ppt

2. Mrs. N / 23 yo/
Referred from Neurosurgery with Axial pain ec Pathologic
Fracture VL5 Susp Spondilitis TB + Paravertebral et Psoas D/S
Abses post Laminotomy VL4-VL5 + Debridement +
Pedicle screw 3,4 + Illiac screw
RAN/TWI/ dr. DW, Sp.K.F.R., Ped. (K)
Morning Report May 22th 2023
2

3. Subjective (History Taking)
Chief Complaint: Nyeri punggung
History of Present Illness:
• The patient complained of pain in the lower back after got an accident on 3/3/2023. The patient fell to his
knees after being hit from behind while riding a motorcycle. The pain on her low back like “kemeng” radiating to
both of the thigh. Pain aggravated with moving position. It decreased with rest and analgetic pain, associated with
tingling sensation until both of the feet. WBS 7-9. The patient does not experience weakness in the legs, but the
patient felt difficult to stand. The patient was immediately taken to the BDH Hospital and an X-ray examination
was carried out. It was found that there was a fracture of the lumbar spine so the patient was referred to
Soetomo Hospital. The patient underwent an MRI on 17/3/2023 and obtained the results of a fracture due to TB
spondylitis after that the patient was planned for surgery on 11/4/2023.
• Currently, the patient has been doing spinal surgery 6 weeks ago. Complain low back pain, especially when
sitting or standing for a long time (WBS 4-5), as well as difficulty trying to stand from the floor. Pain relieved with
rest and taking medicine (WBS 3-4). Before the operation, the pain was felt to radiate to both soles of the feet
(now this symptom didn’t felt). Feels tingling on the the feet (no longer felt at this time). Thickness -. No
complaint for urination and defecation
• The patient had previously complained of back pain since 2019, had an MRI at RSUA and was said to be TB
spondylitis, but because the symptoms was decreased the patient did not continue treatment.Hard to breathe (-).
Cough (-). Coughing up blood (-), chest pain (-). Fever (-), nausea (-), vomiting (-), diarrhea (-), anosmia (-), sore
throat (-). Normal bowel movements, normal urination. Decrease in weight (-), decrease in appetite (-), night
sweat (-). The patient already suggest came to the DOTS OPC and was asked to collect sputum but the sputum did
not come out. 3

4. • History of Functional Ability
Able to eat, groom, dress independently. No urinary and stool incontinence. Able to transfer from lying to sitting, sitting to standing and
standing to chair. Never try to climb up and climb down to the stairs after the operation. She can walk without assistive device. Cleaning the body by
wiping it for 2 months due to fear of doing activities by removing the corset.
II.4. History of Medication and Rehabilitation
 2019  RSUA, she diagnosed with suspect spondylitis TB
 2020 - 2023, once a month treatment in Yumeho Japanese traditional massage Chiropractic  feeling better after the massage but the pain come
again.
 29 March 2023  Done injection therapy 58x, start on anti TB drugs from 2 months ago. She was diagnosed with suspected Spondylitis TB on 2019,
there was no history of intermittent night fever, night sweats and lose of body weight (5kgs) since March 2019. No history of bloody cough.
 No history of seizure, malignancy, or congenital abnormality
 DM -, HT -,
II.6. History of Hobby and Work
 Hobby : She likes to reading novel
 Work : before illness she become ustadzah in Islamic boarding school
II.7. History of Psycho-Social-Economic
• She lives with her husband (22 yo, ustadz in “pondok pesantren”), her mother (44 yo, housewife), grandmother (70 yo, housewife), grandfather (70
yo, retired from laundry business), little sister (21 yo, perfume sales), cousin (21 yo, restaurant employee). Lives in a 1 floor house with a squatting type
toilet. She has BPJS as health insurance.
II.8. Family History:
• Her mother has an illness  Brain TB got illness on 2020, already done treatment in 9 months now feeling better. (note: her family hasn’t took any
tuberculosis tests). No history of malignancy, diabetes, or hypertension.
• II.9. Patient’s Expectation:
She expects to be pain free and do normal activity again

5. • 1. General Status
• Compos mentis, dependent ambulation with wheel chair,
right handed domination.
• Vital sign : BP: 11/68 mmHg; HR: 81x/min;
RR: 18x/min; Temp: 36.6
• Height : 154 cm
• Weight : 50 kg
• BMI : 21.0 kg/cm (Normal BMI)
• Posture : forward head, shoulder,hip and
knee symetry
• Gait : not evaluated
• 4. Lower Extremities Region
• Look: redness -, deformity - oedema +/+
• Feel : warmth -, tenderness (-/-), crepitation (-/-
),hamstring tightness (+/+)
• Move : pain when move (+)
• Neuromuscular:
• Deep Tendon Reflex: KPR +2/+2 APR +2/+2
• Pathological reflex: Babinski -/-, Chaddock -/-
• Sensory: NO deficit sensory
• MMT : 5/5
• ROM : F/F
• 3. Upper Extremities Region
• Look : redness -, swelling -
• Feel : warmth -, tender point -
• Move : pain when move (-)
• Neuromuscular :
• Deep Tendon Reflex : BPR +2/+2 TPR +2/+2
• Pathological reflex : Hofmann -/-, Tromner -/-
• Sensory : exteroceptive: normal;
proprioceptive: normal
III.2. Head/Neck/Trunk
• Look : oedema (-/-), surgical scar lumbal
area +- 10cm, dry +, pus -/-
• Feel : pain at VL4-VL5, paralumbal muscle spasm
+/+
• Move : pain when moving flexion trunk (+)
• Neuromuscular :
- Cranial nerve : within normal limit
- Sensory : no sensory deficit
- MMT and ROM : 5/5 F/F
5

6. PROBLEM LIST / ICF
6
6
DIAGNOSIS :
ASSESSMENT
Low Back Pain ec Burst Fracture VL4-VL5 + Spondylitis TB on Treatment (2 Months) + Paravertebral et Psoas Abscess
Post Debridement et Laminectomy VL4 - VL5 et Post Posterior Stabilization VL3-VL4 et Os Ilium (6 Week) + Severe
Fear of Fall.
Body Function:
b280 Sensation of pain (back pain)
b735 Muscle tone functions (bilateral hamstring tightness,
paralumbal muscle spasm)
b830 Other functions of the skin (wound scar)
Body Structure:
s760 Structure of trunk ( Burst fracture on VL4-VL5,
Spondylitis TB VL4-VL5)
s750 Structure of lower extremity (bilateral edema on
lower extremities)
Activities and Participation:
d410 Changing basic body position
d450 Walking
d859 Work and employment, other specified and
unspecified
d920 Recreation and leisure
Environmental Factors:
e310 Immediate family (support from family)
e580 Health Services, System and Policy (patient covered by
BPJS)

7. • Short term goal:
1. Self-manageable pain (WBS
0-1)
2. Spasm and Tightness
reduces
3. Self care
• Long term goal:
1. ADL independent and
without pain
2. Improve Quality of life
3. Prevent worsening condition
I. PLANNING
Planning Diagnostic: Consult to psychiatrist OPC
Planning therapy:
Medication: continue medication from Pulmonology OPC and Neurosurgery OPC
Modalities therapy:
• Hi-TENS 100 Hz at paralumbal area, intensity as patient's tolerance, for 20 minutes
Therapeutic exercises:
 Posture Correction
 Active breathing exercise with deep breathing
 Chest Expansion exercise
 Core strengthening exercise with abdominal drawing in
 Ankle pumping
 AROM exercise of upper and lower extremities
 Endurance Exercises F: 3-5x/week I: 40-50% HR T: 5-20-5 T: Arm Crank
• Orthosis: LS Corset start from 12/4/23
Planning monitoring: Clinical signs and symptoms, vital sign, WBS, ROM, MMT, Posture,
Planning education:
 Explain about her disease, goal, and the rehabilitation program she will get
 Continue medication from pulmonology and Neurosurgery OPC and control regularly
 Continue exercise at home
 Icing if pain occur, 15 minutes can be repeated each 2 hours
 Educate about using of LS Corset, especially in upright position, and avoid flexion
movement
 Proper back mechanic 7

12. MRI 17/03/23

15. USG