CASE SPINE ( NON-TRAUMA )I. IDENTITYName : Mr. ZStatus : Married

Age : 36 years oldDate of Examination : 19-02-2015

Adress : Ponegoro streetTime : 09.00 a.m

Occupation : FarmerHospital : Anutapura

II. GENERAL CONDITION Mild sickness Vital Sign : BP : 110/70 mmHg HR : 82 x/second RR : 20 x/second T : 37,9oC

III. ANAMNESIS Chief complaint : Low back pain History of illness today : This experienced since 4 months ago. The intensity of pain increasing severely. The pain is not influence by activities, pain is relieved by rest, pain radiated to the knee and leg. The pain also increased when he straining and coughing. The patient sometimes fever, no headache, no heartburn, no nausea, no vomit, no drastic weight loss, no often sweating, no history of trauma and no fall in sitting position. Urine output and defecated is normally. History of previous illness : No hypertension, No Diabetes Mellitus, No history of TB drugs consumption. Family history : no families are experiencing the same with patient.

IV. PHYSICAL EXAMINATION Spine region : Look : Alignment of vertebra from cervical sacral is normal, deformity (-), swelling (-), scar (-) Feel : Tenderness (+) at lumbal 3rd 4th , Muscle spasm (+) ROM : Flexion (active) = 40o Flexion (passive) = 50o Extension (active) = 0o Extension (passive) = 10o Right lateral flexion (active) = 15o Right lateral flexion (passive) = 25o Left lateral flexion (active) = 20o Left lateral flexion (passive) = 30o Rotation (active) = 25o Rotation (passive) = 35o NVD left and right inferior extremities : Pulse of popliteal artery and dorsalis pedis artery adecuate CRT : 2 second Acral : warm, skin colour same with surround

V. NEUROLOGICAL EXAMINATION

Physiological reflex of right and left superior extremities : Patella reflex (KPR) normal Achilles tendon reflex (APR) normal Pathological reflex of right and left superior extremities : Babinsky -/- Oppenheim -/- Chadock -/-VI. TREATMENT MODALITIES Laboratory : whole blood X-Ray : Thoraco-lumbal AP/lateral, Lumbo-sacral AP/lateral, Pelvis AP

VII. DIAGNOSESuspect Spondilosis.VIII. DIFFERENTIAL DIAGNOSEHNP ( Hernia Nucleus Pulposus )

IX. THERAPYa. Medicamentous Natrium diclofenac 2 x 50 mg Eperisone Hcl 2 x 50 mg Methylprednisolone 2 x 8 mgb. Non Medicamentous Bedrest Physiotherapy

X. PROGNOSEDubia ad Bonam.

CASE SPINE ( TRAUMA )I. IDENTITYName : Mr. YStatus : Married

Age : 45 years oldDate of Examination : 20-02-2015

Adress : Nenas streetTime : 05.30 p.m

Occupation : FarmerHospital : Anutapura

II. ANAMNESIS Chief complaint : Two legs could not be moved Trauma mechanism : This experienced since 8 hours ago. This is because the patient felt from a tree clove with height of 15 meters. The patient felt with the supine position and then he could not wake up and could not be moved two his leg. After incident he was taken to the Hospital Anutapura. Patient no loss of consciousness, no headache, no nausea and no vomit. But no urine output and defecated after incident.

III. PRIMARY SURVEY Airway : pattern, no obstruction Breathing : RR 20 x/second, Respiratory type thoraco-abdominal Circulation : BP 130/80 mmHg Disability : GCS 15 (E4M6V5), pupil isokor 2 mm, light reflex +/+ Exposure : Axillar temperature 36,5oC

IV. SECONDARY SURVEYA. General condition : moderate sicknessB. Head to toe examination Head : normocephal, conjungtiva anemis -/-, icterus -/- Neck : no enlargement of lymph gland

Lungs Inspection : normochest Palpation : mass (-), tenderness (-) Percussion : sonor in the left anf right of lungs Auscultation : vesicular, Wh -/-, Rh -/- Heart Inspection : ictus cordis seen left ICS V midclavicular line Palpation : ictus cordis feel left ICS V midclavicular line Percussion : margin of heart no enlargement Auscultation : heart sound I/II regular, murmur (-), gallop (-) Abdomen Inspection : flat shape and follow the movement of breath Auscultation : peristaltic (+) normal impression Percussion : tympani Palpation : tenderness (-), organomegali (-) Genital : no abnormalities Extremities : Upper : appropriate status localis Lower : acral warm, no injuries, edema -/-

V. PHYSICAL EXAMINATION Spine region : Look : Alignment of vertebra from cervical sacral is normal, deformity (-), swelling (-), scar (-) Feel : Tenderness (+) at lumbal 5th sacral 1st , Muscle spasm (+) ROM : Flexion (active) = difficult to be evaluated due to the patient couldnt wake up Flexion (passive) = difficult to be evaluated due to the patient couldnt wake up Extension (active) = difficult to be evaluated due to the patient couldnt wake up Extension (passive) = difficult to be evaluated due to the patient couldnt wake up Right lateral flexion (active) = difficult to be evaluated due to the patient couldnt wake up Right lateral flexion (passive) = difficult to be evaluated due to the patient couldnt wake up Left lateral flexion (active) = difficult to be evaluated due to the patient couldnt wake up Left lateral flexion (passive) = difficult to be evaluated due to the patient couldnt wake up Rotation (active) = difficult to be evaluated due to the patient couldnt wake up Rotation (passive) = difficult to be evaluated due to the patient couldnt wake up NVD left and right inferior extremities : Pulse of popliteal artery and dorsalis pedis artery adecuate CRT : 2 second Acral : warm, skin colour same with surround

VI. NEUROLOGICAL EXAMINATION

Physiological reflex of right superior extremities : Patella reflex (KPR) increase Achilles tendon reflex (APR) increase Physiological reflex of left superior extremities : Patella reflex (KPR) normal Achilles tendon reflex (APR) normal

Pathological reflex of right and left superior extremities : Babinsky +/+ Oppenheim -/- Chadock -/- Rectal tussae : Bulbocavernous reflex loose (not strangling)

VII. TREATMENT MODALITIES Laboratory : whole blood X-Ray : Thoraco-lumbal AP/lateral, Lumbo-sacral AP/lateral, Pelvis AP

VIII. DIAGNOSESuspect fracture of vertebra lumbal 5th sacral 1st

IX. THERAPYa. Medicamentous Natrium diclofenac 2 x 50 mg Eperisone Hcl 2 x 50 mg Methylprednisolone 2 x 8 mgb. Non Medicamentous Bedrest Physiotherapy

X. PROGNOSEDubia ad Bonam.

Created By : Sy. Rugaiyah alkaff (09 Generation) 7 | Page