IDENTITY

Name : Mr. Ikbal

Age : 16 years old
Sex : Male
Address : Poleang
Occupation : Student
Admission : Sept, 17th 2019
Doctor in charge : dr. Tri Tuti H., Sp.OT
 History taking (20.45 p.m)

 Main complain : lump of spine

 Anamnesis (Auto anamnesis):
 suffered since 1 years and was advancing since 1
weeks ago. Pain continuously and localized. Pain (-),
feeling hard (+), fever (+), cold sweat (+), weight
loss (+), cough (-), nausea (-), vomiting (-).
 Other complains: Defecate and urinate within
normally.
 There was history of the same complaint.

 There was history of gland enlargment 1 mount

ago.
 There was history of therapy tuberculosis (+) 8
mounth and not continued.
 There was history of diabetes mellitus.

 There was no hystory of contact TB.

 PHYSICAL
EXAMINATION(20.45 p.m)
General Condition :
Moderate illness
Compos mentis (GCS 15 E4V5M6)
konjungtiva : anemi (+/+)

Vital Sign
BP : 110/70 mmHg
HR: 80 x/minutes, regular, strong
RR : 20x/minutes, regular, spontaneous,
thoracoabdominal
type, symmetric
T : 37,5◦C
 PHYSICAL EXAMINATION
 Head : Within  Ears : Within Normal Limit
Normal Limit
 Neck : Within Normal Limit

 Face : Within  Chest : Within Normal Limit

Normal Limit  Upper Limb : Within

Normal
 Eyes : Within
 Limit Lower Limb : Within
normal limit
Normal Limit  Spine : lokalized State

 Nose : Within
Localized state (Thoracolumbal Spine)

Femoral Region
 Inspection : gibbus (+), kifosis (+),
konsistensi hard (+), blunt edges (+),
swelling (-), eritem (-),
 Palpation : tenderness (-),warm (-)
 ROM : active and passive movement no
limited pain
 NVD : sensibility within normally,
CLINICAL FINDING
 PLANNING

Routine blood test

Blood chemistry test
Plain photo lumbal AP
 LABORATORY FINDING
ROUTINE BLOOD TEST (sept 17th 2019)

PARAMETER RESULT
WBC 13.9 x 103 /uL
RBC 3.94 x 103 /uL
HB 8.4 g/dL
PLT 436 x 103 /uL
 LABORATORY FINDING
BLOOD CHEMISTRY TEST (sept
17th 2019)
PARAMETER RESULT
Blood
113 mg/dl
Glucose
 RADIOLOGI FINDING
lain photo Lumbal AP
 DIAGNOSIS

Spondilitis Tuberculosis
 MANAGEMENT
Pharmacological Non-
• IVFD Pharmacolog
• Steroid injection ical
• Analgesic injection  Rest

• H2R antagonist  Education

injection

Consult to orthopaedic
surgeon
Thank You