IDENTITY (April 5th, 2023) CIN/RIZ/ dr. DW, Sp.K.F.R., Ped.

(K)
Name : Mrs. S
Age : 69 years old
Sex : Female
Religion : Moslem
Marital Status : Married
RM : 12997778
Address : Surabaya
Occupation : Housewife
Referred from Neurology OPC at Soetomo General Hospital with LBP ec Spondylosis Lumbalis + HT

AUTOANAMNESIS
II.1. Chief Complaint: Nyeri punggung bawah
II.2. History of Present Illness:
Pain at her low back area felt since 10 years ago, comes and go, described as ‘cekot-cekot’, usually felt after
standing for too long. Pain worsen since months, with WBS 8 described as aching and burning pain, radiate to both
her buttock, thigh until calf area. Pain aggravated when walking for 300 meters, changing position from sitting to
standing, squatting, sitting for more than 10 minutes and forwad bending.. Coughing, sneezing, does not aggravated
her pain. Taking medication and lying reduced the pain. Pain also accompanied with tingling sensation on both her
limb, mainly on area around right lateral thigh. She has no complain of weakness of lower extremity and there is no
problem in urination and defecation. Currently the pain already decreased (WBS 6) after consuming pain medication
from Neurologic OPC, RSDS.
She also felt mild pain on both her knees since 3 months ago, felt like dull pain with WBS (0-1). Pain usually
felt when start to walk and gradually relieve. Pain accompanied with morning stiffness of both knees (<30 minutes)
and sometime cracking sound (kretek2) when move. Since 2 months ago, sometime her foot will be swelling when
sitting for too long (>6 hours) and relieved after lifting her foot. There was no history of trauma, fever, nor decreased
of body weight. She also doesn’t complain for shortness of breath during resting or activities.

II.3. History of Functional Ability

She could do any ADL (eating, bathing, grooming, dressing, bowel, bladder, and transfer), but there was
limitation on walking up the stairs. She pray in sitting position due to pain.

II.4. History of Medication and Rehabilitation

· Primary Health Care since July 2022 got medication, pain not relieved.
· September 15th 2022, got referred to William Booth Hospital, was told her condition due to muscle spasm, got
medication (Vit b kompleks, elkana, eperison, dexketoprofen, lapibion, na diclofenac) and Rehabilitation
Program ( Modality: TENS and exercise)
· March 24th 2023, got referred to Neurologic OPC, Soetomo Hospital for MRI examination. Currently got
medication (PDA 2 x 1 tab, Gabapentin 1 x 100 mg, Vitamin B12 2 x 50 mcg), but not advised for MRI yet due
to patient rejected surgery.

II.5. History of Past Illness:

· Hypertension since 9 months ago, consumes Candesartan and Furosemide
· No history of trauma nor other illnesses.

II.6. History of Hobby and Work

She is a housewife, likes to cook

II.7. History of Psycho-Social-Economic

Lives in 3-storey house, sitting toilet, with her 5th daughter’s family and her sister (66 yo, housewife). Her daughter
family consist of her daughter (43 yo, designer), son in law (43 yo, enterpreneur) and 5 children. She has 6 children
but other children lives separately. The patient is covered by BPJS insurance.

II.8. Family History

No history of same illness and no history of malignancy in the family.

II.9. Patient’s Expectation

Can do activity without pain
PHYSICAL EXAMINATION
III.1. General Status
GCS : E4 V5 M6
Posture : Forward head, flattened back
BP: 160/70 mmHg, HR: 73 x/min, RR: 20 x/min, Temp: 36,2oC, SpO2: 98%
BW: 59 kg BH: 145 cm BMI: 28,06 kg/m2 (Obese Grade I)
Dominant extremity: Right handed. Ambulation: independent

Head/Neck : Conjunctiva anemia (-/-), icterus (-/-), cyanosis (-), enlargement lymph node in the neck (-)
Thorax
Cor : S1-S2 normal, regular, murmur (-), gallop (-)
Pulmo : Vesicular (+/+), wheezing (-/-), ronchi (-/-)
Abdomen : Soefl, peristaltic (+), tenderness (-),
Extremities : Warm acral (-/-), cyanosis (-), edema (+/+), ulcus decubitus -

III.2. Head/Neck/Trunk,
Look : deformity (-|-), swelling (-|-)
Feel : tender point (-|-), warmth (-|-), edema (-|-) step off (-), knock pain (-), doorbell sign (-|-), tender
point at level VL 4, paralumbal muscle spasm (+)
Move : pain when flexion (+)
Sensoric : Normal
Propioceptive : Normal
Special Test : SLR +/+, Bragard +/+, Siccard +/-, Thomas -/-, Patrick -/-, Contra patrick -/-, Pelvic compression -/-,
Pelvic Rock -/-, Gaenslen test -/-, Ober test -/-, Piriformis test -/-, Freiberg test -/-, Beatty test -/-, Pace test -/-, Ely test
-/-, Hamstring tightness +/+, Reverse SLR -/-

Region Joint Movement Muscles Strength

Range of Motion MMT
Neck F/F 5/5
Trunk F/F 5/5

III.3. Upper Extremities Region

Look : redness (-|-), swelling (-|-)
Feel : warmth (-|-), tender point (-|-), crepitation (-|-)
Move : pain when move (-|-)
Neuromuscular :
- Muscle tone : Normal tone (+/+)
- Deep Tendon Reflex : BPR (++/++), TPR (++/++)
- Pathological reflex : Hoffmann (-/-), Tromner (-/-)
- Sensorics : normal
- Spasticity : -/-
Region Movement ROM Movement MMT
Shoulder Flexion(0-1800) F/F Flexor 5/5
Extension (0-600) F/F Extensor 5/5
Abduction(0-1800) F/F Abductor 5/5
Adduction(0-450) F/F Adductor 5/5
Internal Rotation (0-900) F/F Internal Rotator 5/5
External Rotation (0-700) F/F External Rotator 5/5
Elbow Flexion(0-1350) F/F Flexor 5/5
Extension (135º-0) F/F Extensor 5/5
Pronation (0-900) F/F Pronator 5/5
 Supination(0-900) F/F Supinator 5/5
Wrist Flexion (0-800) F/F Flexor 5/5
Extension (0-700) F/F Extensor 5/5
Radial deviation (0-200) F/F Radial Deviator 5/5
Ulnar deviation (0-350) F/F Ulnar Deviator 5/5
Fingers Flexion F/F Flexor 5/5
Extension F/F Extensor 5/5
Abduction F/F Abductor 5/5
Adduction F/F Adductor 5/5

III.4. Lower Extremities Region.

Look : redness (-|-), pitting edema (+|+) pretibial and dorsal area of foot
Feel : warmth (-|-), crepitation (+|+) on knees, tenderness (-|-)
Move : pain when move (-|-)
Neuromuscular :
- Tonus : normal
- Deep Tendon Reflex : KPR ++|++; APR ++|++
- Pathological reflex : Babinski -|- Chaddock -|-
- Sensorics : (see table)
- Propioceptive : Normal
- Special Test : PGT (+|+), Valgus stress test (-|-), Varus stress test (-|-), ADT (-|-), PDT (-|-)
- Spasticity : -/-
Region Movement ROM Movement MMT
Hip Flexion(0-1250) F/F Flexor 5/5
Extension (0-300) F/F Extensor 5/5
Abduction (0-450) F/F Abductor 5/5
Adduction (0-200) F/F Adductor 5/5
Internal Rotation (0-450) F/F Internal Rotator 5/5
External Rotation (0-450) F/F External Rotator 5/5
Knee Flexion (0-1350) F/F Flexor 5/5
Extension (135º-0) F/F Extensor 5/5
Ankle Dorsiflexion (0-200) F/F Dorsiflexor 5/5
Plantarflexion (0-500) F/F Plantarflexor 5/5
Eversion (0-150) F/F Evertor 5/5
Inversion (0-350) F/F Invertor 5/5
Big Toes Flexion F/F Flexor 5/5
Extension F/F Extensor 5/5
Toes Flexion F/F Flexor 5/5
Extension F/F Extensor 5/5

Sensorics MMT Dermatome and Myotome MMT Sensorics

70% 5 L2 5 90%
90% 5 L3 5 90%
90% 5 L4 5 90%
90% 5 L5 5 90%
90% 5 S1 5 90%
ALL : 85/85 cm
TLL : 80/80 cm

III.5. Functional Status

Balance : Sitting balance (static and dynamic) is good, standing balance (static and dynamic) is good
Romberg (Able), sharpened Romberg (Able), tandem walking (able)
Transfer : Lying to sitting independent, sitting to standing independent, bed to chairindependent
Coordination : Dysdiadokokinesia -|-, finger to nose +|+, finger to finger +|+, heel to shin: +|+
Count test : 23
Chest expansion : 4cm/4cm/4 cm
Walk on heel : able
Barthel Index : 95/100
Feeding 10/10 Bladder 10/10
Grooming 5/5 Toilet use 10/10
Bathing 5/5 Mobility 15/15
Dressing 10/10 Transfer 15/15
Bowel 10/10 Stairs 5/10

Frax score:
Major osteoporotic 10
Hip Fracture 1.8

SUPPORTING EXAMINATION
Lumbosacral AP/Lateral 15/10/22:
Spondylosis lumbal L3, L4, L5

Lumbosacral AP/lateral 3/4/23

- Degenerative disease of the spine dengan gambaran :
1. Degenerative disk disease
2. Spondylosis thoracolumbalis
- Paralumbal muscle spasm
- Terpasang IUD bentuk spiral di cavum pelvis

PROBLEM LIST
 Low Back pain (WBS 6)
 Bilateral knee pain (WBS 1)
 Sensory deficit
 Uncontrolled HT
 Bad posture
 Obese Grade I

ICF
Body Function
b270 Sensation of pain (low back pain, WBS 6; knee pain, WBS 1)
b265 Touch function (sensoric deficits of L2, L3, L4, L5 and S1 area of both limbs)
b530 Weight maintenance function (obese grade I)
b420 Blood pressure function (hypertension stage II)
b530 Weight maintenance functions (Obese grade I)
b789 Movement functions (Difficulty in walking for long distance due to low back pain)
Body Structure
s740 structure of trunk ( suspect HNP, lumbar spondylosis, paralumbal muscle spasm)
s750 Structure of lower extremity (bilateral hamstring tightness, knee OA)
Activities and Participation
d410 Changing basic body position (pain on Sitting to standing)
d415 Maintain Body Position (Unable to stand for a long time due to low back pain)
d450 Walking (Unable to walk for long distances due to low back pain)
d930 Religion and spirituality (pain when sholat)
Environmental factors
e310 Immediate family
e580 Health services and system (she had BPJS)

ASSESSMENT
Low Back Pain ec Suspect HNP VL2-VL3 et Paralumbal Muscle Spasm et Bilateral Hamstring Tightness + Lumbar
Spondylosis + Bilateral Knee Pain ec Bilateral Knee OA + Hypertension Stage II (Uncontrolled) + Obese Grade I

PROGNOSIS
Ad vitam : Bonam
Ad sanactionam : Dubia
Ad functionam :
- Transfer : Independent lying to sitting, sitting to standing, bed to chair
- Ambulation : Independent ambulation without assistive devices
- Other ADL : Independent ADL, BI 100

Goals:
Short Term :
1. Establish the diagnosis
2. Decrease pain 1-2 level below
3. Good posture
4. Improved sensory function
5. Reduced paralumbar muscle spasm
6. Reduced hamstring tightness
7. Improved sensory function
Long Term :
1. Achieved good posture
2. Prevented worsening of condition
3. Reduced body weight
4. Controlled comorbid
5. Better quality of life

PLAN :
PDx :
· Consult to Cardiologist OPC
· Xray Knee AP/Lat D/S
· CGA on next visit

PTx :
Modalities:
 IFC 4000-4100 Hz at paralumbal area intensity as patient tolerance for 20 minutes
 SWD 27,12 mHz contraplanar at genu D/S
Medicamentosa: Continue medication from Neurology OPC

Therapeutic Exercise:
 Posture correction during sitting, standing & activities.
 Active breathing exercise with deep breathing and chest expansion exercise
 AROM exercise AGA/AGB D/S
 Core strengthening exercise with abdominal drawing in
 Sensory resensitization
 McKenzie exercise
 Hamstring stretching exercise
 Isotonic strengthening exercise of bilateral quadriceps and hamstring with Q bench
OP : LS Corset (patient already have, need to reevaluate), knee decker

PMx : Clinical, VS, WBS, MMT, BMI, sensory, blood pressure

PEd :
· Explain the patient's condition, rehabilitation program, and therapy goals
· Continue exercising at home
· Icing for 15-20 minutes when it hurts, can be repeated every 2 hours
· Proper back mechanic
· Knee joint conservation
· Routinely controlled and consume medicine from neurologist OPC