Preskas LBP

8/13/2019 Preskas LBP

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

COMPRESSION


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atients rofileName : Mr. W

Age : 45 YEARS OLD

Sex/Religion : Male/ Islam

Occupation : Farmer

Address : mojogedang,karanganyar

MR number : 01-21-56

Date of Administered (DOA) : September 4th , 2013


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BACK PAIN


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MEDICAL HISTORY (Hx)

History of Presenting Complaint (HPC)

The patient feels severe back painafter worked in a rice field.

The pain was feltlike burned, continuous, the location at theback 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

Obtained from the Patient itself


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PMHx

Blood Pressure :

normal

Often headache (-)

Used anti hypertensionmedicine (-)

Diabetes Mellitus :unremarkable

Smoking :

(+) since 10 years ago,

smokes a pack ofcigarretes in a day

Alcohol abuse:unremarkable

Hospitalization :

unremarkable


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FamilyHistory

(FH)

Hypertension:unremarkable

DiabetesMellitus :

unremarkable

Heart disease:

unremarkable


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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 : unremarkableSports History : not frequent


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SOCIAL & ECONOMIC HISTORY

Patient a man 45 years oldworking as a labour in fields

as farmers for approximately15 years

Patients treated in hospitalsDr. Moewardi by using

JAMKESMAS


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I-II heart sound intensity

normal, regular, noisy (-) limitthe right heart dilated left no

impression

Eye : pale conjunctive (-/-)

icteric sclera (-/-)

Mouth : Dry lips (-),

sianosis (-)

Neck : JVP not KGB was not palpable

AbdomenInspection: abdominal wall / / chest

wall, venektasi (-)

Auscultation: peristaltic (+) normal

Percussion: timpani

Palpation: outgoing, tenderness (-),

liver and spleen not palpable

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 expandingRight =Left

P: Tactile FremitusRight = Left

P: sonor/sonor

A: Basic sound (+/+), crackles (-/-),

basal rales (+/+)

edema (- / -), akral cold (- / -)

Enlargement of the axillary

nodes dekstra


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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


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Photo Lumbo SacralAP/ Lateral

Picture impression :

BONE COMPRESSION VL III AND

IV


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Socialmedis

Help patient to find

financial solution (menyesuaikan

dengan kondisipasien setelahpulang dari rawatgelap)

Home visit

FT

TENS

Exercise passive andactive

OT Mobility exercice

according to thelevel considered

Psikologi

Support mentally andmoral

Caunseling to the patient


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Impairment:low back pain

Disability:

lower back pain,difficulty movingand standing too

long


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Releive thepain

Minimizeimpairment

and disability

Help patient sothat he can

independentlydo activity


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Ad vitam:

dubia at bonam

Ad sanam:

dubia at malam

Ad fungsionam:

dubia at malam


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eview of theliterature


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Pain, soreness, stiffness

that occurs in the lower

back area


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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

Clasification


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Congenital abnormalities

Traumatic and mechanical disorders

Inflammation / inflammatory

Tumor / neoplasm

metabolic disorders

psychological

ETIOLOGY


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Anamnesis

Search forthe causeand the

factors thataffect pain

Physical

Examination

Motoric

Sensoric

Reflex Provocation

pain

Supported

Examination

X-ray

Myelography

CT-scan MRI

EMG

Diagnosis


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PHOTO

Plain

Simply X-ray Test,and is very helpful toshow the abnormality

on the bone. Positionanteroposterior (AP),lateral, and ifnecessary, right and

left oblique.

SupportedExamination
http://bimaariotejo.files.wordpress.com/2009/07/71.jpg


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Myelography

X-ray examination tospinal cord and spinalcanal

invasive actions

for diagnosis of thediseases associatedwith intervertebraldiscs, spinal tumors, orfor spinal abscess.

Supported

Examination


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Computed Tomografi Scan ( CT- scan )

dan Magnetic Resonance Imaging

(MRI)

CT-Scan as picture 3-

dimensional X-ray.

MRI :

Clearer Than CT-scan.

Dont Have Any

Radiation Effect.

Supportedexamination


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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( areaproximalis or distal )

4. The severe of nerve damage

5. Monitor the healing process of damagenerve.

SupportedExamination


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THERAPY

Medicine:Analgesic

Physiotherapy& Helping

ToolsOperation


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Physiotherapya. 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


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a. Lying supine

hamstring stretch

b. Knee to chest stretch
http://bimaariotejo.files.wordpress.com/2009/07/141.jpghttp://bimaariotejo.files.wordpress.com/2009/07/121.jpg


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c. Pelvic Tilt Punggung ke bawah, pantat ke

atas

Tangan fisioterapis diletakkan dibawah punggung untukmengecek apakah punggung kebawah

d. Sitting leg stretch

E. partial sit up

F. Starting position

G. Sit to stand
http://bimaariotejo.files.wordpress.com/2009/07/18.jpghttp://bimaariotejo.files.wordpress.com/2009/07/161.jpg


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e. Hip and quadriceps stretch


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Supporting Tools

1. Back corsets.

2. Walking stick


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