Niluh Mirawati

Female/11y.o
PRE OPERATIVE
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 IDENTITY
Name : Niluh Mirawati

Age : 11 years old / Female

Admission : November 3nd, 2022

Registration : 739747
 ANAMNESIS

Chief Complain: Pain at the back

• back not straight realized since 7 years ago. In 6 months ago patient feel pain at the back of her body, the pain sometimes arised when she sit and
stand position, and getting better when she was in the prep towards position. Patient sometimes got annoyed with her pain, but she still can do her
daily activity normally, there are history of controlled her complain in Unhas general hospital, patient was applied korset , but she rare used her brace

• No history of trauma

• Patient got menarche in 11 years old

• There is no family history of the same complaint as the patient.

• There is no history of taking TB drugs

• No history of shortness of breath

• There is no history of blue body as a child

• There is no history of fever and cough for a long time

• No history of weight loss

• Patient is junior high scholl student

GENERAL STATUS
• Compos Mentis/ Well-nourished
• Vital Signs:
Blood Pressure : 110/70 mmHg
Pulse rate : 82 x/min
Respiratory rate : 20 x/min
Temperature : 36,5 0C
LOCAL STATUS
Vertebra region
Look: deformity (+), hematoma (-), swelling (-), gibbus (-)
Feel : tenderness (-)
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5 5

Yes
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REFLEX
Physiologic Reflex Pathologic Reflex

R L R L
Biceps (++) (++) Hoffmann- tromner (-) (-)
Triceps (++) (++) Babinski (-) (-)
Patellar (++) (++) Chadock (-) (-)
Achilles (++) (++) Openheim (-) (-)
Klonus (-) (-)
Voluntary
anal
(-)
contraction
Perianal
sensation
(-) Bulbocavernosus (+)
reflex
Deep anal
sensation
(-)
LABORATORY FINDING
DIAGNOSIS
• Adolescent idiopatic scoliosis
MANAGEMENT
• Scoliosis correction