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Chief Complain History of Present Illness
Chief Complain History of Present Illness
y.o
Chief Complain
weakness at her lower extremity since 2 months ago
History of Present Illness
2 months ago,patient complains for numbness and mild weakness on both
legs , with pain, suddenly occured without history of trauma, fever or
chronic cough. Patient still able to walk, so the patient didnt take any
medication, but the complains didnt resolve and getting worse. Urination
and defecation both normal.
1 year before, she found mass at her back. The mass is hard and doesnt
get bigger. The mass didnt make any complain before.
2 month ago, the patient started the treatment at Internist and Orthopaedi
unit at Ulin Hospital, the patient felt that the weakness become worse, and
she had no problem of defecation and urination. The bodyweight also
decreased about 3kg. There is no history of prolong cough, night sweating
or fever. The patient then hospitalized in orthopaedy ward. And start
Tuberculosis medication. Now the patient has taken Tuberculosis
medication for more than one month but her leg didnt resolve. She also
got her DM type II medication from internist.
History of Past Disease
Diabetes (+), hypertension(+), no history of allergy or asthma
Physical Examination
Compos mentis, BP : 140/70 mmHg, HR : 80x /min, RR :
16x/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
Physical Examination
Reflexes
Right
Left
++
++
Autonom
Achilles tendon (S1)
++
++
Babinsky group
Clonus
Right
Left
C5
C6
C7
Right
Left
C5
C6
C7
C8
C8
T1
T1
Physical Examination
Right
Left
Right
Left
L2
L2
L3
L3
L4
L4
L5
L5
S1
S1
Lumbosacral
AP and Lateral, 2016
Pre
Op X Ray
Sagital
Sagittal MRI
AprilMRI
2014
Axial
MRI
Axial MRI
MRI
Sagittal Coronal
MRI April
2014
th
Thorax
AP,
October
6
Sagittal MRI April 2014 2016
th
EKG,
October
6
2016
Sagittal MRI April 2014
Laboratory
CBC : 11.4/32.2/5500/328000
PT : 9.6
aPTT : 21.9
AST / ALT : 14/33
Ur / Cr : 36/1.2
Fasting blood glucose/2HPP BG :
108/194
Electrolyte :146/4.6/115
Assessment
Diagnosis
TB spine L1
List of Problems
Infection
Instability
Pain
Deformity
Pathologic fracture
Neurological deficit
Socioeconomic
Performed
TOTAL TREATMENT 4
Basic TB treatment:
Anti TB drugs
Orthoses (TLSO)
Bedrest
Surgical:
Debridement, posterior
stabilization
Physical Examination
Compos mentis, BP : 130/70 mmHg, HR : 109x /min,
RR : 27x/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
Physical Examination
Reflexes
Right
Left
Autonom
Achilles tendon (S1)
Babinsky group
Clonus
Right
Left
C5
C6
C7
Right
Left
C5
C6
C7
C8
C8
T1
T1
Physical Examination
Right
Left
Right
Left
L2
L2
L3
L3
L4
L4
L5
L5
S1
S1
SagitalMRI
MRIApril
October2016
Sagittal
2014
Axial
MRI
October2016
Axial MRI
CoronalMRI
MRIApril
October2016
Sagittal
2014
Laboratory
CBC : 11.3/33.0/9500/201.000
PT : 10.6
aPTT : 23.4
AST / ALT : 27/16
Ur / Cr : 24/019
Fasting blood glucose : 111
Electrolyte :146/4/115
BMA
Conclusion:
Monoclonal gammopaty (s.multiple
myeloma)
Assessment
Diagnosis
Performed
Myelodenopaty
vertebrae Thoracal
6&7 MBD dd MM
List of Problems
Instability
Deformity
Neurological deficit
Surgical:
Decompression
Stabilization
Tumor removal