SKOLIOSIS

1. Identity : Name
Sex (♀ >> ♂),

Age 0-3 : Infantile, 4-10 : Juvenile, > 10 adolescent

Address, religion

2. Chief complaint : Posture , Shoulder asimetri since

3. History of Present Illness :
Deformity of spine : onset ,

progresivitas,

effect from deformity ( dyspnoe

~ cardiopulmoner , gait, back pain )

intelegensia

mental

4. History of Past illness :

History of disease, surgery,trauma

5. History of Psychosocial & Environment : Pekerjaan, rumah tempat tinggal, penghasilan, anak
6. Family history : is there any family affected line this
7. Menarche

 PF :
AMBULATION : dependent / independent

+ / - assistance

GAIT :

BALANCE :

GENERAL CONDITION.

 Conciousness :
 Vital sign : BP, HR,RR,Temp
 Body weight IMT BB = BB Ideal ( TB -100) – 10 %
 Body Height TB2
  Cognition  MMT, AMT ( N : 8-10, kognisi sedang : 4-7 )
 10 pertanyaan : umur, alamat, tgl lahir px/ anak terakhir ,

jam/waktu, ada dimana, kenal orang RS, th merdeka, Presiden

sekarang siapa, th berapa ?

Cranial nerves

MUSKULOSKELETAL SISTEM

HEAD : symetri, deformity

EYE : conjungtiva not anemic, exophtalmus -/- , nistagmus -/-

sclera icteric -/-

pupil isokor, anisokor, diameter 3mm/3mm

direct consentual reflex : +/+

indirect consentual reflex : +/+

EAR, NOSE , THROAT ; w.n.l

MOUTH : oral hygiene

NECK : deformity (+/-), nodule (+/-)

THORAX : Inspection : symetri (static and dynamic)

Bulging (-), papilla mamae

Palpation : Lung : symetric (static and dynamic)

Vocal fremitus, chest expansion : axilla, papilla mamae,

arcus costarum

Heart : border of the heart  WNL

Auscultation : Lung : Vesiculer , ronki, wheezing

Heart : 1st , 2 nd heart sound are pure, murmur (-), gallop (-)

ABDOMEN : I : convex
 Pa: soepel, Hepar & lien are not palpable

A ; bowel sound (+)

TRUNK : alignment :

- straight

- scoliosis

- atrofi

GENITAL : Deformity (-)

ANUS : haemorhoid +/-

INTEGUMEN : dry skin (-)

Ulcer (-)  (+) a/s …..gr…..

SPECIAL TEST : LOCAL STATUS

General  Patognomonic sign of scoliosis non structural

TB/ height of body and arm spain  Marfan Syndroma

Chest expansion,areolla mamae

Sex 2nd : masurasi/pubertas

Examination upright from front, back, lateral :

- Height of scapula/shoulder

- Scapula prominent

- Hump

- Protrusion hip : penonjolan hip

- Pelvic obliquity

- Spine position to pelvic measure with plumb line

Wurea puss  tinggi hump

- Flexibilitas of curve : untuk mengetahui lat bending and forward

- Size of mamae
 - Schober Test : dimple of venous

- Lordosis lumbal koreksi

- LLD : True, apparent leg , koreksi 2 cm

- Prominent b.f.m paralumbal

- Body arm distance –dari epicondial med – badan > lebar

- gluteal fold

Flexibility of the curve :

- Lat bending Test

- Forward bending test

UPPER EXTREMITY :

Look : shoulder symetris / deformity

Inflamation sign

Normotrophy

Trunk : Café au lait  neurofibromatosis

Feel : Normotonus

Pain on pressure

Sensibility : superficial , proprioception

Muscle spasm : +/-

Atrophy

Move ( shoulder, elbow, wrist, hand) :

 pain in movement
 ROM
 MMT
 Physiological reflex
 Pathological reflex
Hand prehension

Clonus
Coordination : Finger to nose

Finger – nose – finger

Finger –finger

Pronation –supination

Dysdiadokinesis

LOWER EXTREMITY (NON AFFECTED LIMB)

LOOK : symetri/ deformity/LLD

Normothrophy :

FEEL : Pain on pressure

Tonus

Muscle spasm

Sensibility : - superficial  stocking hip/anesthesia

- Proprioception

Atrophy

MOVE :

 pain in movement
 ROM
 MMT ( hip, knee, ankle)
 Physiological reflexes
 Pathological reflexes
 Clonus
 Coordination

LOCALIZED

LOOK : Deformitas

Alignment

Apex
FEEL : Pain on pressure

Tonus

Muscle spasm

MOVE :

 pain in movement
 ROM
 MMT ( hip, knee, ankle)
 Pelvic obliquity
 Physiological reflexes
 Pathological reflexes
 Clonus

CONCLUSION :

 Clinical diagnosis : Scoliosis idiopatik structural/ non structural dg C/S curve pada segmen
thoracolumbal ka/ki, Sudur Cobb, Balance/tidak Balance
 Etiology diagnosis : idiopatik  90 %
 Localized diagnosis ; Vertebra Th ….atas dan bawah….

PROGNOSIS ;

 Quo Ad vitam : Bonam

 Ad sanationam : tgt usia, structural/non struktural
 Ad functionam

ADDITIONAL EXAMINATION

RADIOLOGY

 Upright (without shoe) : AP + Lat ( all of the spine)  to know the biggest deformity with weight
bearing
 Lying : AP  deformity without weight bearing
AP with right & left bending  correction from scoliosis +/-

 Pelvic AP : Caping Iliac apophysis (growth of bone)

Elongation according to Riesser

RONTGENT SKOLIOSIS
  Berdiri tegak tanpa alas kaki:
AP,vertebra cervical lumbal/lateral/oblique

Pelvis : lihat maturasi tulang

Lateral bending kanan/kiri

Kemudian evaluasi setelah 3 bulan

PROBLEM INVENTORY

-Kelainan postur/postur problem

-Gangguan chest expansi

-Pain

-LLD

GOAL JANGKA PENDEK (mg)

 menghilangkan nyeri
 koreksi LLD
 Increase chest expansion
GOAL JANGKA PANJANG…..

(ROS)

Impairment :

 Scoliosis
 Flexibilitas structural/non structural
 Curve C/S
 Right/left
 Angle cobb’s
 Balance or not
Disability : Rare except severe scoliosis

Handicap : Psychologis

MANAGEMENT DEPEND ON :
1. Age and skeletal maturity (growth potential +/-)

2. Etiology

3. Degree of scoliosis

4. Long/Sum of vertebrae which form scoliosis

5. Mobility of the curve (lateral bending)

COBB’S ANGLE

0-200 : Observation + exercise

20-400 : Brace (konservatif), Milwaukee + Boston

40-500 : Borderline (if mobile, trial with brace), MSO

> 500 ; Operation Harington Post fusion spinal instrumentation

0-50 Exercise E,D, L, F (Elongation, Derotation, Latero flexion)

REHABILITATION PROGRAM

 Decrease pain & muscle spasm with modalitas therapy, traction and massage
 Exercise :
- with/without brace

- Pra surgery for spinal fusion

ORTHOSE-BRACE
- High profile brace /CTLSO : Milwaukee Brace > T 8

- Low profile brace /TLSO : Boston Brace ≤ T 8

Taken from :

1. Kumpulan makalah : Prof H.Soelarto R.SpBO

2. Simposium radiology anak : dr.Angela BM Tulaar SpRM
3. SOAP –IKFM
Reiser Foto pelvis untuk melihat maturitas tulang : belum matur 1-2

Matur : 4-5

DEFINISI SKOLIOSIS :

Kelengkungan lateral yg tidak normal

ETOLOGI :

-Congenital

-Neuromuskuler

-Idiopatik

Struktural

Fungsional

PF:

ANAMNESIS

benjolan pada punggung

Nyeri +
Rasa pegal pada pinggang
Dada lebih besar sebelah

PF :

L : DEPAN : bahu simetris

Papilla mamae simetris

BLK : level bahu

alignment

scapula simetris

penonjolan scapula
 Hip level

Arm hand/ arm body distance

FEEL : spasme

Nyeri

Sisi konvek

Sisi konkaf

MOVE :

- Plumb line dari C7-Gluteal Fold

- Himb diukur water pass

- Arm body distance diukur

- LLD

- Forward bending test

CONTOH : ada gambar lengkung

Cekung/konkaf konvexx/kembung

Spasme lemah

Stretching Strengthening

Humb

Body arm distance >>

PENATALAKSANAAN COBB’S ANGLE

0-200 : Observation + exercise

20-400 : Brace (konservatif), Milwaukee + Boston

40-500 : Borderline (if mobile, trial with brace), MSO

> 500 ; Operation Harington Post fusion spinal instrumentation

0-50 Exercise E,D, L, F (Elongation, Derotation, Latero flexion)

RONTGENT SKOLIOSIS

 Berdiri tegak tanpa alas kaki:

AP,vertebra cervical lumbal/lateral/oblique

Pelvis dan tangan : lihat maturasi tulang

Lateral bending kanan/kiri

Kemudian evaluasi setelah 3 bulan

TUJUAN THERAPY LATIHAN

1. Memperbaiki posture
2. Meningkatkan flexibilitas tulang
3. Mencegah progresivitas kurva
4. Memperbaiki system respirasi
5. Menghilangkan sakit punggung

PROGRAM ;

 Lat EDLF
 Modalitas : Heat th/
IR

Traksi cotrail

Massage

OP : Milwaukee Brace diatas T10

Boston dibawah T 10

Latihan tanpa brace dg penguatan otot trunkus abdominal untuk stabilitas trunkus
- Pelvic tilt dg flexi hip & knee

- Pelvic tilt dg extensi hip & knee

- Sit up partial dg semi flexi hip /knee

- Pelvic tilt

- Hiperextensi trunk dg deep breathing exc

 Latihan dg brace
- Sama +

- Menarik punggung yg menonjol menjauhi pad dg menarik ke lateral

- Menjauhi bantalan dagu memanjangkan tubuh dg memanjangkan col.vert

- Body shift untuk koreksi body tilt

- Tubuh didorong berlawanan sisi ambang

STROKE STATUS  Bremmer

IDENTITY ; Name

Sex (♀ >> ♂),

Age

Address, religion, occupation

Kinan/kidal

CHIEF COMPLAIN :

HISTORY OF PRESENT ILLNESS

Risk Factor for stroke

NON MODIFIABLE MODIFIABLE POTENTIAL MODIFIABLE

Age HT,DM Obesity
Genetic Predisp Cardiac Physical inactivity
Gender Lipid Heavy alcoholism
Race Cigarette smoking Drug abuse
Etnicity Stenosis carotid HRT
Sicle cell ds Oral contraceptive

ETIOLOGY AND CLASSIFICATION

LTEMPORAL

TIA : neurology deficit lasting < 24 hours & resolving completely

RIND : Reversible Ischemic Neurologic Deficit

 Temporary Neurologic Deficit Lasting > 24 hours

Eventual resolution

STROKE : Neurologic Deficit Lasting > 24 hours & Lasting Neurologic

THROMBOTIC : Symptom progress over hours to days.

Classic Pattern : awake with minimal deficit that progress in a slep

wise pattern, history prior TIA

EMBOLI : symptom very rapidly in seconds

Typically awake, involve in activity

No history of TIA stroke

HEMMORHAGIC :

Headache , loss of consciousness >>

Include : nausea,vomiting, elevated blood flow

May not fit in anatomy distribution of specific blood vessel

Nuche rigidity & Retinal hemorrhage ( not exclusive to hemorrhage )
Many intracranial hemorrhage are lobar occipital ipsilateral
Hemianopsia

LPARIETAL

Antetemporal,headache,contralat sensory loss, mild hemiparesis

LFRONTAL

Bifontal, headache, contralat arm weakness

LTEMPORAL

Dysphagia , pain around ear

OTHER COMMON LOCATION

Putamen

Talamus
CLINICAL SYNDROM :

Left Vs Right side

HEMISPHERE

Mediates learns behaviour in initiation, planning, general intellectual / function, visual-spatial & visual
motor judgement (right parietal lobe)

Emotional disorder = flat affect, impulsivity, emotional lability also may seen,

Generally slower in relearning activities of ADL

LEFT HEMISPHERE

Control language in 97 % population

VASCULAR DISTRIBUTION & CLINICAL DEFICITS

DETERMINING CLINICAL SEVERITY

NIH Stroke scale based on 15 item

Hunt & Hess scale , classifier subarachnoid hemorrhage on a scale of 1-5 based on severity
symptom
MMSE

LAB

RADIOLOGIC IMAGING

Head CT, MRI, MRA, Cerebral angiography,others

ACUTE MANAGEMENT OF ISCHAEMIC STROKE

o Anticoagulant
o BP Management
o Fever
o Seizure
o Electrolyte, fluid and balance nutrition
 -Hiponatremi
  -Avoidance hiponatremia and fluid
 -Aggressive management
o Acute setting DVT profilaksis

ACUTE MANAGEMENT OF HEMMORHAGIC STROKE

- BP Management
 bleeding from ruptured cerebral arteries and arterioles
Recommendation :

-MAP of 130 mmHg

-CPP > 70 mmHg

-Sist > 90 & < 180 mmHg

- Intracranial Pressure (ICP)

-Elevated ICP define as ≥ 20mmHg for >5mnt

-Presentation 48-72 hours with peak edema 3-5 days

- Seizure
- Vasospasme
- Surgical intervention

MEDICAL PROBLEM :

- Cardiovascular
- Pulmonary
- Gastrointestinal
- Genitourinary
- Skin
- Depresion
- Neurologic
- Pain
- Falls

NEUROLOGICAL FUNCTION RECOVERY

- General
- Neurologic recovery phase
- early < 3 month

- late state > 3 month

- Motor recovery pattern

 - Language recovery pattern
- Stroke and impairment scale
- Disability : Barthel Index, FIM

- Overall neurologic & Functional recovery determinants of poorer prognosis

- Recovery specific neurologic deficit

- ambulation

- UE function

- aphasia

REHAB SETTING

- Acute impatient rehab

- Subacute impatient rehab
- External care facility
- Day treatment rehab
- Output rehab
- Home rehab