CASE REPORT

1. Data
1.1 Identity
Nama : Ny. S
Jenis Kelamin : Perempuan
Usia :
Agama : Moslem
Pekerjaan : Barber
Alamata : Surabaya
Reffered from Orthopedic Departement with Spondilitis TB VL4-5 Fr.E post body jacket for 4
months, asking for external support.( Jan 7 th 2009 )
1.2 Chief Complaint : Benjolan di punggung.
1.3 History of Present Illness:
 There was mass at the back area since 1 ½ years ago and than getting bigger,
 About 1 ½ years ago she felt weakness at the lower extremity for 1 week after she
falled at the bathroom in a sitting position. After that she was able to walk again.
 1 ½ years ago she got cough and fever for about 6 months, after that she was
hospitalized at Dr. Sutomo General Hospital for 3 months. During in patient she
got streptomycin injection for 2 months.
 2 months later ( after hospitalized ) she used external support (body jacket) until
now.
 For 4 months until now, She still consumed TB drug ( COMBIPAK ) from
Paediatric depart.
 Now she doesn’t complain about back pain, weakness at the extremity, numbness
sensation, or dispneu.
 There was no disturbance of bladder and bowel.
1.4 History of Past Illness
 No serious illness before.
1.5 History of Family
 Youngest child of 3. About 2 years ago, her mother suffered TB and has been consumed
TB drug for 9 months.

1.6 Prenatal & Perinatal history

Prenatal : mother age when pregnant: 38 y.o., antenatal care by traditional

midwife at Bangkalan, no serious illness noted.

Natal : full term, spontaneous birth, head presentation by traditional midwife, birth
weight (?) , no complication.

Post natal : not yet immunization

1.7 Developmental history

Milestone : Head control : (?)  her mother was forgetted
Prone : 4 month
Rolling : (?) month
Sitting : (?) month
Standing : (?) month
Walking : 9 month
1.8 Physical Examination
1.8.1. General Status

- Composmentis, independent ambulation normal gait, right handed dominant.

- HR 84 x/minutes RR 20 x/minutes normal temperature
- Height : 109 cm Weight : 19 kg
 Head and Neck : No anemia, icterus, cyanosis & dyspneu .
 Thorax : Kypotic posture.
Cor : S1-S2 sound, murmur -, gallops –
Pulmo : wheezing -/- , ronchi -/-.
 Abdomen : Nothing abnormal detected.
 Upper Extrimities : Nothing abnormal detected.
 Lower Extrimities : Nothing abnormal detected.
 Physiatric Examination
Musculoskeletal System
Part of Body Joint Movement Muscles Strength
Movement Range of Motion Muscles MMT
Neck Flexion Full Flexor Kesan 5
Extension Full Extensor Kesan 5
Lateral flexion Full / full Lateral Flexor Kesan 5/5
Rotation Full / full Rotator Kesan 5/5

Trunk Flexion Not evaluated Flexor good

Extension Extensor balance
Lateral flexion Lateral Flexor
Rotation Rotator

Shoulder Flexion Full / full Flexor 5/5

Extension Full / full Extensor 5/5
Abduction Full / full Abductor 5/5
Adduction Full / full Adductor 5/5
Int. Rotation Full / full Int. Rotator 5/5
Ext.Rotation Full / full Ext.Rotator 5/5
Elbow Flexion Full / full Flexor Kesan 5/5
Extension Full / full Extensor Kesan 5/5
Pronation Full / full Pronator Kesan 5/5
Supination Full / full Supinator Kesan 5/5
Wrist Flexion Full / full Flexor Kesan 5/5
Extension < 800 / full Extensor Kesan 5/5
Radial Dev. Full / full Radial Deviator Kesan 5/5
Ulnar Dev. Full / full Ulnar Deviator Kesan 5/5

Fingers Flexion Full / full Flexor Kesan 5/5

Extension Full / full Extensor Kesan 5/5
Abduction Full / full Abductor Kesan 5/5
Adduction Full / full Adductor Kesan 5/5

Hip Flexion Not evaluated Flexor 5/5

Extension Extensor 5/5
Abduction Abductor 5/5
Adduction Adductor 5/5
Int. Rotation Int. Rotator 5/5
Ext.Rotation Ext.Rotator 5/5
Knee Flexion Full / full Flexor 5/5
Extension Full / full Extensor 5/5
Ankle Dorsoflexion Full / full Dorsoflexor 5/5
Plantarflexion Full / full Plantarflexor 5/5
Eversion Full / full Evertor 5/5
Inversion Full / full Invertor 5/5
Toes Flexion Full / full Flexor 5/5
Extension Full / full Extensor 5/5

Level of myotom

Dextra Level Sinistra

5 C5 5
3 C6 5
5 C7 5
5 C8 5

Level of dermatom
Dextra Level Sinistra
1 C5 2
1 C6 2
1 C7 2
1 C8 2

Walk on toe : Normal / normal

Walk on heel : Normal / normal

Chest expansion

Inspiration Expiration
Axilla 37 cm 35 cm
Pap. Mamae NE NE
Proc. Xyp NE NE

1.8.3 Neurological Status

 Deep tendon reflex : BPR++/++ TPR++/++
KPR++/++ APR++/++
 Pathologic reflex : Babinski -/- Hoffmann Tromner -/-
  No sensory deficit.

1.8. Local Status ( Regio back )

 Inspection : Kypotic posture.
Wear body jacket.

1.9. Supporting Examination

.
 X-Ray Thoracolumbal AP/LAT view : ( February 3rd 2009 )
o Appearance destruction at VL 3,4,5 with lesion at superior & inferior endplate VL
3,4,5.
o Not appearance destruction of the pedicle.
o Appearance narrowing of the spatium intervertebra VL3-4 & VL 4-5.
o Normal trabeculation (out of lesion).

 MRI Thoracolumbal ( July 8th 2008 )

 o Mal Alignment
o Appearance decrease of bone marrow intensity VL 3,4,5, S1.
o Colapse and compression  posterior angulation at level VL4-5, VL5-S1 that
cause narrowing of canal spinalis and foramen neuralis.
o CONCLUSION : Support Spondylitis TB with paravertebral abcess granulation at
the level VL4-5, VL5-S1.
 Laboratory Examination : June 28th 2008Q
 WBC : 12,0
Hb : 10 g/dl
Antibody M.TB ( Rapid test / ICT-TB ) : positif
 Barthel Index

Activity Score
Feeding 10
Bathing 0
Grooming 5
Dressing 10
Bowels 10
Bladder 10
Toilet use 5
Transfers 15
Mobility 15
Stairs 10
TOTAL 90 ( moderately dependent )

II. DIAGNOSIS
 Diagnosis: Spondylitis TB VL3-S1 ASIA E.
 Functional Diagnosis : Impaired, Disabled, Handicapped

III. PROBLEM LIST

 Medical : Spondylitis TB VL3-S1 ASIA E.

 Surgical : Spondylitis TB VL3-S1 ASIA E.
  Rehabilitation Medicine
R1 (Ambulation) : (-).
R2 (ADL) : Limitation in bathing, toileting and playing
activities.
R3 (Comunication) : (-)
R4 (Psicological) : sad because of her illness
R5 (Social Economy) : (-)

R6 (Vocational) : can’t joint at school.

R7 (Others) : - Limitation in chest expansion

- Kypotic posture.

- Spondylitis TB VL3-S1 ASIA E.

IV. PLANNING

 Medical :
PDx : -
PTx : Continue TB drug, with child COMBIPAK ( fase lanjutan )
(INH 100 mg, Rifampicin 150 mg)

PMx : Sign & symptom, chest expansion.

PEx : - Routine controlled at paediatric department.

- good nutrition

 Surgical : Routine controlled to orthopaedic department.

 Rehabilitation Medicine
- R1 ( Ambulation )
- R2 (ADL)
PDx : -
PTx : - Chest expansion exercise
- Breathing exercise
 - ROM exercise active at Upper and Lower extremity.
- Back extensor exercise
- Posture correction.
PMx : Clinical sign and symptom, ADL activities.
PEx : Regular exercise at home.
- R3 (Communication) : -
- R4 (Psychology)
PDx : -
PTx : - give support for patient and her parents.
PMx : Psychological condition
PEx : Education about her disease to her parents.
- R5 (Social economy) : -
- R6 (Vocational ) :
PDx : -
PTx : -

PMx : -
PEx : - Give support for back to school again.
- R7 (others)
PDx : -
PTx : - Chest expansion exercise
- Breathing exercise
- ROM exercise active at Upper and Lower extremity.
- Back extensor exercise
- Posture correction.
- OP : TLSO ( Plastic body jacket with bivalve )
PMx : Clinical sign and symptom,
PEx : - Routine control & continue TB drug.
- Good nutrition.
- Regular exercise at home.
- Keep wear orthosis.