Vivo/M/28yo

Paravertebral Abscess
Spondylitis TB L2-S1 Frankel D

Performed :
Drainase Abscess
(Wednesday, 11th Octoboer 2023)

Attended by:
dr. Benny, M.Ked(Surg), Sp.OT(K)

ICD X: M48.5
ICD IX: 81.08, 03.09

dr. Arya, dr. Gendeddy, dr. Rama, dr. Luthfi, dr. Irvan, dr. Immanuel
History
Chief Complaint: Back pain

It has been suffered since 13 months prior hospital admission (Oct 2022). History of trauma (-). Initially, he
experienced chronic cough for 1 months. In the second month, he started to feel pain in the back. There
was history of loss body weight 6 kg in the last 6 months. History of night sweat. The pain was aggravated
with sitting position and was alleviated with resting position. The pain radiated to the right leg. He went to
Setiabudi Hospital in July 2023 and was referred to Adam Malik Hospital for further treatment.

History of loss of consciousness : (-)

History of past illness / treatment :
- Abscess in the chest —> Abscess evacuation by dr. Joni Sp.B
History of food / drug allergy :
Present State General State
Sens : CM • Head
TD : 120/80 • Eye : Pupil isochor equal 2mm/2mm, sclera normal,
HR : 81 x/min conjunctiva normal
• Nose : normal
RR : 20 x/min
• Lips : normal
Temp : 36.7oC
• Jaw : normal
VAS : 3-4 • Ears : normal
• Neck : Lymph node normal, trachea in the middle
• Chest : Vesicular, rh -/-, wh -/-, heart sound normal
• Abdomen : Symmetrical , soepel, tenderness (-), mass (-), tympanic,
shifting dullness (-), peristaltic (+) normal
• Extremity : No abnormalities
• Genitalia : Male, no abnormalities
Back
L:
Deformity (-), abnormal bony prominence (-), wound (-),
Gibbus (-), Swelling (-)
F:
Tenderness (-), step off deformity (-)
M:
AROM Cervicothoracal normal
AROM Thoracolumbar normal
AROM Lumbosacral limited d/t pain

Motorik
C5/C6/C7/C8/T1
5/5/5/5/5 // 5/5/5/5/5
L2/L3/L4/L5/S1
5/5/5/5/5 // 5/5/5/5/5
Sensory
L1 Above +2/+2
L2-L3 +1/+1
L4-S1 +2/+2

R. Fisiologis : +/+
R. Patologis : -/-

Clonus : -/-
DRE: TSA Tight, perianal sensation (+), BCR (+)
 X-Ray Lumbal AP/Lat
August 16th, 2023
Setiabudi Hospital

A: Anterior vertebral line disruption (-)

Posterior vertebral line disruption (-)
Spinolaminar line disruption (-)
Spinous process line disruption (-)
B: Loss of vertebral body height (-)
C: Superior and inferior end plate disruption
(+) L3, L4
D: Loss of intervertebral disc space (+) L3, L4
E: Fusiform swelling (-)
 MRI Whole Spine
Sept 20th, 2023
Adam Malik Hospital
 MRI Whole Spine
Sept 20th, 2023
Adam Malik Hospital
 MRI Whole Spine
Sept 20th, 2023
Adam Malik Hospital
 MRI Whole Spine
Sept 20th, 2023
Adam Malik Hospital
List of Problems:
• Back Pain
• Radiating Pain
• Neurologic deficit

Diagnosis:
• Paravertebral Abscess
• Spondylitis TB L2-S1 Frankel D

Performed
• Drainase Abscess (Wednesday, 11th October
2023)
Pre-operative

C
R
A
N
I
A
L
Pus
Wound Closure

C
R
A
N
I
A
L
Pre-operative

C
R
A
N
I
A
L
Design Incision

C
R
A
N
I
A
L
Wound Closure

C
R
A
N
I
A
L
Samples
Letter of Agreement