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Chief Complain
Crooked spine
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.
Feel
No Tenderness, muscle spasm (-),
Move
Spinal ROM N
Physical Examination
Reflexes Right Lef
Autonom
Achilles tendon (S1) ++ ++
Urinary incontinence (-)
Fecal incontinence (-)
Babinsky group - -
Clonus - -
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.
Feel
Tenderness, muscle spasm (-), step
off (-)
Move
Spinal ROM limited due to pain
Physical Examination
Reflexes Right Lef
Autonom
Achilles tendon (S1) + +
Urinary incontinence (catheter)
Fecal incontinence (-)
Babinsky group - -
Clonus - -
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