POMR IKFR

Low Back Pain

DATA BASE
I. IDENTITY
Name / Sex / Age
Married / Not Married
Occupation / Education
Religion
Address
Health Insurance

II. CHIEF COMPLAINT : (Bahasa)

Nyeri Punggung Bawah

III. HISTORY OF PRESENT ILLNESS

 Chief Complaint
 Site: where is the pain? Maximal site of pain
 Onset: when did it start, was it sudden or gradual? What caused the pain
 Character: Is it dull or sharp pain?
 Radiation: Does the pain radiate anywhere?
 Association: any other symptom follow the pain? Numbness, tingling
sensation
 Time: is it occur in any particular time?
 Exacerbation/ Relieving factor: Does anything increase or decrease the
pain?
 Severity: How Bad is the pain? VAS?
 History of heavy lifting object
 Other complaints
 Weakness
 Location: is it localized or generalized? Affecting single or bilateral
lower limb? Proximal or distal?
 Onset: gradual, sudden or progressive? Following after trauma?
 Character: episodic, steady or fluctuating?
 Sensory disturbance
 Location: is it localized or generalized? Affecting single or bilateral
lower limb? Proximal or distal? Dermatomal or doesnt follow the
dermatom?
 Onset: gradual, sudden or progressive? Following after trauma?
 Is there any “burning” or “hot” sensation? Is there any “tingling”
sensation?
 ADLs Basic ADL

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 Advance – social interaction
A working ability to
 Review of systems
 Bowel/Bladder: incotinence uri or alvi? Sexual dysfunction?

IV. HISTORY OF PAST ILLNESS

 Trauma
 Malignancy
 Surgery
 Infection
 Diabetes mellitus
 Hypertension

V. PHYSICAL EXAMINATION
 Mental state, ambulation status, gait, hand dominance
 Paralytic gait? Antalgic gait? Wide base gait? Steppage gait?
 Vital sign
 Musculosceletal examination :
 ROM for Trunk and Lower Extremity joint
 MMT for trunk and lower extremity muscle
 Neurologic examination :
 Cranial nerves
 Muscle tone  spasticity? Flaccid?
 DTRs  Increasing? Decrease? Absent?
 Pathological reflexes
 Sensation  any sensory deficits ~dermatome? Peripheral nerve?
 Local status:
 Inspection :
 general body posture
 deformity
 palpation :
 leg length discrepency
 nyeri ketok
 step off
 atrophy  thigh or calf circumference, muscle spasm
 Special Test
 Walk on heel
 Walk on toe
 Patrick
 Contra Patrick
 SLR
 Bragard

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  Siccard
 Gaenslen
 Ober
 Thomas
 Door bell sign
 Hamstring Tightness

VI. PROBLEM LIST

I. Medical : Low Back Pain ec ?
II. Surgical
III.Rehabilitation medicine:
a.R1= Mobilization  independent or dependent? gait?
b. R2= ADL  Basic ADL disturbance?
c.R3= communication
d. R4=psychological  depression? Worried?
e.R5=sociological  social activity participation?
f. R6= vocational  main role or working disturbance?
g. R7= Other

VII. DIAGNOSIS
LBP ec ?

I. FUNCTIONAL DIAGNOSIS
Impairment : pain, weakness, sensory disturbance
Disability : disturbance in ADL
Handicap : work?

II. GOALS
pain management, posture correction, muscle strengthening for trunk stability,
weight reduction, increase quality of life

III.PLANNING
Diagnosis : X-ray Vertebra Thoracolumbal AP and Lateral
X-ray Vertebra Lumbosacral AP and Lateral
X-ray Pelvis AP and Lateral
Therapy :
- rest
- cold pack (in first 48 hours), Infra red or electric heating, TENS or
Diatermi if there is no contraindication
- Corset or Orthesa as a support in upright position
- Muscle strengthening exercise that appropiate with the patient
condition
- Sensory reeducation if there is a sensory deficit.

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 Monitoring : clinically, VAS, MMT, Sensory
Education : Explain about patient condition
Proper back mechanism
Use corset
Continue exercise at home

VIII. PROGNOSIS
Ad vitam
Ad sanam
Ad functionam