CASE REPORT

2017
LOW BACK PAIN DUE TO SPONDYLITIS TB LUMBAR IV-V

By:
Ahmad Jairullah Bin Johari Ine Wahyuni Dean
Muhammad Naufal Zuhdi Nurul Husna Binti Rashid
Wan Salahuddin Bin Wan Abdullah Zubir

Advisor :
dr. Zulpan Zukarnain
dr. Loli Anton

Supervisor :
Dr. dr. Karya Triko B. SpOT(K) SPINE

CLINICAL STUDENT ASSIGNMENT ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT

MEDICAL FACULTY HASANUDDIN UNIVERSITY
2017
 PATIENTS IDENTITY

Name : Orpa Sakti Pasande

Gender : Female
Age : 41 years old
Admitted to hospital : Jun 6rd 2017
Medical record : 794145
Occupation : Housewife
 HISTORY TAKING
Chief complaint : low back pain

Suffered since 1 years before admitted to Wahidin General

Hospital.
Pain is felt suddenly but not continuously. Pain worsened
during activities and get better after rest. The pain is described
as electric / burning pain radiating from the back to both leg
Patient was slipped and fell down in a sitting position (with
right side come first to the ground) 5 years ago while she was
walking on street. After falling, patient didnt seek medical
treatment due to she not felt any pain and did not affect his
daily basis, but she had fever chills for 2 days and only
consume paracetamol.
 HISTORY TAKING
Patients treated at RS Pangkep in 2016 with a numb complaint
on the left side of the body, but still can walk as usual. There
are no weaknesses in the limbs. There the patient was
diagnosed with stroke and hospitalization for 1 week, but still
no change. The patient went to the shaman for a massage for 3
days but still no change. Month 1 year ago, the patient went to
Pangkep Hospital with complaints of lower back pain and was
referred to RS Wahidin.
There is history of cough within the past month
Patient lost his weight approximately 3 kgs in the past year.
 HISTORY TAKING
History of previous disease
She had hypertension since 3 months ago and consume
Amlodipine 1x1 ever since.

Family history :
There is history of family (niece) with TB disease

History of medication :
Patient taking the drug TB (Rifampisin), just 1 month ago.
 GENERAL STATUS

Well Nourished/mild illness/compos mentis

BP : 140/90 mmHg
RR : 18 X/minute
HR : 90 X/minute
Temperature : 370 C
NRS : 4
 PHYSICAL EXAMINATION
Vertebra Region

Look : Deformity (-), Gibbus (-), haematoma (-),

swelling (-)
Feel : Tenderness (+) as level as Lumbal 4, Step off (-)
5 5
5 5
5 5
5 5
5 5

3 3
3 3
3 3
3 3
3 3

yes
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2 2 2 2
2 2 2 2
2 2 2 2
21 21 21 21
20 20 20 20
20 20 20 20
10 10 10 10
10 10 10 10
1 1 1 1
01 01 01 01
01 01 01 01
10 10 10 10
01 01 01 01
01 01 01 01
01 01 01 01
01 01 01 01
10 10 10 10
 REFLEX
Physiologic Reflex Pathologic Reflex

R L R L
Biceps (++) (++) Babinski (-) (-)
Triceps (++) (++) Chadock (-) (-)
Achilles (++) (++) Openheim (-) (-)
Patellar (++) (++) Hoffman (-) (-)
Tromner
Klonus (-) (-)
CLINICAL FINDINGS