CASE REPORT

Data base identity (July 1st 2013) : Name Sex Age Marital status Address Religion Job Sport : : : : : : : : Mr. H male 31 yo Married Karang Menjangan Surabaya Christian Jobless( ex Medical Record Staff at Mojowarno Hospital) Bicycle (recreational)

Patient was referred by Orthopaedic Surgeon with suspicion of ACL rupture of right knee Chief Complaint : pain at the right knee History of Present Illness : He feels pains at the right knee since 5 years ago after got traffic accident. Its a dull pain, not radiating, at anterior part of knee especially when he is walking, feel giving away. Pain increases when he bends his knee and decreases if he use knee decker when walking or rest the leg. He has got rehabilitation for 3 months at Soetomo Hospital (TENS, laser, and isotonic strengthening quadriceps exc twice a week), bicycling at home for 30 minutes / day and consume bone supplement once a day. Now, he use knee decker when walking, no pain and without assistive device. History of Past Illness : January 2008 : he got traffic accident, his right knee was hit by motorcycle from medial sidepain, swelling, hematomeIRD RS. Soetomo (casting for 1 month & elastic bandage for 3 months, no operation)walked with double axillary crutch 2009 : Controlled to orthopaedist (suggested to get operation refused suggest to rest his right leg & go to rehabilitation) he still worked with double axillary

Shoulder Disarticulation

crutches 4 hours / day until 4 months and got TENS/day at Mojowarno + consume bone mineral supplement once a day)quit from Mojowarno and stop TENS, just consume supplement. 2011: Right knee become worst (pain , warm, edema) got operation at Brawijaya Hospital (evakuasi pus dan reposisi???) No history of diabetes mellitus

Physical Examination Compos mentis, independent ambulation with limping gait, right handed dominant Vital sign BW : 83 kg : BP 130/80 HR 80x/mnt RR 16x/mnt BH : 175 cm BMI : 27,1 kg/m2

Head & Neck : anemic/icteric/cyanosis/dypsneu Thorax Cor Pulmo Abdomen : simetris : normal sound, murmur -, gallop : vesiculer +/+, ronchi -/-, wheezing -/: flat, meteorismus H/L unpalpable Extremities : Right shoulder disarticulation, edema -

Muskuloskeletal system
Part of body Movement Cervical Flexion Extension Lateral Flexion Rotation Joint Movement ROM Full Full Full/Full Full/Full Muscle Flexor Extensor Lateral Flexor Rotator Muscle strength MMT 5 5 5/5 5/5

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Trunk

Flexion Extension Lateral Flexion Rotation

Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full Full/Full 135 -(-5 )/Full Full/Full Full/Full
0 0

Flexor Extensor Lateral Flexor Rotator Flexor Extensor Abductor Adductor Endorotator Exorotator Flexor Extensor Pronator Supinator Flexor Extensor Rad deviator Ulnar deviator Flexor Extensor Abductor Adductor Flexor Extensor Abductor Adductor Endorotator Exorotator Flexor Extensor Dorsoflexor Plantarflexor

5 5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5*/5 (pain) 5*/5 (pain) 5/5 5/5

Shoulder

Flexion Extension Abduction Adduction Endorotation Exorotation

Elbow

Flexion Extension Pronation Supination

Wrist

Flexion Extension Radial Dev Ulnar Dev

Fingers and Thumb

Flexion Extension Abduction Adduction

Hip

Flexion Extension Abduction Adduction Endorotation Exorotation

Knee

Flexion Extension

Ankle

Dorsoflexion Plantarflexion

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Eversion Inversion Toes & big toe Flexion Extension

Full/Full Full/Full Full/Full Full/Full

Eversion Inversion Flexor Extensor

5/5 5/5 5/5 5/5

Neurologic Examination Cranial Nerve I XII : Normal DTR : BPR -/+2 KPR +2/+2 TPR -/+2 APR +2/+2 Pathological Reflex : Babinski -/-, Chaddock -/-, Hoffman Tromner Sensory : Exteroceptive (light touch & pin prick) : Normal Propioceptive (joint position) : Normal Local State (Regio Knee) Stump/right shoulder I : swelling- deformity redness - atrophy of thigh D P : tender point at anterior knee (medial & lateral side) (VAS=3-4 when walking wo knee decker)

Diameter M o Patella d iVMO (Above MTP) f Quadriceps (10cm i e MTP) d Gastroc Soleus

Right 36 cm 40 cm

Left 33 cm 43 cm 43 cm

above

40 cm

38 cm

35 cm

Barthel Index : 100 independent

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Supporting Examination MRI

DIAGNOSIS Functional Diagnose Impairment : Right 7th nerve paralysis (perifer type) and Right shoulder disarticulation

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Disability Handicap

: difficulty in toilet use : unable to work (make and sell bandeng presto) and do social activity (e.g pengajian and go to market because of ashamed)

Problem List Medical Surgery :: Right Shoulder Disarticulation and TBI

Rehabilitation Medicine R1 (Mobilisation) R2 (ADL) : independent ambulation with normal gait : difficulty in toilet use,

R3 (Communication) : R4 (Psychological) : She feels worried & ashamed with her condition and sometimes afraid when see truck R5 (Social Economic): Covered by Jamkesmas R6 (Vocational) R7 (Others) : She cant make and sell bandeng presto : - Right 7th nerve paralysis (perifer type) GOAL Short term goal Improve the strength of right facial muscles Long term goal Improving quality of life Right Dry eye Sensory deficit of right 2/3 anterior tongue Positive stapedius reflex at right side Right Shoulder disarticulation

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PLANNING Medical PDx PTx ::: metamizole 3 x 1 amp, alinamin 2 x 1 amp, amitriptilin 1x 12,5 mg

PMx : Pex :-

Rehabilitation Medicine R1 (Mobilisation) PTx : - Electrical stimulation on right and left dorsoflexor ankle and extensor big toe - Strengthening exc of R & L lower ext. with MMT 3 (60 80 % of 1-RM, 2-4 sets with 8-12 repetitions per set with rest interval 2-3 minutes between sets, 2-3 days/week) -ROM exc of R & L lower ext. with MMT < 3 (2-3 sets with 5-10 repetitions per set with rest interval per set 1-2 minutes, 7 days/week) -Endurance exc (40% - < 60% VO2R with 30 minutes / day, 3-5 days/week) -LS corset -AFO splint (patient needed time to think) PMx : Gait pattern, vas, MMT PEx : -Proper back mechanic -Routinely do exercise R2 (ADL) PTx : -LS corset & AFO splint when walking (flat surface or up & down stairs)

PMx : Barthel Index PEx : Routinely use the orthosis when activity

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R3 (Communication) : R4 (Psychology) PDx : PTx : gives opportunity to the patient to let out his worries (e.g tell his problem and try to find solutions) PMx : His psychological condition R5 (Social economy) PEx : suggest the patient to continue use Jamkesmas

R6 (Vocational) PTx PEx : : educate the patient to use the orthosis when activity

R7 (Others) PTx : -Icing at low back area -WF exc (Knee to chest & pelvic tilt) + SLR exc (2-3 sets with 5-10 repetitions per set with rest interval 1-2 minutes, 7 days/week) -Strengthening exc trunk extensor & flexor (isometric, 2-4 sets with 8-12 repetitions per set with rest interval 2-3 minutes between sets, 2-3 days/week) -Sensory reeducation PMx : VAS, sensory PEx : explain about his disease Proper back mechanic Do exercise routinely

Shoulder Disarticulation

Shoulder Disarticulation

PROGRESS NOTE
Date 7/10/2011 S Pain (VAS=4) O TD:110/70 N:83x/mnt RR:18x/mnt A LBP caused by HNP L2L3; L3-L4; L4-L5; L5-S1 D/S P PTx :- icing Active breathing exc -ES at muscles with MMT < 3 -AAROM exc ankle D/S (dorsoflexor & extensor big toe) -sensoric reeducation -knee to chest exc -SLR exc -endurance exc - strengthening exc trunk extensor & flexor (isometric) & LE with MMT > 3 PMx: vas, MMT, sensory PEx:-proper back mechanic - use LS corset and dorsal spring when activity PTx :- Active breathing exc -ES at muscles with MMT < 3 -AAROM exc ankle D/S (dorsoflexor & extensor big toe) -sensoric reeducation -knee to chest exc -SLR exc -endurance exc - strengthening exc trunk extensor & flexor (isometric) & LE with MMT > 3 PMx: vas, MMT, sensory PEx:-proper back mechanic - use LS corset and dorsal spring when activity

Hypersensitivity on the area of right and left L4100% 5 L2 5 100% L5-S1 dermatome 100% 5 L3 5 100% Patient choose to change 300% 1 L4 1 200% AFO splint with dorsal 300% 1 L5 1 200% 200% 3- S1 3- 200% spring

Paralumbal muscles spasm Hamstring tightness Steppage gait

1/11/2011

Pain (VAS=2)

TD:120/85 N:81x/mnt RR:17x/mnt

Hypersensitivity on the 100% 5 L2 5 100% area of right and left L4100% 5 L3 5 100% L5-S1 dermatome 100% 1 L4 1 100% 100% 1 L5 1 100% 100% 3- S1 3- 100% Local status : paralumbal spasm +/+ and hamstring tighness +/+, no tender point. Steppage gait

LBP caused by HNP L2L3; L3-L4; L4-L5; L5-S1 D/S

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3-5-12

OP(30/4): #Posterior stabilization Th11-12, L1-L3-L4 #Total laminectomy L1-L3 #Osteotomy L2 #repotition of L2-L3 #Fusion of Th 12-L3 Pain (VAS=5, operation site) pain at

Patient bedridden LBP caused by HNP L2TD:100/60 HR:72x/mnt RR:20x/mnt L3; L3-L4; L4-L5; L5-S1 D/S (post posterior 100% 5 L2 5 100% stabilization 3rd day) + 100% 5 L3 5 100% Suspicion TB Paru 100% 1 L4 1 100% 100% 1 L5 1 100% 100% 3- S1 3- 100%

PTx :-icing -PP + turning /2 jam -Active breathing exc -AROM exc AGA D/S -PROM exc AGB D/S as tolerated PMx: VAS, MMT, sensory PEx:-proper back mechanic -sensoric reeducation From neurology : -PRC and albumin 20% transfusion -metamizole 3x1 -ranitidin 2x1 -Alinamin F inj 2x1 -mecobalamin 2x1

Local status : paralumbal spasm +/+ and hamstring tighness +/+, no tender since 5th April he cough point. for 2 weeks, sputum (-) Chest x-ray (23/4): Hyperaerated lung, fibroinfiltrat w/ multiple cavitas on supra-parahiler D/S Thorax : I : simetris, no deformity P: Lung : Rh-/- , Wh-/Heart : S1S2 normal, m- gTes Faal paru (26/4): FEV1/FVC = 57% (Normal) BTA (sps): Lab(2/5): WBC: 10,8x103(N) RBC: 2,98x106() Hb :8,36() PLT: 103x103() Albumin: 2,9() BUN :4() Kreatinin serum : 0,9(N) GDA:122(N)

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3-6-12 (out patient clinic)

No Pain at lowback MMT -Both of legs feel hot (like Neck 5 Full ROM spicy) and weak Trunk 5 Full ROM UE 5 Full ROM 100% 5 L2 5 100% 100% 5 L3 5 100% 100% 1 L4 1 100% 100% 1 L5 1 100% 100% 3- S1 3- 100% Local status : paralumbal spasm +/+ and hamstring tighness +/+, no tender point.

LBP caused by HNP L2L3; L3-L4; L4-L5; L5-S1 D/S (post posterior stabilization 5th week) + TB Paru

PTx :- Active breathing exc -ES at muscles with MMT < 3 -AAROM exc ankle D/S (dorsoflexor & extensor big toe) -sensoric reeducation -knee to chest exc -SLR exc -endurance exc - strengthening exc trunk extensor & flexor (isometric) & LE with MMT > 3 -flexibility trunk exc PMx: vas, MMT, sensory PEx:-proper back mechanic - use LS corset and dorsal spring when activity From DOT (pulmonary) outpatient clinic: OAT kategori 1

3-7-12

No Pain at lowback 100% 5 L2 5 100% -Both of legs feel hot (like 100% 5 L3 5 100% spicy) and weak 100% 1 L4 1 100% 100% 1 L5 1 100% 100% 3- S1 3- 100% Local status : paralumbal spasm +/+ and hamstring tighness +/+, no tender point.

LBP caused by HNP L2L3; L3-L4; L4-L5; L5-S1 D/S (post posterior stabilization 9th week) + TB Paru

PTx :- Active breathing exc -ES at muscles with MMT < 3 -AAROM exc ankle D/S (dorsoflexor & extensor big toe) -sensoric reeducation -knee to chest exc -SLR exc -endurance exc - strengthening exc trunk extensor & flexor (isometric) & LE with MMT > 3 -flexibility trunk exc PMx: vas, MMT, sensory PEx:-proper back mechanic - use LS corset and dorsal spring when activity

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From DOT (pulmonary) outpatient clinic: 2nd month OAT kategori 1 3-8-12 No Pain at lowback -Both of legs feel hot (like spicy) and weak Get OAT for 3 months 100% 5 L2 5 100% 100% 5 L3 5 100% 100% 1 L4 1 100% 100% 1 L5 1 100% 100% 3- S1 3- 100% Local status : paralumbal spasm +/+ and hamstring tighness +/+, no tender point. LBP caused by HNP L2L3; L3-L4; L4-L5; L5-S1 D/S (post posterior stabilization 3rd month) + TB Paru PTx :- Active breathing exc -ES at muscles with MMT < 3 -AAROM exc ankle D/S (dorsoflexor & extensor big toe) -sensoric reeducation -knee to chest exc -SLR exc -endurance exc - strengthening exc trunk extensor & flexor (isometric) & LE with MMT > 3 -flexibility trunk exc PMx: vas, MMT, sensory PEx:-proper back mechanic - use LS corset and dorsal spring when activity

From DOT (pulmonary) outpatient clinic: 3rd month OAT kategori 1 4-9-12 -No Pain at lowback 100% 5 L2 5 100% -Both of legs feel hot (like 100% 5 L3 5 100% spicy) and weak 100% 1 L4 1 100% -Can ride bycicle w/o 100% 1 L5 1 100% dorsal spring 100% 3- S1 3- 100% Local status : paralumbal spasm -/and hamstring tighness -/-, no tender point. Steppage gait. LBP caused by HNP L2L3; L3-L4; L4-L5; L5-S1 D/S (post posterior stabilization 4th month) + TB Paru PTx :- Active breathing exc -ES at muscles with MMT < 3 -AAROM exc ankle D/S (dorsoflexor & extensor big toe) -sensoric reeducation -knee to chest exc -SLR exc -endurance exc - strengthening exc trunk extensor & flexor (isometric) & LE with MMT > 3 PMx: vas, MMT, sensory PEx:-proper back mechanic

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- use LS corset and dorsal spring when activity From DOT (pulmonary) outpatient clinic: 4th month OAT kategori 1 3-10-12 -No Pain at lowback -Both of legs feel hot (like spicy) and weak -Can ride bycicle w/o dorsal spring -Get OAT for 5 months 100% 5 L2 5 100% 100% 5 L3 5 100% 100% 1 L4 1 100% 100% 1 L5 1 100% 100% 3- S1 3- 100% Local status : paralumbal spasm -/and hamstring tighness -/-, no tender point. Steppage gait LBP caused by HNP L2L3; L3-L4; L4-L5; L5-S1 D/S (post posterior stabilization 5th month) + TB Paru PTx :- Active breathing exc -ES at muscles with MMT < 3 -AAROM exc ankle D/S (dorsoflexor & extensor big toe) -sensoric reeducation -knee to chest exc -SLR exc -endurance exc - strengthening exc trunk extensor & flexor (isometric) & LE with MMT > 3 PMx: vas, MMT, sensory PEx:-proper back mechanic - use LS corset and dorsal spring when activity From DOT (pulmonary) outpatient clinic: 5th month OAT kategori 1

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SUMMARY

It has been reported a patient 58 y.o, male referred from neurologic ward with suspicious HNP. He has felt weakness since 1 year ago, first his left leg felt tingling and like burning from foot until inguinal fold and 2 months after that became weakness and had to lift his leg higher to make stepping. Four months ago, his right leg also felt tingling and burning from foot until knee and became weakness. Patient also felt pain at the lower back since 2 years ago. Pain is a sharp pain, radiating to both of legs, no tingling, no numbness. The pain increased when he changed position form sitting to standing, coughing, and sneezing. Patient still can walk but need helping because both of legs were felt heavy. He went to GP, and got medicine, pain just decreased for a while. Micturition and defecation are continence. Now, he cant work because he is difficult to walk and cant ride bicycle. And for living, covered by his children. History of trauma when 42 years ago (terjatuh dari kerbau), slight scoliosis.Smoking since 15 years old (1/2 pak a day). No history of chronic coughing and contact with TB patient, diabetes mellitus, hypertension. From initial physical examination was found independent ambulation with steppage gait, weakness and sensory changing due to myotome and dermatome L4-L5S1, pain at low back area (vas=6) with paralumbal muscles spasm and hamstring tightness.Low back manuver : SLR, siccard and bragard +/+. From EMG-NCV we got axonal neuropathy peroneal nerve D/S (S>D) and nerve root irritation L5-S1 D/S with axonal degeneration. Denervation sign at m. Tibialis ant. D/S. We assess with LBP caused
by HNP L2-L3; L3-L4; L4-L5; L5-S1 D/S.

For initial treatment, he was given elctrical stimulation on dorsoflexors ankle and extensors big toe D/S. AAROM exc ankle D/S (dorsalflexor & extensor big toe), proper back mechanic, sensoric reeducation, knee to chest exc, SLR exc, endurance & strengthening exc trunk (isometric) extensor & flexor, use LS corset and dorsal spring when activity. Now he has no pain at lowback and can ride bycicle w/o dorsal spring.

Shoulder Disarticulation

Shoulder Disarticulation