MORNING REPORT

IDENTITY

 Name : Mrs. WK
 Age : 67 Years old
 Sex : Female
 Address : Raha, West Muna.
 Occupation : Housewife
 Admission : Sept, 10 2019/18.50 P.M
 Doctor in charge : dr. Tri Tuti Hendarwati, Sp.OT
 History Taking (at 20.00 P.M)


 Chief Complaint: Pain on back waist
 Anamnesis :
Suffered since ± a year ago. Initially, the pain felt her back waist and
then spread to the legs. Intermittent prickling-like pain and cramps.
She has a diffuclty walking. Fever (-) gastric pain (+), defecation and
urination was normal.
 There wasn’t history of same complaint before
 There wasn’t history of HT (-) and DM (-)
 There was history of trauma: fell from motorcycle a year ago.
 There was history of previous medication: oral analgesic
consumption to ease the pain.
 Physical examination (at 20.00 p.m)

 Generalized state: 
Moderate illness, composmentis
 Vital sign:
 Blood pressure : 180/100 mmHg
 Heart rate : 88x/m, regular, strong
 Respiratory rate : 20x/m, spontaneus, symmetric,
regular, thoracoabdominal type
 Temperature : 36,5 celcius degree/axillary
 VAS 6/10
 Physical examination (at 19.13 p.M)
Present State
Head : Within normal limit
Face : Within normal limit
Eyes : Within normal limit
Nose : Within normal limit
Mouth : Within normal limit
Ears : Within normal limit
Neck : Within normal limit

Chest : Within normal limit
Abdomen : Within normal limit
Back : Localized state
Upper Limb : Within normal limit
Lower Limb : Within normal limit
Genitalia : Within normal limit
PHYSICAL EXAMINATION (AT 20.00 P.M)

LOCALIZED STATE

Waist and Leg Region
Inspection
Deformity (-), Hematoma (-), Swelling (-), Wound (-)

Palpation
Tenderness on the vertebral lubosacral region.

SPECIAL TEST
- Laseque test (+/+)
- Patrick and kontra-patrick test
(+/+)
 PLAN OF DIAGNOSTIC


Hematology, Chemical blood test
(GDS, Uric Acid and cholesterol)
X-ray lumbosacral AP/Lateral
LABORATORIUM FINDINGS


Hematology
• Hb: 11,8 g/dl
• PLT: 193x10*3/uL
Chemical blood test
- GDS : 110 mg/dL
- Uric Acid : 3,5 mg/dL
- Total Cholesterol : 140 mg/dl
X-ray lumbosacral AP/Lateral



 DIAGNOSE


Differential Diagnosa
:
Diagnosa : 1. Spondylolisthesis
Ischialgia 2. Spondylosis
3. RA
 MANAGEMENT


Non Farmacology Farmacology

• Rest • IVFD
• Immobilization • Analgesic injection
• Compress ice • Kortikosteroid
• Education (life injection
style modification) • H2RA injection
• Physiotherapy • Vitamin injection

Consult To Orthopedic Surgeon

