A MAN 45 YEARS OLD WITH SEVERE BACK PAIN (LOW BACK PAIN) ec POST TRAUMATIC COMPRESSION

Patients Profile
Name Age Sex/Religion : Mr. W : 45 YEARS OLD : Male/ Islam

Occupation
Address MR number

: Farmer
: mojogedang,karanganyar : 01-21-56

Date of Administered (DOA)

: September 4th , 2013

BACK PAIN

MEDICAL HISTORY (Hx) History of Presenting Complaint (HPC)

Obtained from the Patient itself The patient feels severe back pain after worked in a rice field. The pain was felt like burned, continuous, the location at the back hip right sited. He felt comfortable in a sleeping position He felt painful when standing long and walking long distances Dyspnea (-), palpitation (-), nausea (-), vomiting (-), cough (-).

Came To Poli Rehabilitation For A Therapy Consulted By Neurology Department

Smoking :

(+) since 10 years ago, smokes a pack of cigarretes in a day Diabetes Mellitus : unremarkable
Alcohol abuse :unremarkable

Blood Pressure :

normal
Often headache (-) Used anti hypertension medicine (-)

PMHx

Hospitalization : unremarkable

Hypertension: unremarkable

Family History (FH)

Heart disease : unremarkable Diabetes Mellitus : unremarkable

HISTORY OF HABITS & NUTRITION

Patients were fed three times a day with a plate of rice and side dishes such as tempeh, tofu, vegetables, along with meat, and fruit. Smoking History : (+) passive smoker since 10 years ago, per day 14cigarettes. History drink alcohol : unremarkable Sports History : not frequent

SOCIAL & ECONOMIC HISTORY

working as a labour in fields as farmers for approximately 15 years

Patient a man 45 years old

Patients treated in hospitals Dr. Moewardi by using JAMKESMAS

General Appearance
Nutrition Status

He was alert, responsive to surroundings, Generally well Height : 165 cm Weight : 60 kg BMI : 22,03 kg/m2 Normoweight BP : 130/80 mmHg Heart Rate : 80 bpm, regular Pulse Rate : 80 bpm, regular Respiratory Rate : 20 per minutes Temperature : 36,5 oC

Vital Sign

I-II heart sound intensity normal, regular, noisy (-) limit the right heart dilated left no impression

Eye : pale conjunctive (-/-) icteric sclera (-/-) Mouth : Dry lips (-), sianosis (-) Neck : JVP not KGB was not palpable Abdomen Inspection: abdominal wall / / chest wall, venektasi (-) Auscultation: peristaltic (+) normal Percussion: timpani Palpation: outgoing, tenderness (-), liver and spleen not palpable edema (- / -), akral cold (- / -) Enlargement of the axillary nodes dekstra

Anterior lung: I: Static: chest surface right = left; Dynamic: Development chest right = left Q: fremitus conjecture right = left P: resonant / resonant A: Basic sound (+/+), crackles (-/-), basal rales (+/+)
Posterior lung I: Chest expanding Right =Left P: Tactile Fremitus Right = Left P: sonor/sonor A: Basic sound (+/+), crackles (-/-), basal rales (+/+)

ROM EXAMINATION
Limitations of the superior dexter extermity Limitations of the inferior sinister extermity

MMT EXAMINATION
Weakness in the shoulder dekstra region Weakness in the region of the left hip

PSYCHIATRY STATUS
Normal

NEUROLOGY STATUS
Decrease in motor function superior ext dextra Decrease in the left inferior ext motor function

Photo Lumbo Sacral AP/ Lateral

Picture impression : BONE COMPRESSION VL III AND IV

Asessment

Low back pain

Social medis

Help patient to find financial solution (menyesuaikan dengan kondisi pasien setelah pulang dari rawat gelap) Home visit
TENS Exercise passive and active

FT

OT

Mobility exercice according to the level considered

Support mentally and moral Psikologi Caunseling to the patient

Impairment: low back pain

Disability:
lower back pain, difficulty moving and standing too long

Releive the pain

Minimize impairment and disability

Help patient so that he can independently do activity

Ad vitam: dubia at bonam

Ad sanam:
dubia at malam Ad fungsionam:

dubia at malam

Review of the literature

 Pain, soreness, stiffness that occurs in the lower back area

Clasification

Acute low back pain

Sudden onset short duration traumatic injury

Chronic low back pain

> 3 months, repeated or recurrence osteoarthritis, rheumatoidarthritis, the process of intervertebral disc degeneration and tumor

Congenital abnormalities
Traumatic and mechanical disorders Inflammation / inflammatory Tumor / neoplasm metabolic disorders psychological

ETIOLOGY

Diagnosis

Anamnesis

Physical Examination

Supported Examination

Search for the cause and the factors that affect pain

Motoric Sensoric Reflex Provocation pain

X-ray Myelography CT-scan MRI EMG

Supported Examination

PHOTO Plain Simply X-ray Test, and is very helpful to show the abnormality on the bone. Position anteroposterior (AP), lateral, and if necessary, right and left oblique.

Supported Examination

Myelography X-ray examination to spinal cord and spinal canal invasive actions for diagnosis of the diseases associated with intervertebral discs, spinal tumors, or for spinal abscess.

Supported examination Computed Tomografi Scan ( CT- scan ) dan Magnetic Resonance Imaging (MRI)
CT-Scan as picture 3dimensional X-ray.

MRI : Clearer Than CTscan. Dont Have Any Radiation Effect.

Supported Examination

Electro Miography ( EMG ) / Nerve Conduction Study ( NCS )

safe and non-invasive examination of the nerves to the arms and legs. provide information about the : 1. The damage to the nerve 2. Long nerve damage( acute or chronic ) 3. Location of nerve damage happens( area proximalis or distal ) 4. The severe of nerve damage 5. Monitor the healing process of damage nerve.

THERAPY
Medicine: Analgesic
Physiotherapy & Helping Tools Operation

Physiotherapy
a. Heat therapy b. Electro Stimulation - Acupunture - Ultra Sound - Radiofrequency Lesioning - Spinal Endoscopy - Percutaneous Electrical Nerve Stimulation (PENS) - Elektro Thermal Disc Decompression - Trans Cutaneous Electrical Nerve Stimulation ( TENS ) c. Traction d. Massage

 a. Lying supine hamstring stretch

b. Knee to chest stretch

c. Pelvic Tilt Punggung ke bawah, pantat ke atas Tangan fisioterapis diletakkan di bawah punggung untuk mengecek apakah punggung ke bawah

d. Sitting leg stretch E. partial sit up F. Starting position G. Sit to stand

 e. Hip and quadriceps stretch

Supporting Tools 1. Back corsets.

2. Walking stick