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1. MORNING REPORT EMERGENCY ROOM WAHIDIN SUDIROHUSODO GENERAL HOSPITAL MAKASSAR December 31 st , 202 1 ME/MS

2. IDENTITY Name : Muhammad Tola Age/ Sex : 66 y ear s old /Male Admission : December 31 st , 20 21 at 18.00 WITA Registration : 960573 Status : JKN Phone Number : xxxxxxx

3. AUTOANAMNESIS (at 18.00) The patient came with complaints of back pain, experienced since 15 months before admission to the hospital, worsening since the last 7 months. Initially the patient fell in a sitting position 15 months ago, the next day the patient felt severe pain in the back radiating to the right leg, the pain made it difficult for the patient to walk. Complaints improved 1 month later, the patient was able to walk but with the help of a cane. Complaints reappeared and worsened since the last 7 months. History of the installation of DJ stent 2 times at December 2020. ESWL history 4 times at December 2020, end of march 2021 History of black stool 2 weeks ago. History of anemia with Hb 3,2 weeks ago. Total transfusion 7 bags last 2 weeks. History of pulmonary medication denied History of tumor in the area of the upper front chest wall since 4 years ago. Growing up slowly. No weight loss history. History of smoking more than 30 years. There is no history of DM, there is a history of hypertension since 2 years ago. Not routine treatment Chief Complaint: Low back pain

4. GENERAL STATUS (at 18.00 ) Conscious / well nourished Vital Signs: Blood pressure : 160/90 mmHg Pulse rate : 84 x/min Respiratory rate : 20 x/min Temperature : 36,6 C NRS: 3/10

5. CLINICAL FINDING (18.00)

6. CLINICAL FINDING (18.00)

7. CLINICAL FINDING (18.00)

8. CLINICAL FINDING (18.00)

9. LOCAL STATUS (at 02.10) Look : Deformity (-) , Swelling(-),Gibbus (-), wound(-), hematoma (-) There is a mass on the left paravertebral measuring 16x8x2cm Feel : Tenderness (+), as level as Lumbar 4, step off (-)

10. Yes 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

11. 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 2 2 2 1 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

12. REFLEX Physiologic Reflex Pathologic Reflex R L R L Biceps (++) (++) Babinski (+) (+) Triceps (++) (++) Chadock (-) (-) Achilles (+++) (+++) Openheim (-) (-) Patellar (+++) (+++) Hoffman Tromner (-) (-) Klonus ( - ) ( - )

13. RADIOLOGY FINDING at 02.40

14. RADIOLOGY FINDING at 02.40

15. L ABORATO RY FINDING ( at 03.00 ) WBC : 12.3 x10 3 / mm 3 HGB : 12,3 g/dL HCT : 39 % PLT : 505 x 10 3 / mm 3 PT : 10,4” APTT : 22,7” INR : 1,00 RBS : 148 mg/dl Ureum : 14 mg/dl Creatinin : 0,76 mg/dl ALT : 27 mg/dl AST : 21 mg/dl HbsAg : Non reactive Sodium : 138 mmol/L Potassium : 3,7 mmol/L Chloride : 103 mmol/L

16. DIAGNOSIS Low back pain due to compression fracture vertebra thoracal VI-VII, thoracal XII Burst fracture vertebral lumbal I

17. MANAGEMENT IVFD RL Analgesic Report to Orthopaedic senior, advice : Report to Orthopaedic consultant, advice CT-Scan columna vertebra + analgetic

18. THANK YOU

19. RADIOLOGY FINDING at 02.40