Low Back Pain

Steven Felim 1115021

Preceptor: dr. Yenni Limyati,
Sp.KFR

GENERAL INFORMATION

Name : Mrs. A
Age : 54 y.o
Sex : Female
Address : Cibaduyut
Occupation : Housewife
Religion : Islam
Marital Status : Married
Date of examination : 6/2/2016

ANAMNESIS
Chief Complaint: pain and discomfort on the
waist
Specific history: Patient presented with pain and
discomfort on the left waist and strained feeling
from the left waist to left lateral thigh and above the
knee bone since 2 months ago. Patient felt the pain
was throbbing from the inside, comes and goes
every 10-15 minutes, and not affected by position or
rest. Patient activity was disturbed and found
difficulty in walking. She found that the pain
increases when she coughs
No history of pain or discomfort in urinating,
throbbing pain on the waist, or fall down.

-Past Medical History:

-No similar experience

-Family Medical History : No particular

history
-Patient habits : No particular habit
- Drug Allergies : None

PHYSICAL EXAMINATION
Weight : 52 kg
Height: 156 cm
Body Mass Index : 21.36 kg/m2 (normal)
Conciousness : Compos mentis
Vital Sign
Blood Pressure : 140/90 mmHg
Heart Rate : 68x/ minute
Respiration Rate : 24 x/minute
Temperature : 36,8oC, by axilla

GENERAL EXAMINATION
Head
: Within normal limits
Neck
: Within normal limits
Thorax
: Within normal limits
Abdomen : Within normal limits
Extremity
: Within normal limits
Blood vessel : Within normal limits

NEUROLOGICAL
EXAMINATION
Appearance :
Head Normal size and shape
Vertebral column No abnormalities

Meningeal Signs :
Nuchal rigidity (-)
Brudzinky I (-)
Brudzinky II (-)
Brudzinky III (-)
Laseque (-)
Kernig (-)

Radicular Signs
Patrick : -/+
Contrapatrick : -/+

 Cranial Nerves
CN. I :
Olfactory : normosmia

CN. II :
Visual acuity test : normal
Confrontation test : good
Funduscopy : not performed

CN. III, IV, VI

Ptosis (-)
Pupil round, isochors, 3 mm
Indirect light reflex (+/+), Direct light reflex(+/+)
Eye orientation: normal
Eye movement : normal
Convergension test(+)

 CN. V :
Sensory of ophtalmic, maxillary, and mandilbular +/ Motoric :
the lower jaw to the right , move to the left is limited

CN. VII :

Eyebrow movement: symmetric

Eye closure : symmetric
Nasolabial plica : symetric
Facial movement : asymmetric
2/3 Anterior tasting : within normal limits

CN. VIII :
Hearing : not performed
Balance : not performed

 CN. IX, X :

Voice : dysphonia (-)

Swallowing : disphagia (-)
Pharyngeal arched : symetrical
Uvula
: central
Palatal conraction
: symentrical
Pharyngeal reflex : not perfomed
1/3 posterior tasting
: within normal limits

CN. XI :
Shoulder lift: left shoulder lift limited
Left and right head movements : within normal limits

CN. XII :
No tongue deviation
Atrophy (-)
Fasiculations/tremor (-)

 Motoric Examination
Strength

Tone

Atrophy

Fasiculatio
n

Upper extremity

5555/5555

Normoton
es

Lower extremity

5555/5555

Normoton
es

Involuntarry
Movement

Gait

ROM : pain on right side- bent

The Other

Lumbar Myotomes (L2-S2)

Myotomes

Motoric

Result

L2

Hip Flexion

Within normal
limit

L3

Knee Extension

Within normal
limit

L4

Ankle
Dorsoflexion

Within normal
limit

L5

Great toe
extension

Within normal
limit

S1

Ankle Flexion
Ankle Eversion
Hip Extension

Within normal
limit

S2

Knee Flexion

Within normal
limit

Reflexes

KPR +/+

APR +/+

 Sensory Examination
Upper limbs
Trunk
Lower limbs

Superficial

Visceral

+/+

+/+

Within normal
limit

Within normal
limit

+/+

+/+

Coordination test : not perfomed

 Physiological Reflexes
Biceps +/+
Triceps +/+
Radius +/+
Ulna +/+
KPR +/+
APR +/+
Epigastric : not
perfomed
Mesogastric : not
perfomed
Hypogastric : not
perfomed
Chemaster : not
perfomed

Pathological
Reflexes

Hoffman Tromner -/Babinsky -/Chaddock -/Oppenheim -/Gordon -/Schaeffer -/-

 Clonic (-)
Primitive Reflexes
Glabella : Snout : Palmo mental : -

 Cognitive Examination
Psychological connection : Good
Motoric aphasia
: Sensory aphasia
: Short memory term : within normal
limits
Long memory term : within normal
limits
Calculation ability : Good

RESUME
Chief Complaint: Pain and discomfort on the
waist
Specific history: A 54 years old female
presented with pain and discomfort on the left
waist and strained feeling from the left waist to
left lateral thigh and above the knee bone since 2
months ago. Throbbing pain from the inside,
comes and goes every 10-15 minutes, not
affected by position or resting. Disturbed activity
and claudication. Pain increases when cough.
No history of pain or discomfort in urinating,
throbbing pain on the waist, or fall down.

-Past Medical History:

-No similar experience

-Family Medical History : No particular

history
-Patient habits : No particular habit
- Drug Allergies : None

PHYSICAL EXAMINATION
Vital Sign:
HR=68x/minute, RR=24x/minute, BP=140/90 mmHg, T=36,8 oC
by axilla
Consciousness : Compos Mentis
General Examination : within normal limit
Meningeal Signs : Radicular Signs : left Patrick Contrapatrick (+)
Cranial Nerves : normal
Motorical Examination : 5555/5555
5555/5555
ROM : right side bent ()
Sensorical Examination : normal
Physiological Reflexes : +/+
Pathological Reflexes : -/Cognitive Examination: Good

Status Fungsional (ADL

Barthel)
Jenis Kegiatan

II

Mengendalikan
rangsang
pembuangan tinja
Mengendalikan rangsang berkemih

Membersihkan diri

Menggunakan jamban

Makan

Berubah sikap dari berbaring ke

duduk
Berpindah/berjalan

Memakai baju

Naik turun tangga

Mandi

Total

20
15
(mandiri) (ketergantung
an ringan)

III

IV

Instrumental Activities of Daily Living (IADL)

No.
1

Aktivitas
Menyampaikan
pesan/menggunakan
telpon (Besok rapat di
rumah pak RT jam 10)

Nilai

0
1
2

Berbelanja

Menyiapkan makanan

Mengurus rumah

0
1
2
0
1
2
0
1
2

Keterangan
Tidak mampu menyampaikan pesan
Sebagian tersampaikan (mampu menjawab
telpon, tetapi tidak dapat mengoperasikan
telpon)
Mampu mengoperasikan telpon/semua pesan
tersampaikan
Tidak mampu
Mampu berbelanja sendiri untuk sejumlah
keperluan terbatas (3 buah/kurang),
selebihnya perlu bantuan oranng lain
Mandiri
Tidak mampu
Mampu menyiapkan makanan bila telah
disiapkan bahan-bahannya atau
menghangatkan makanan yang telah
dimasak
Mandiri
Tidak mampu
Mampu mengerjakan bagian yang ringan
(menyapu, merapikan tempat tidur) lainnya
perlu bantuan orang lain
Mandiri (mampu mengurus rumah sendiri
termasuk mengepel dan mencuci baju)

Bila ada yg
membantu
siapa yg
mengerjakan

Mencuci pakaian

Menggunakan alat
transportasi

Tanggung jawab
pengobatan/menyia
pkan obat sendiri

0
1
2
0
1
2
0
1
2

Mengatur keuangan

0
1
2

Total nilai

13 (Perlu pengawasan ringan)

Tidak mampu
Mampu mencuci/menyetrika jenis
pakaian yang ringan, lainnya perlu
bantuan orang lain
Mandiri (termasuk menggunakan
mesin cuci)
Tidak mampu bepergian dengan
sarana transportasi apapun
Bepergian dengan sarana
transportasi umum/taksi atau mobil
pribadi bila dibantu/ditemani orang
lain
Mandiri
Butuh pertolongan orang lain untuk
menyiapkan dan mengkonsumsi
obat-obatan
Mampu bila obat-obatan yang sudah
disiapkan sebelumnya
Mandiri (mampu menyiapkan obat
sendiri sesuai dengan dosis dan
waktu yang sudah ditentukan)
Tidak mampu
Mampu mengatur belanja harian,
tetapi butuh pertolongan dalam
urusan bank/pembelian jumlah
besar
Mampu mengatur masalah
keuangan (anggaran rumah tangga,
membayar sewa, kuitansi, urusan
bank) atau memantau penghasilan

Sebutkan tiga objek : tiap 1 detik pasien disuruh mengulangi

(bola, kursi, sepatu)
Pengurangan 100 dengan 7 (hentikan setelah lima jawaban)
93-86-79-72-65
Responden disuruh menyebut kembali ketiga nama objek di
atas tadi
Responden disuruh menyebut pensil, buku

Nila
i
5
5
3

Responden disuruh mengulangi kata namun, tanpa, bila

Responden disuruh melakukan perintah: Ambil kertas itu

dengan tangan Anda, lipatlah menjadi dua dan letakkan di
lantai
Responden disuruh membaca kalimat kemudian melakukan
perintah kalimat Pejamkan mata
Responden disuruh menulis dengan spontan

2
1
3

1
1
30

Max
MINI MENTAL STATE EXAMINATION (MMSE)
Sekarang hari, tanggal, bulan, musim, tahun apa?

Kita berada di mana? Negara, propinsi, , RS, lantai/kamar

Responden disuruh menggambar bentuk di bawah ini

Jumlah

1
30

Vertebral X-Ray
January 13, 2016
Impression : Osteophyte at L3-L4 and
change in vertebral alignment e.c.
muscle spasm
Result : Lumbar spondylosis L3-L4

WORKING DIAGNOSIS
Clinical
Location
Etiology

: Low back pain

: lumbal L3-L4
: osteogenic (osteophyte)

FUNCTIONAL DIAGNOSIS
Disease : Low back pain e.c lumbar
spondylosis
Impairment : Waist pain and discomfort
Body structure : waist bent
Activity limitation : Walking disorder,
difficulty in activities
Participation restriction : difficulty to walk
Environmental factor : Personal Factor : -

MANAGEMENT
Non Pharmalogical
Medical Rehabilitation

Pharmalogical
Consider analgetic if the pain is
unbearable : GABApentin 500mg 3 times
daily
Muscle relaxan : eperisone 50mg 2
times daily for a week

MEDICAL REHABILITATION PROGRAM

The clinical finding on the patient
which could be rehabilitated include :
Waist discomfort
Waist bent
Difficulty in walking

 Initial Phase
Aims to maintain lumbar function to its
maximum limit term
Includes proper bed positioning, range-of-motion
exercises, electrical stimulation, and stretching.

Continuation Phase
Aims to maintain or improve functional
independence in daily mobilization and
activities.
Physiotherapy:
Superficial heat therapy (infrared) to loosen muscle
stiffness
Passive or active range of motion exercises
Back muscle strengthening
Back stretching exercise
Lumbar stabilization exercise

PROGNOSIS
Quo ad vitam
: ad bonam
Quo ad functionam : dubia ad bonam
Quo ad sanationam : dubia ad bonam

Appendices

Appendices