Patient List

No Identity Admission Diagnosis Treatment

to E.R.
1. Mr. Ngadino/ April 6th Observation of Tetraplegy due to VS Obs
Spinal Cord Injury on VC6 IVFD RL
2015 at
64yo/1-14 - 14.00
Frankle C Analgesic
64-12 H2Blocker
WITA
Consult to
orthopedic Surgeon:
Cervical CT SCAN
Hospitalized

A L R CT ECG
1. Mr. Ngadino/ 64yo/1-14 -64-12
April 6th 2015 at 14.00 WITA
Chief Complain :
Unable to move both of hand and legs
History :
One week before admission patient had fallen when he was
riding bicycle caused hit by a car. His neck was bumped and
stretched up on his back position. He immediately unable to
move four of his extremities. History of fainted (+), Bleeding
from mouth/nose/ear (-/-/-). His family rushed him to
Boedjasin Pelaihari Hospital. The patient was recommended to
be referred to Ulin Hospital but he refused and requested to be
dismissed after several days of hospitalization. The patient went
to Ulin Hospital 1 week later. In boedjasin hospital there is no
improvement of patient motoric.

L R CT ECG
Primary Survey
Clear, snoring (-), gurgling (-), C-spine
A
control (-)

Clear, RR= 20 bpm, symmetric

B
respiratory movement, VBS

Blood Pressure: 100/70 mmHg

C
Pulse rate : 80 bpm, reguler, strong lifted

GCS E4V5M6 (15), Round and symmetric pupils

diameter (3mm/3m), Light reflexes (+/+)
D Motoric 0 0
0 0

A L R CT ECG
A -

M -

Broken right arm 8

P years ago
3 hours before
L admission
On the road of
E Pleihari

A L R CT ECG
Secondary survey
Head : Normocephaly
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Head/Neck Mouth : Moist mucous membrane
Neck : JVP enhancement (-/-), lymphatic nodes
enlargement (-/-)

I : symmetric respiratory movement, retraction (-),

wound (-)
Chest P : symmetric VF
P :sonor
A : VBS, Rh (-/-), Wh (-/-)

I : Wound (-), distension (-), hematoma (-)

A : Normal bowel sound
Abdomen P : H/L/M not palpable, tenderness (-), rebound
tenderness (-), muscular defense (-)
P : Tympanic in all quadrants

Warm extremities, parese (-), edema (-)

Extremities Motoric 0 0
0 0
A L R CT ECG
Neurological Status
GCS E4V5M6 (15), Round and
symmetric pupils diameter
(3mm/3m), Light reflexes (+/+), Brill
hematom (-/-), Battles sign (-/-),
parese (-), lateralization (-)

Motoric : lift both shoulder (+)

Sensoric : (+) decreased till papilla
mammae
A L R CT ECG
Clinical Pictures

A L R CT ECG
Laboratory Result April 6th 2015
Items Result Normal Value Unit

Hemoglobine 13,1 14.00 - 18.00 g/dl

Leukocyte 6,4 4.0 10.5 thousand/ul

Eritrocyte 3,99 4.00 5.50 million/ul

Hematocrit 37 32.00 44.00 Vol%

Thrombocyte 160 150 450 Ribu/ul

RDW-CV 14,1 11.5 14.7 %

MCV 92,9 80.0 97.0 Fl

MCH 32,8 27.0 32.0 Pg

MCHC 35,4 32.0 38.0 %

A R CT ECG
 Items Result Normal Value Unit

Gran% 66,1 50.0-70.0 %

Lymphosite% 23,9 25.0-40.0 %

MID% 10,0 4.00-11.00 million/ul

Gran# 4,30 2.50-7.00 Billion/ul

Limfosit # 1,5 1.25-4.0 Billion/ul

MID# 0,6 Billion/ul

A R CT ECG
 Items Result Normal Value Unit
GDS 107 <200 Mg/dL

SGOT 54 0-46 U/l

SGPT 59 0-45 U/l

Ureum 66 10-50 mg/dL

Creatinin 0,8 0,7-1,4 mg/dL

Natrium 138,2 135-146 mmol/L

Kalium 4,4 3,4-5,4 mmol/L

Chloride 101,4 95-100 mmol/L

A R CT ECG
Thorax X-Ray March 27th 2015 at
Boedjasin Hospital

A L CT ECG
VT VL and VC X-Ray March 27th 2015 at
Boedjasin Hospital

A L CT ECG
VT VL and VC X-Ray March 27th 2015 at
Boedjasin Hospital

A L CT ECG
VT VL and VC X-Ray March 27th 2015 at
Boedjasin Hospital

A L CT ECG
Working Diagnosis
Observation of Tetraplegy due to Spinal Cord
Injury on VC6 Frankle C

A L R CT ECG
Management
VS Obs
IVFD RL
Analgesic
H2Blocker
Consult to orthopedic Surgeon:
Cervical CT SCAN
Hospitalized

A L R CT ECG