MR_Low Back Pain ec HNP facet joint_STE.pdf

MORING REPORT

1. 1
LBP ec HNP CV L3-L4 Grade I, CV L4-L5 Grade II, Facet
Joint Effusion L3-L4 Dextra, L4-L5 Bilateral + Overweight
PPDS : Stephanie
Supervisor : Dr. dr. Nuralam Sam, Sp.KFR, MS(K), FEMG, AIFO-K
Morning Report

2. PATIENT IDENTITY
2
Name : Mrs. M
Age : 46 years old
Gender : Female
Address : Makassar
Religion : Christian
Marital Status : Married
Occupation : House Wife
Date of Examination: July 17
th
2024
Referred from Neurologic OPC with Low Back Pain ec suspect HNP

3. HISTORY TAKING
Chief Complaint:
Nyeri pada area punggung bawah
History of Present Illness:
•Pain in the lower back experienced since 2 years ago, got worsened since 1 week ago after she slipped and fell
from chair with sitting position
•Pain described as dull and pulling sensation
•There is a radiating pain to the left knee
•There is a tingling sensations in the left knee.
•Pain is persistent, worsening when standing and sitting for >30 minutes, changing position from sit to stand (NRS
8/10).
•Pain reduced when patient lying supine and take analgetics (NRS 6/10).
•There is no pain when coughing or sneezing.
•Defecation and urination can be felt and held.
3

4. HISTORY TAKING
History of Past Illness
•There is a history of trauma before. The patient slipped and fell
from chair in sitting position one week ago.
•There is no similar complaint before
Comorbidities and Family History:
•History of DM (-), HT (-) , CVD (-)
•History of current fever (-), significant weight loss (-), malignancy
(-)
History of Medication and Rehabilitation:
•He got medication from Neurologist:
oEperison50mg2x/day
oMeloxicam15mg2x/day
oPregabaline75mg1x/day
oRanitidine1tab2x/day
oMecobalamin500mg1x/day
•There is no history of rehabilitation program before
4
History of functional ability, vocational and avocational:
•Patient has no issue with feeding, bathing, toileting, grooming and dressing
•The patient is a house wife. Patient has a maid who do house chores.
•The patient likes to cooking and running. She feels pain while cooking with
standing position for a long time and running, so she rarely does her hobby
History of psycho-sosio-economic:
•The patient lives with her husband in two-floor house in Makassar and her
bedroom at the second floor. Currently, she has difficulty when climbing stairs
because of pain at her lower back
•The patient likes to join arisan but now cannot join because of pain
•Toilet is sitting toilet. She has no problem toileting.
•Her health insurance was covered by BPJS
•Her life expenses is covered by her husband (AURI)
Hopes and Expectations:
She can do activities without pain

5. 5
Consciousness Compos Mentis (GCS 15)
Vital Sign BP:138/87mmHg
Pulse:74x/minute
RR:16x/minute
Temp:36,6°C
SpO2:99%
NRS:8/10 (standing and sitting > 30 minutes, changing position from sit
to stand)
Nutritational StatusBodyWeight: 60Kg
BodyHeight:155 Cm
BMI :24,9 kg/m
2
(Overweight)
Head & Neck Conjunctiva anemis (-) icterus (-) cyanosis (-)
Thorax Simetris, no retraction
Cor : S1-S2 sound regular
Pulmo: Vesicular, No Ronchi or wheezing
Abdomen normal peristaltic sound, liver and spleen unpalpable
Extremities Warmth acral, pitting edema (-), CRT < 2”, TC: 40/40, CC: 35/35
Skin/Integument Scar (-), Redness (-)
PHYSICAL EXAMINATION

6. •Look:
Redness (-), Discoloration (-), Edema (-), Deformity (-), Scar (-)
•Feel:
Warmth (-), Stepoff(-), Tenderness (+) a/r CV L5-S1
Move:
(MMT and ROM as listed)
•Special Test : Straight Leg Test (SLR) -/+, Bragard -/-, Sicard -/-,
Patrick -/-, Contrapatrick -/-, Sacral Thrust -/-, Thomas -/-,
Hamstring tightness +/+, Ely test -/+, Kemp +/+
Status Localis: Lower back
LOCAL STATUS
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7. ROM MMT
Movement Right Left Movement Right Left
Neck
Flexion 0 – 40 Flexion 5
Extension 0 – 50 Extension 5
Lateral Flexion0 – 45 0 – 45 Lateral Flexion5 5
Rotation 0 – 70 0 – 70 Rotation 5 5
Trunk
Flexion 0 – 80 Flexion 5
Extension 0 – 20 Extension 5
Lateral Flexion0 – 30 0 – 30 Lateral Flexion5 5
LE Myotomal MMT Right Left
L2 (Hipflexion) 5 5
L3 (Kneeextension) 5 5
L4 (Ankledorsoflexion) 5 5
L5 (Big toe extension) 5 5
S1 (Ankleplantarflexion) 5 5

8. 8
Propioceptive and touch function :
Proprioceptive : Exteroceptive :
Joint Motion : adequate
Joint Position : adequate
Sensory functions and pain :
Pain at the lower back (NRS 8/10)
Balance functions:
•Static and dynamic sitting balance adequate
•Static and dynamic standing balance adequate
Coordination Functions :
•Finger to Nose : adequate
•Disadokinesia : adequate
•Heel to shin : adequate
Dermatome Right Left
L2 100% 100%
L3 100% 100%
L4 100% 100%
L5 100% 80%
S1 100% 80%
Reflexes
Physiologi Reflex: BPR +2/+2 TPR +2/+2 KPR +2/+2 APR +2/+2
Physiologi Reflex: Hoffmen, tromner -/-, Babinsky -/-

9. POSTURE
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Anterior :
Head in the midline
Symmetrical shoulder
Symmetrical Body Arm Distance
No Pelvic Obliquity
No knee varus
No Rotation of Tibia/ Ankle
No out /in-toeing of the foot
Lateral Side :
No Forward head/Protruded Head
No rounded shoulder
Cervical normolordotic
Thoracal normokifotic
Normordotic lumbal
No Pelvic Tilt
No genu recurvatum
No inversion/ eversion of ankle
Posterior :
Head in the midline
Symmetrical shoulder
Symmetrical Body Arm Distance
No Pelvic Obliquity
No Knee Varus
No Rotation of Tibia/ Ankle
No valgus/Varus on both ankle

10. GAIT FUNCTION
10

11. 11
SELF CARE
Barthel index
20/20
(Independent)
ACTIVITY AND PARTICIPATION

12. Supporting Examination (12/7/2024)
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13. MEDICAL DIAGNOSIS
HNP CV L3-L4 Grade I, CV L4-L5 Grade II, Facet
Joint Effusion L3-L4 Dextra, L4-L5 Bilateral +
Overweight
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14. Health Condition
HNP CV L3-L4 Grade I, CV L4-L5 Grade II, Facet Joint Effusion L3-
L4 Dextra, L4-L5 Bilateral + Overweight
Body Functions and Structures
•B28013 pain in the back: pain at the lower back (NRS 8/10)
•B7800 Sensation of muscle stiffness : Hamstring bilateral
•S7600 structure of vertebral column : HNP CV L3-L4 Grade I,
CV L4-L5 Grade II, Facet Joint Effusion L3-L4 Dextra, L4-L5
Bilateral
•B780 Sensations related to movement and muscle functions :
decreased sensation
•B530 Weight maintenance function : overweight
Environmental Factors
Facilitator:
•E310 Immediate family: family is supportive of the patient condition and wishes
the patient to get better
•E580 Health services, system and policies: The patient’s treatment is paid by
BPJS
Barrier:
•Bedroom at second floor
Personal Factors
Facilitator :
Self motivation
Barrier :
Overweight
Activity
•D410 Changing basic body
position: Pain when sit to stand
•D415 Maintaining body position:
Pain when standing and sitting for
>30 minutes
•D4551 Climbing : Climbing stairs
•D630 Preparing meals : Cooking
FUNCTIONAL
DIAGNOSIS
Participation
D910 Community life : pain
while join arisan
D920 Recreation and Leisure :
running

15. REHABILITATION PROBLEM AND GOALS
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Short term goals
•Reduced pain
•Reduced muscle tightness
•Improved sensory function
Intermediate goals
•Improved sensory function
•Decreased BMI
Long term goals
•ADL and Participation without
pain
•Maintained BMI
Rehabilitation Problems
1.Pain in the lower back and left
buttock
2.Bilateral Hamstring tightness
3.Decreased sensation
4.Daily activity disturbance → Pain
when forward standing and sitting
for >30 minutes, changing from sit to
stand, climbing stairs, cooking
5.Participation restriction → Pain when
do hobby (cooking and running)
and community (arisan)
6.Overweight

16. PLAN →
Planning Diagnose:
Planning Threapy: continue medication from
neurology clinic
Modalitas:
•TENS at regio tender point lumbal with continuous
biphasic pulsatile 100 Hz with duration pulse 80 μs,
intensity as patient tolerated, 30 minutes, 2x/week
•SWD at regio tender point lumbal, 27,12 mHz, intensity
as heat tolerated, 15 minutes, 3x/week
Therapeutic Exercise:
•Core strengthening exercise, 3-5x/week, hold 10-30
seconds, 2–4 sets and the progression is as patient
tolerated
•Stretching exercise ar hamstring bilateral, 3-5x/week,
hold 10- 30 seconds, 2–4 sets and the progression is as
patient tolerated.
•Aerobic exercise 3x/week, intensity 40-60% HRR,
duration 30-60 minutes, low impact (static cycle)
OT : Sensory Reeducation, from coarse to soft texture,
3x/week
OP : LSO Corset
Planning Monitoring
Clinical sign and symptoms (NRS)
Planning:
•Explain to the patient about her prognosis, risk
factor, complication, and our goal &
rehabilitation program
•Explain to the patient to be compliant with our
rehabilitation program
•Emphasize to the patient about the importance
of proper body mechanics and back protection
•Home Exercise (SLR exercise)
•Set Reminders to take breaks and get body
stretch in 20 min (avoid sitting continuously for >30
minutes)
•Consult to nutritionist and encourage the patient
to manage her diet and get a normal BMI

17. THANK YOU
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