CHAPTER I

CASE ILLUSTRATION
I.

II.

Identity
Name
Gender
Address
Religion
Ethnicity / country
Age
Occupation
Marital status
Admission date to CM Hospital
Medical record

: Mrs. T
: Female
: Pekayon, Bekasi
: Moslem
: Indonesia
: 36 years
: house wife
: married and have three children
: November 20rd, 2008
:

History
(autoanamnesis on January 14th, 2008)
Chief complaint
Back pain since three month before admission
History of present illness
Three months before admission, patient felt pain on her back, pain refer to
both limb, Pain became worse during forced defecation, patient felt that her
bent back has been worsening. Pain became less at supine position, patient
was feeling weakness in her limbs, especially area bellow umbilicus.
numbness of the limbs was felt too.
One months before admission, patient felt that there was a lump on her back,
and her back was not straight in line. Difficult to move her legs. couldnt
stand for a long duration and needed help for walking activities. Paraesthesia
in both legs. chronic cough (-),decreased body weight (+), Fever(-).Defecation
and micturation in normal condition.
History of past illness
Five months before admission patient had a cesar operation for third child.
Previous history of trauma at spine and thoracal region denied.
History of family illness
Theres history of TBC of her children. Both of her children had a TBC.
History of occupation, social and behavior
Patient is a house wife.

III.

Physical examination
Level of illness
: mild illness
Awareness
: compos mentis
Vital signs
Blood pressure
: 120/70 mmHg
Pulse rate
: 96 x per minute
Respiration rate
: 18 x per minute
Temperature
: 36,7 oC
General sign
Head
Hair
Eye
Ear
Nose
Throat
Neck
Thorax
Lung

Heart
Abdomen
Back
Anal
Extremity

: normocephal, deformity (-)

: black, not fragile
: pale conjunctiva -/-, icteric sclera -/-, ptosis -/: deformity (-),
: middle nasal septum, nose dilating respiration (-)
: middle placed uvula, pharynx arc normal,
pharynx not hyperemic, tonsil T1-T1
: Unpalpable lymph region.

: Thoracal inspection symmetrical static and dynamic

Fremitus palpation equally symmetric
Percussion dull in lower area of the right lung
Breath sound vesicular in both area of lung
No additional respiratory sound
: heart sound I II normal, no additional heart sound
: flat, supple, tenderness (-), liver and spleen not
palpable,peristaltic sound (+) normal
: gibus (+) in area thoracal spine 11th-12th
: not examined
: warm acral, CRT test < 2

Local sign. Thoracolumbal region

Look
Kyphotic deformity (+), Gibus (+), in area thoracal spine 11th-12th
Feel
Tenderness (+)

Move
Motoric

Sensoric
Autonomic
Reflex

Hip flexor
Knee extention
Dorsoflexion
Great toe extention

4/4
4/4
4/4
4/4

within normal borderline

incontinensia, retensio uri and alvi negative
physiologic +/+
pathologic
-/-

Neurological Examination
Level of awareness and GCS
Composmentis. GCS 15. pupil isochors, diameter 3 mm/3 mm.
Direct pupil reflex +/+, indirect pupil reflex +/+,
Meningeal sign
Neck stiffness (-)
Kernig
>135o />135o
Lasague
>70o /> 70o
Brudzinski I & II (-)
Cranial nerves
Cranial nerves within normal borderline
Motoric
Paraparesis

5555 5555
4444 4444
Physiologic reflex
+
+
Pathologic reflex
+
+
Sensibility
Hipo-estesi thoracal XI dermatom to distal area bilaterally
Proprioseptive

+ +
- -

Cerebellar function
Disdiadochochinesia (-)
Nystagmus (-)
Autonomic nerve
Incontinensia uri and alvi (-)

IV.

Additional examination
Laboratory examination
Haematology (20/11/2008)

ESR : 20
Hb: 12,5 g/dL
Ht : 37,5 %
MCV : 60.7 fL
MCH : 19.7 pg
Leukocyte : 9500
Thrombocyte: 441,000/uL
Diff. count: 0/
1.1/61/35.2/3.2
SGOT/SGPT : 14/ 20

2 January : AFB sputum 3x show results negative

Bone Scan November 27th 2008 show destruction and compression fracture of
11-12th thoracal.
Radiologic examination (November 20th, 2008)
Conclusion: destruction and compression fracture of 11-12 th .
Interpretation: spondylitis
V.

Summary
Woman, 36 years, with chief complaint had a back pain, patient felt pain on
her back, pain refer to both limb, Pain became worse saat mengedan, patient
felt that her back was getting worse which made her bent, pain became less at
supine position, patient was feeling weakness in her limbs, especially area
bellow umbilicus. patient felt that there was a lump on her back, and her back
was not straight in line. Difficult to move her legs. couldnt stand for a long
duration and needed help for walking activities. Paraesthesia in both legs.
chronic cough (-),decreased body weight (+), Fever (-).Defecation and
micturation in normal condition.History of trauma at spine an thoracal region
(-), Pasient had a ccfesar operation three months efore admission. Theres
history of TBC of her children. Both of her children had a TBC. Physical
examination on vital sign and generally is in normal range. Local sign found
that there are kyphotic deformity (+), Gibus (+), Tenderness (+) and muscle
limbs strength slightly decrease.Patient had paraparese and hipesthesia in both
limb. Additional examination showed increase in ESR, AFB sputum 3x show
results negative.Radiology esamination showed destruction of 10-11th thoracic
vertebral. Bone Scan November 27th 2008 show destruction and compression
fracture of 11-12th thoracal.

VI.

Diagnosis
Spondylitis tuberculosis at Th11th 12th accompanied by compression fracture

VII.

Treatment
Diagnosis plan
- thoracolumbal MRI
- Posteroanterior thoracal roentgenogram
Theurapeutic plan
- Head elevation 35
- Isoniazid 1x 300 mg
- Ripamficin 1x 450 mg
- Pirazinamyde 3 x 500 mg
- Ethambutol 3 x 250 mg
- Vit B 3x1g
- Ketorolac 2 x 50 mg
- Dexamethasone 10 mg, continued 4 x 5 mg
- Laxadine 3 x C I
- Ranitidine 2 x 1 amp
- Methylcobalt 3x500mg
Surgical plan

VIII.

Prognosis
Quo ad vitam
: bonam
Quo ad functionam : bonam
Quo ad sanactionam : bonam