Presentasi Dyah

CASE REPORT

A 30 YEARS OLD MAN WITH ANKYLOSING

SPONDILITIS

Dyah Gita Rambu Kareri

I. IDENTITY

Name : Mr. Sulistyo Utomo Age : 30 years old Sex : Male Address : Sudipayung RT 04/RW 02 Ngampel-Kendal Religion : Moslem Occupation : Private worker Payment : BPJS

II.ANAMNESIS

Chief complaint : neck and back stifness History of present ilness:

- 8 years ago pain in low back improved by activity & not relieved by rest. About 6 months later stiff on his back, ascenden to his neck & shoulder - 6 months ago red eye & blurred vision (+) Kendal hospital, got medicine didn’t improved went to William Booth hospital referred to the Kariadi hospital got an eye and laboratory examination and referred to the rheumatology department got an x-ray examination and medicine (sulfazalasine) referred to the Medical Rehabilitation department get a pool therapy once a week

II.ANAMNESIS

- Now stiffness become worse turning his body to look at something or someone beside him, palpitation (-), dyspneu (-), heel pain (-), gastrointestinal disturbances (-), fatigue (-), weight loss (-). ADL independently, wears a sock by putting his leg on the chair, put something on the floor by bend his knee. Transfer and ambulation independent, bowel and bladder problem (-)

History of past illness : trauma (-) History of family : - Social economy profile: Patient is a private

worker (bicycle mechanical). He is single. Payment by BPJS

III. PHYSICAL EXAMINATION

General condition : contact & comprehension good

Posture : slough anterior of the head, thorakal kyphotic (+), flexion hip and knee

Vital Sign: BP 120/80 mmhg, RR 18 x/min, HR 82 x/min. BW: 48 kg, BH: 165 cm, BMI: 17,78 (normoweight)

Head, nose, mouth: within normal limit

Eyes: conjunctiva hiperemis (-/-), hiperlacrimasi (-/-), blurred vision (-/-), photophobia (-/-), pupil regular (+/+)

Neck & trunk : local site

III. PHYSICAL EXAMINATION

ThoraxCor/pulmo : within normal limitChest expansion : 1-2 cm

Ekspirasi InspirasiAxilla 81 cm 83 cmTh IV 80 cm 81 cmProc. Xyphoideus 75 cm 76 cm

Abdomen: within normal limit Vegetative: bladder & bowel: within normal

limit

III. PHYSICAL EXAMINATION

Motoric

III. PHYSICAL EXAMINATION

Neck : I : kypothic (+), inflammation sign (-)P : paravertebra muscle spasm (-/-), sternocleidomastoideus muscle spasm (-/-), trapezius muscle spasm (-/-); tenderness (-) ROM : S: 300 – 0 – 350 F: 50 – 0 – 50 R: 300 – 0 – 350 MMT: Neck flexor: 5 , neck extensor: 5, lateroflexor: 5, rotator: 5Provocation test : Lhermitte (-), Spurling (-), Distraksi (-), Valsava (-), Naffziger (-)

III. PHYSICAL EXAMINATION

Shoulder: I : deformity (-), inflammation sign (-)P : tenderness (-), crepitation (+/+)ROM : S : 600 – 0 – 1050 600 – 0 – 1200 F: 1000 – 0 – 450 1100 – 0 – 450 R : Full FullMMT: shoulder flexor: 5; shoulder extensor: 5, shoulder abductor: 5, shoulder adductor: 5, shoulder ext rotator: 5, shoulder int rotator: 5Provocation test: Yergason (-/-), Drop arm (-/-), Neer (-/-), Appley scratch test (-/-)

III. PHYSICAL EXAMINATION Trunk :

I : kypothic (+), inflammation sign (-)

P : paravertebra muscle spasm (-/-), tenderness (-)

ROM : S: 50 – 0 – 700;

F: 100 – 0 – 100 ;

R: 300 – 0 – 300

MMT: lumbar flexion: 5; extension: 5

Provocation test: Schober test = 1,5 cm

III. PHYSICAL EXAMINATION

Hip : I : deformity (-), inflammation sign (-)P: tenderness (-)

ROM: Dekstra Sinistra S 50-0-1200 50-0-1200

F Full Full R Full FullProvocation test: Patrick (+/+), Kontra patrick (+/+), Thomas test (+/+)

III. PHYSICAL EXAMINATION

Knee:I : deformity (-), inflammation sign (-)P: tenderness (-), crepitation (-)

ROM: Dekstra Sinistra

S 00-0-1350 00-0-1350

Poplitea angle 50 / 50

III. PHYSICAL EXAMINATION

Activity Daily Living (Modified Barthel index): 20 BASFI (Bath Ankylosing Spondylitis Functional Index)

= 46 BASMI (Bath Ankylosing Spondylitis Metrology Index)

= 4 Balance: Static : sitting and standing: good

Dynamic: good

IV. ADDITIONAL EXAMINATION

X-photo thorakolumbal AP/lateral (21 Mei 2014)Impression: Ankylosing spondylosis

X-photo pelvis AP ( 30 Mei 2014)Impression: suspect coxitis dextra-sinistra;

sacroilitis dextra Laboratorium (21 Mei 2014)

Hematologi: ESR 1 hour : 12 mm/hour ESR 2 hour : 27

mm/hourImmunoserologi: RF (-)

V. DIAGNOSIS

• Ankylosing spondilitisCLINICAL DIAGNOSIS

• IMPAIRMENT:• ROM limitation of the neck,

shoulder and trunk• Decrease of chest expansion • Poor posture

• DISABILITY: -• HANDICAP: -

FUNCTIONAL DIAGNOSIS

VI. PROBLEM LIST

Mobility : - ADL : - Communication : - Socioeconomy : - Psychological : - Vocational : - Others:

ROM limitation of the neck, shoulder and trunk

Decrease of chest expansion Poor posture

VII. GOAL• Maintain ROM/flexibility• Maintain function of

cardiorespiration Short term

• Prevent progressivity• Prevent the further

complicationLong term

VIII. PROGRAM

Education: disease, exercise Pool therapy Breathing exercise Increase chest expansion with

macrame

IX. PROGNOSIS

ad vitam: dubia ad bonam ad fungsionam: dubia ad malam ad sanam: dubia ad bonam

THANK YOU