CASE REPORT

A 30 YEARS OLD MAN

WITH ANKYLOSING
SPONDILITIS

Dyah Gita Rambu Kareri

I. IDENTITY
Name
: Mr. Sulistyo Utomo
Age
: 30 years old
Sex
: Male
Address
: Sudipayung RT 04/RW 02
Ngampel-Kendal
Religion
: Moslem
Occupation : Private worker
Payment
: BPJS

II.ANAMNESIS
Chief complaint : neck and back stifness
History of present ilness:
- 8 years ago pain in low back improved by activity
& not relieved by rest. About 6 months later stiff on
his back, ascenden to his neck & shoulder
- 6 months ago red eye & blurred vision (+) Kendal
hospital, got medicine didnt improved went to
William Booth hospital referred to the Kariadi
hospital got an eye and laboratory examination and
referred to the rheumatology department got an x-ray
examination and medicine (sulfazalasine) referred to
the Medical Rehabilitation department get a pool
therapy once a week

II.ANAMNESIS
- Now stiffness become worse turning his body
to look at something or someone beside him,
palpitation (-), dyspneu (-), heel pain (-),
gastrointestinal disturbances (-), fatigue (-), weight
loss (-). ADL independently, wears a sock by putting
his leg on the chair, put something on the floor by
bend his knee. Transfer and ambulation
independent, bowel and bladder problem (-)
History of past illness : trauma (-)
History of family : Social economy profile: Patient is a private
worker (bicycle mechanical). He is single. Payment
by BPJS

III. PHYSICAL EXAMINATION

General condition : contact &
comprehension good
Posture : slough anterior of the head,
thorakal kyphotic (+), flexion hip and
knee
Vital Sign: BP 120/80 mmhg, RR 18
x/min, HR 82 x/min. BW: 48 kg, BH: 165
cm, BMI: 17,78 (normoweight)
Head, nose, mouth: within normal limit
Eyes: conjunctiva hiperemis (-/-),
hiperlacrimasi (-/-), blurred vision (-/-),
photophobia (-/-), pupil regular (+/+)
Neck & trunk
: local site

III. PHYSICAL EXAMINATION

Thorax
Cor/pulmo : within normal limit
Chest expansion : 1-2 cm
Ekspirasi
Inspirasi
Axilla
81 cm
83 cm
Th IV
80 cm
81 cm
Proc. Xyphoideus
75 cm
76 cm
Abdomen: within normal limit
Vegetative: bladder & bowel: within normal limit

III. PHYSICAL EXAMINATION

Motoric

III. PHYSICAL EXAMINATION

Neck :
I : kypothic (+), inflammation sign (-)
P : paravertebra muscle spasm (-/-),
sternocleidomastoideus muscle spasm (-/-),
trapezius muscle spasm (-/-); tenderness (-)
ROM : S: 300 0 350
F: 50 0 50
R: 300 0 350
MMT: Neck flexor: 5 , neck extensor: 5, lateroflexor:
5, rotator: 5
Provocation test : Lhermitte (-), Spurling (-),
Distraksi (-), Valsava (-), Naffziger (-)

III. PHYSICAL EXAMINATION

Shoulder:
I : deformity (-), inflammation sign (-)
P : tenderness (-), crepitation (+/+)
ROM : S : 600 0 1050 600 0 1200
F: 1000 0 450 1100 0 450
R : Full
Full
MMT: shoulder flexor: 5; shoulder extensor: 5,
shoulder abductor: 5, shoulder adductor: 5,
shoulder ext rotator: 5, shoulder int rotator: 5
Provocation test: Yergason (-/-), Drop arm (-/-),
Neer (-/-), Appley scratch test (-/-)

III. PHYSICAL EXAMINATION

Trunk :
I : kypothic (+), inflammation sign (-)
P : paravertebra muscle spasm (-/-), tenderness (-)
ROM : S: 50 0 700;
F: 100 0 100 ;
R: 300 0 300
MMT: lumbar flexion: 5; extension: 5
Provocation test: Schober test = 1,5 cm

III. PHYSICAL EXAMINATION

Hip :
I:deformity (-), inflammation sign (-)
P: tenderness (-)
ROM:
Dekstra
Sinistra
S
50-0-1200
50-0-1200
F
Full
Full
R
Full
Full
Provocation test: Patrick (+/+), Kontra patrick (+/+),
Thomas test (+/+)

III. PHYSICAL EXAMINATION

Knee:
I:deformity (-), inflammation sign (-)
P: tenderness (-), crepitation (-)
ROM:
Dekstra
Sinistra
S
00-0-1350
00-0-1350
Poplitea angle 50 / 50

III. PHYSICAL EXAMINATION

Activity Daily Living (Modified Barthel index): 20
BASFI (Bath Ankylosing Spondylitis Functional Index) =
46
BASMI (Bath Ankylosing Spondylitis Metrology Index) = 4
Balance: Static : sitting and standing: good
Dynamic: good

IV. ADDITIONAL EXAMINATION

X-photo thorakolumbal AP/lateral (21 Mei 2014)
Impression: Ankylosing spondylosis
X-photo pelvis AP ( 30 Mei 2014)
Impression: suspect coxitis dextra-sinistra;
sacroilitis dextra
Laboratorium (21 Mei 2014)
Hematologi: ESR 1 hour : 12 mm/hour
ESR 2 hour : 27 mm/hour
Immunoserologi: RF (-)

V. DIAGNOSIS
CLINICAL
DIAGNOSIS

Ankylosing spondilitis

FUNCTIONAL
DIAGNOSIS

IMPAIRMENT:
ROM limitation of the neck,
shoulder and trunk
Decrease of chest expansion
Poor posture
DISABILITY: HANDICAP: -

VI. PROBLEM LIST

Mobility
: ADL
: Communication : Socioeconomy
: Psychological
: Vocational
: Others:
ROM limitation of the neck, shoulder and
trunk
Decrease of chest expansion
Poor posture

VII. GOAL

Short
term

Maintain
ROM/flexibility
Maintain function of
cardiorespiration

Long
term

Prevent progressivity
Prevent the further
complication

VIII. PROGRAM
Education:

disease, exercise
Pool therapy
Breathing exercise
Increase chest expansion with macrame

IX. PROGNOSIS
ad

vitam: dubia ad bonam

ad fungsionam: dubia ad malam
ad sanam: dubia ad bonam

THANK YOU