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VL3-VL4, VL4-VL5
Juwita Arum Mayangsari, dr
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DATABASE PEBRUARY 21,
2018
Identity
Name : Mrs. S
Sex : Female
Age : 51 yo
Address : Rusun Sombo, Surabaya
Religion : Islam
Occupation : Bakso Maker (husband selling bakso)
Marital Status : Married
Ethnic : Javanese
Referred from neurology outpatient clinic with Low Back Pain
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Chief Complaint : Nyeri pada punggung kiri bawah
Patient felt dull pain at lower back area, since 10 years ago, worsen
since 2 months ago. Pain radiated to right and left thigh and calf with
VAS 7-8.The pain was aggravated by position changing from lying to
sitting, from sitting to standing, walking a long distance, walking
upstairs, sitting in a long time, forward bending the trunk, sneezing and
coughing. The pain was relieved when she was in lying position or taking
medication. Muscle weakness, numbness, bowel and bladder problem
were denied.
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History of Past Illness
The patient felt pain in the lower back area since 10 years ago, after
being hit by the cart from behind. Initially the pain was fluctuating with no
radiation pain, no tingling sensation. The pain get worsen with walking in a
long distance, walking up the stairs and lifting heavy object. The pain get
worsen since 2 years ago, and radiated to right and left thigh and calf. Due
to the pain, the patient can’t help her husband selling bakso and she get
consult to PMR clinic at Al-Irsyad, Surabaya. She got SWD twice a week and
medication. She felt a little improvement in 2 years of therapy. She had
overed to had spine surgery, but she refuse and referred to neurology out
patient clinic os RSDS for MRI and further evaluation.
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History of Medication
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History of sosioeconomic:
Patient living in 4 floor building of Rusun Sombo, Surabaya. She live
in the first floor, but she frequently going to the 2nd, 3rd and 4th floor
in the diferent building to go to the marital/sircumsition ceremony
(about 2-4 x/week), sometimes 3x/day. Nowadays she unable
walking up to the upper floor to attend the ceremony. There’s no lift
nor escalator in the building.
The patient frequently lift the pan (about 10 kg) from the floor to
the stove (±1m height) and otherwise.
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Physical Examination (20/02/2018)
General status
Compos mentis, independent ambulation, normal gait, right handed
domination.
Weight : 52 kg, Height : 147 cm,
BMI : 24.06 kg/m2 (Asian criteria: overweight)
BP : 130/90 mmHg HR : 88x/minute RR: 20 x/min
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Musculoskeletal Status
NECK ROM MMT
Flexion F (0-450) 5
Extension F (0-450) 5
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FINGERS ROM MMT
Flexion
MCP F/F (0-900) 5/5
PIP F/F (0-1000) 5/5
DIP F/F (0-900) 5/5
Extension F/F (0-300) 5/5
Abduction F/F (0-200) 5/5
Adduction F/F (200-0) 5/5
Opposition F/F 5/5
HIP ROM MMT
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BIG TOE ROM MMT
Flexion
Flexion
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Neurological Status
Sensory :
Eksteroseptive : No sensory
deficit
Proprioseptive : Normal
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Locally Status at Regio Back
Inspection :
Kyphotic posture, Redness -/-, Swelling -/-, gibbus -/-
Palpation :
Tender point + at paralumbar ~ L4 D/S
paralumbal muscle spasm +/+
Warmth -/- ; step off (-)
Knock pain (-)
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Chest expansion :
T2 : 3 cm
T4 : 3 cm
T6 : 3 cm
Count test : 24
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Dermatome and Myotome
Dermatome Myotome Area Dermatome Myotome
D D S S
100% 4P L2 100% 4P
100% 5 L3 100% 5
100% 5 L4 100% 3P
100% 5 L5 100% 4
100% 5 S1 100% 5
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Special Test Barthel index
Feeding = 10
SLR test : +/+ Grooming =5
Braggard test : +/+ Bathing =5
Sicard test : +/+
Dressing = 10
Thomas test : -/-
Patrick test : -/- Bowels = 10
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Degerative disease of the spine dengan gambaran:
Spondylosis Thoracolumbalis
Degenerative disc disease pada VL3-4
Bulging disc yang menyebabkan slight indentasi anterior
thecal sac di level VL1-2, VL2-3, VL3-4, VL4-5
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Problem List
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Clinical Diagnosis LBP ec HNP VL2-VL3, VL3-VL4, VL4-VL5
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ICF Diagnosis
Health Condition
LBP ec HNP VL2-VL3, VL3-VL4, VL4-VL5
Activities:
Participation:
Body Functions and Structures: d649: household tasks,
b530: weight maintenance function
d859: Work and
other specified and
(pre-obese) employment (Unable to lift
unspecified (difficulties in
b710: mobility of joint functions heavy object at farm)
changing positions)
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Planning
1. Surgical : -
2. Medical : Continue medication from neurologic
outpatient clinic
3. Rehabilitation Medicine :
P. Dx :-
P. Tx :
Modality:
Laser 3J/cm² pada tender point 100% continous
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PMx:
Clinical Findings
MMT
VAS
BMI
PEx
HE/HEP
Explain the patient condition
Proper back mechanic
Icing when pain
Continue the exercise at home
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Summary
Female 51 y.o, referred from Neurologic Outpatient Clinic with LBP ec
Degenerative disc disease.with Chief Complaint :Nyeri punggung bawah
Patient felt dull pain at lower back area, since 10 years ago, worsen
since 2 months ago. Pain radiated to right and left thigh and calf with VAS
7-8.The pain was aggravated by position changing from lying to sitting, from
sitting to standing, walking a long distance, walking upstairs, sitting in a
long time, forward bending the trunk, sneezing and coughing. The pain was
relieved when she was in lying position or taking medication.
From physical examination we found BMI 24,06 kg/m2, kyphotic posture,
paralumbal muscle spasm, weakness at ankle dorsiflexor S, and big toe
extensor.
We diagnosed with LBP ec. LBP ec HNP VL2-VL3, VL3-VL4, VL4-VL5.
Our therapy consist of Hi TENS at paralumbal area, intensity 100Hz, 20
minutes, continue medication from neurologic outpatient clinic, therapeutic
exercise, and use LS corset. We planned to monitor the clinical sign and
symptoms, VAS and MMT. We educate the patient about her disease, icing when
pain at tender area, proper back mechanic, continue exercise at home .
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TERIMA KASIH
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