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  • 26 April 2017 SCI

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    A 44-year-old female patient was admitted to the hospital with weakness in her upper and lower extremities. She had fallen two weeks prior while doing laundry and experienced numbness and loss of sensation from her legs up to her arms since then. On physical examination, she had weakness throughout her extremities consistent with tetraparesis. Imaging showed abnormalities in her cervical spine. Her lab results were normal. She was diagnosed with tetraparesis in her extremities due to a spinal cord injury and was started on methylprednisolone, bed rest, and other treatments.

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    A 44-year-old female patient was admitted to the hospital with weakness in her upper and lower extremities. She had fallen two weeks prior while doing laundry and experienced numbness and loss of sensation from her legs up to her arms since then. On physical examination, she had weakness throughout her extremities consistent with tetraparesis. Imaging showed abnormalities in her cervical spine. Her lab results were normal. She was diagnosed with tetraparesis in her extremities due to a spinal cord injury and was started on methylprednisolone, bed rest, and other treatments.

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    11 views13 pages

    26 April 2017 SCI

    Uploaded by

    Rikizu Hobbies
    A 44-year-old female patient was admitted to the hospital with weakness in her upper and lower extremities. She had fallen two weeks prior while doing laundry and experienced numbness and loss of sensation from her legs up to her arms since then. On physical examination, she had weakness throughout her extremities consistent with tetraparesis. Imaging showed abnormalities in her cervical spine. Her lab results were normal. She was diagnosed with tetraparesis in her extremities due to a spinal cord injury and was started on methylprednisolone, bed rest, and other treatments.

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    of 13

    Morning Report ,

    26 th April 2017
    On Duty:
    dr. Milani
    dr. Sandy
    dr. Feliana
    dr. Herdy
    dr.Yasinta
    dr. Flora
    dr. Bima
    DPJP:
    dr. Corry N.Mahama, Sp.S
    Statistic
    1. Mrs. OF / 30 yo / dx unconsciusness ec ME TB
    2. Ms. LA/ 16 yo/ Dx : Mrs. KA/ 67 yo/ Dx : Unconsciousness ec Status
    Epilepticus
    3. Mrs. MM/ 61 yo / dx : unconsciusness ec sepsis dd CVD SI onset H-
    2+STEMI
    4. Mrs. NM/ 44 yo / dx : Tetraparesis UMN ec SCI Asia Imsop
    Grade A with clinical improvement
    5. Mr. DD/ 44 yo/ Dx : Periodic Paralisis Hipokalemia
    6. Mrs. MB / 32 yo / dx : moderate head injury + alcholismn
    7. Mrs. MR/ 44 yo / dx : moderate head injury+epilepsi
    8. Mr. JJ/ 43 yo / Dx : moderate head injury
    9. Mr. MP/ 61 yo/ Dx : moderate head injury
    10. Mr. BR/ 24yo/ Dx : moderate head injury+ alcoholism
    11. Mrs. SC/ 28 yo/Dx:TTH
    History Taking
    Female 44 yo admitted to hospital with chief complain weakness in both
    lower and upper extrimity
    2 weeks before admission At admission

    Weakness in both lower and upper Weakness in both lower and upper
    extrimity after she felt down. She slipped extrimity
    down when she was doing the laundry and Numbness from her leg until her both
    was found in the ground. After that incident arm
    patient couldnt move her lower and upper Couldt feel to miction and defecation
    extrimitiy, feel numbness from her leg until
    her both arm. She couldt feel to miction and
    defecation and feel stiff and pain to move her
    neck. Unconsious (-), vomit(-), seizure (-),
    dyspnea(-) She delivered to Kotamobagu
    Hospital and being hospitalized for 1 week.
    After one week she still couldnt move her
    both leg and his both finger, couldt feel to
    miction and defecation still exist.
    Physical Examination

    General status:
    General condition: moderate, Consciousness : CM
    BP: 130/80 mmHg, HR: 76 x/m reg, RR: 22x/m , T: 36,5 C
    Sp02 97%
    Conjunctiva : anemis (-/-), sclera ikteric (-/-)
    JVP ; normal
    Thorax : Rh -/-, Wh -/-, heart sound I/II normal, gallop -, murmur
    Abdomen : supel, normal turgor, peristaltic normal
    Extremitas : warm acral
    Neurologic examination
    GCS E4M6V5 (15) PERRL, +/+ 3 mm/3 mm; Direct light Reflex +/+
    Indirect Light Reflex +/+
    Meningeal Sign: not evaluated
    Cranial Nerves: N II-XII Intact
    Motoric State : 4455 5544
    2222 2222
    MT : N N PhyR : ++/++/++ ++/++/++ PathoR : - -
    +++/+++ +++/+++ + +
    Clonus +/+
    Sensoric State :
    Exteroceptive : hipestesi C7
    Propioceptive : not affected
    Autonomic State : incontinentia urine et alvi (+)
    WDx
    Tetraparesis UMN ec SCI ASIA IMSOP Grade A with clinical
    improvement
    Planning Dx
    X- Photo Cervical AP/Lat
    X-Ray Thorax
    Lab examination
    Planning Tx
    C-Spine Control ( collar neck)
    Bedrest
    Catheter (approval from fam)
    IVFD NaCl 0,9% 500 cc 20 gtt/mnts
    Inj Ranitidin 2x1 amp IV
    Methyl prednisolone 3x500mg IV
    Natrium diclofenac 2x50mg PO
    Amitriptiline 25mg 3x1/4tab PO
    Laboratory Examination
    Hb : 13.3
    Ht : 37.5
    WBC : 13.890
    PLT : 217.000
    RBC : 4,37 x 106
    CBG : 152
    Cr : 0.7
    Ur : 22
    Na : 138
    K : 3.80
    Cl : 106
    X-Ray Thorax
    X-Ray Cervical
    WDx
    Tetraparesis UMN ec SCI ASIA IMSOP Grade A with clinical
    improvement
    Thank You

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