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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
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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
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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
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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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