SHORT CASE

IDENTITY

• Name : Mr. L
• Age : 61 Years old
• Sex : Male
• Address : Gunung Jati
• Occupation : -
• Admission : August, 25 2019/10.00 A.M
• Doctor in charge : dr. Tri Tuti Hendarwati, Sp.OT
 HISTORY TAKING (AT 19.00 P.M)

• Chief Complaint : Low back pain radiating to the left legs

• Anamnesis :
Suffered since ± 3 day ago
• History :
 Low back pain radiating to the left legs since 1 year ago but
burdensome since 3 day ago. The pain feel sharp and
intermitten and also radiating to the left legs. Become heavy
when the patient walking or lift heavy weights and decreased
when rest/lying and consumption of analgesic.
 There was history of previous treatment (practition) : analgesic
but the patient was forget it.
 History of the other diseases :
- There was history of same complaint since 1 years ago.
- There was no history of same complaint in family.
- There was no history of fever and weight lose.
- There was no history of trauma.
 There was no other complaint
PHYSICAL EXAMINATION (AT 10.00 A.M)

• Generalized state:
Moderate illness, normalweight, composmentis
• Vital sign:
Blood pressure : 130/90 mmHg
Heart rate : 72x/m, regular, strong
Respiratory rate : 20x/m, spontaneus, symmetric,
regular, thoracoabdominal type
Temperature : 36,6 celcius degree/axillary
VAS 4/10
 PHYSICAL EXAMINATION (AT 10.15 A.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 : Localized state
Genitalia : Within normal limit
PHYSICAL EXAMINATION (AT 19.20 P.M)

LOCALIZED STATE
LUMBAR REGION
Inspection
Deformity (-), Hematoma (-), Sweeling (-), Wound (-)

Palpation
There was tenderness and knock pain

ROM
Active and passive movement at hip joint and knee joint
SPECIAL TEST
limited due to pain
- Laseque test (-/-)
- Patrick and kontra-patrick test
(-/-) NVD
Sensibility was normally, pulsation dorsalis pedis artery
was palpable and CRT < 2 seconds
CLINICAL FINDING
 PLAN OF DIAGNOSTIC

• Blood routine test (Leukosit, HB,

trombosit)
• Chemical blood test (GDS,
Uric Acid)
• X-ray lumbosacral AP/Lateral
LABORATORIUM FINDINGS

• Blood routine test

- WBC : 14,0 x 103/uL
- RBC : 3,86 x 106/uL
- HB : 11,8 g/dL
- PLT : 172 x 103/uL
• Chemical blood test
- GDS : 178 mg/dL
- Uric Acid : 5,6 mg/dL
 DIAGNOSE

Differential
Diagnosa :
Diagnosa :
1. HNP
Ischialgia
2. Spondylosis
Lumbalis
 MANAGEMENT

Non Farmacology Farmacology

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

Consult To Orthopedic Surgeon