in the level of L2-S1
 Vegetative : normal
N N 5/5/5 5/5/5
R R 3/3/4 4/4/4

17. Neurology Examination
Clonus Pathological
Reflexes
Physiological
Reflexes
- - +2 +2
- - - - +1 +1
Tonus Trophy
normotonus normotonus eutrophy eutrophy
normotonus normotonus eutrophy eutrophy
5
5
3
4
5
5 5
5
4
3

18. LBP examination

19. Supportive Examination MRI lumbal 21/2/2020

20. Parameters Result Normal Range
Leukocyte 11.5 x 103/µL 4,50 – 11,50
Eritrocyte 4.46 x 106/µL 4,60 – 6,00
Hb 12.1 g/dL 13,0 – 18,0
Ht 38 % 40,0 – 54,0
MCV 85.2 fL 80,0 – 94, 0
MCH 27.1 pg 26,0 – 32,0
MCHC 31.8 g/dL 32,0 – 36,0
Platelet 402 x 103/µL 150 – 450
Neutrofil 69.1 % 50,0 – 70,0
Limfosit 20.9 % 18,0 – 42,0
Monosit 7.5 % 2,0 – 11,0
Eosinofil 2.1 % 1,0 – 3,0
Basofil 0.4 % 0,0 – 2,0
Glucose 107 mg/dL 74 – 140
Laboratory
Examination
21-2-2020

21. Parameters Result Normal Range
Albumin 3.86 mg/dL 3,40 – 5,00
AST 21 U/L 15 – 37
ALT 23 U/L 12 – 78
BUN 24.9 mg/dL 7 – 18
Creatinin 0,84 mg/dL 0,80 – 1,30
Natrium 143 mmol/L 136 – 145
Kalium 3.54 mmol/L 3,50 – 5,10
Klorida 108 mmol/L 98 – 107
Laboratory
Examination
21-2-2020

22. Problems
 Diagnostic??
 Therapy management
 Neurologic Defisite

23. Low back pain mixed typed onset sub acute
progressive cum paraparese type flaccid cum
dermatomal hypoestheesia in the level L2-S1
Radix Spinalis dermatomal in the level L2-S1
Canalis stenosis ec HNP lumbal
Topical Diagnosis
Ethiological Diagnosis
Clinical Diagnosis
Final Diagnosis

24. Therapy
Pharmacological Therapy:
- IVFD NaCl 0.9% 16 drops/minute
- Dexamethasone IV inj 5 mg/6 hours
- Paracetamol infusion 1g/8 hours
- Ranitidine 50mg/12 hours
- Gabapentin 1x 300mg
Plan:
ENMG

25. Prognosis
Death : ad bonam
Disease : ad bonam
Dissability : ad malam
Discomfort : ad bonam
Dissatisfaction : ad bonam
Destitution : ad bonam