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    Catatan Kemajuan Tan Ggal Keadaan Klinis Program Terapi/tindakan

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    dea_p27
    1. The patient presented with low back pain radiating down the left leg. Examinations showed reduced range of motion and tenderness over the lumbar spine. 2. Diagnostic tests including x-rays and MRI revealed spondylosis at L4-L5. Treatment included analgesics, anti-inflammatory medications, muscle relaxants, and physiotherapy. 3. Over the course of 6 days, the patient's pain levels decreased and mobility improved. They were discharged with a home exercise program including ultrasound over the piriformis muscle and TENS along the left sciatic nerve. The final assessment was low back pain suspected to be due to herniated nucleus pulposus.

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    Catatan Kemajuan Tan Ggal Keadaan Klinis Program Terapi/tindakan

    Uploaded by

    dea_p27
    15 views7 pages
    1. The patient presented with low back pain radiating down the left leg. Examinations showed reduced range of motion and tenderness over the lumbar spine. 2. Diagnostic tests including x-rays and MRI revealed spondylosis at L4-L5. Treatment included analgesics, anti-inflammatory medications, muscle relaxants, and physiotherapy. 3. Over the course of 6 days, the patient's pain levels decreased and mobility improved. They were discharged with a home exercise program including ultrasound over the piriformis muscle and TENS along the left sciatic nerve. The final assessment was low back pain suspected to be due to herniated nucleus pulposus.

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    follow up

    Original Title

    follow up

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    1. The patient presented with low back pain radiating down the left leg. Examinations showed reduced range of motion and tenderness over the lumbar spine. 2. Diagnostic tests including x-rays and MRI revealed spondylosis at L4-L5. Treatment included analgesics, anti-inflammatory medications, muscle relaxants, and physiotherapy. 3. Over the course of 6 days, the patient's pain levels decreased and mobility improved. They were discharged with a home exercise program including ultrasound over the piriformis muscle and TENS along the left sciatic nerve. The final assessment was low back pain suspected to be due to herniated nucleus pulposus.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    15 views7 pages

    Catatan Kemajuan Tan Ggal Keadaan Klinis Program Terapi/tindakan

    Uploaded by

    dea_p27
    1. The patient presented with low back pain radiating down the left leg. Examinations showed reduced range of motion and tenderness over the lumbar spine. 2. Diagnostic tests including x-rays and MRI revealed spondylosis at L4-L5. Treatment included analgesics, anti-inflammatory medications, muscle relaxants, and physiotherapy. 3. Over the course of 6 days, the patient's pain levels decreased and mobility improved. They were discharged with a home exercise program including ultrasound over the piriformis muscle and TENS along the left sciatic nerve. The final assessment was low back pain suspected to be due to herniated nucleus pulposus.

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    CATATAN KEMAJUAN

    Tan

    Keadaan klinis

    Program

    ggal

    terapi/tindakan

    2/3/

    Keluhan: nyeri punggung sampai tungkai kiri.

    - Infus RL 20

    2014

    KU: sadar, kesakitan (+), nafas spontan (+)

    tetes/menit
    - Inj. Ketorolac 2x1

    TV: TD: 130/80 mmHg

    amp (bila nyeri)


    - Inj. Ranitidin 2 x 1

    Nadi: 82 x, reguler, isi dan tegangan cukup

    amp
    -Meloxicam 1x1 tab
    -Sohobion 1x1 tab

    RR: 22x/menit
    t: 36,50C axilla

    Evaluasi KU, TV,

    Status Internus : dbn

    nyeri punggung
    Tunggu hasil rontgen.

    Status Neurologis :
    Pemeriksaan
    Gerakan
    Kekuatan

    Superior
    Dekstra
    Sinistra
    (+)
    (+)

    Inferior
    Dekstra
    Sinistra
    (+)
    (+)

    Otot
    Tonus Otot

    5/5/5/5

    5/5/5/5

    5/5/5/5

    5/5/5/5

    normotonus

    normotonus

    normotonus

    normotonus

    Atrofi Otot

    (-)

    (-)

    (-)

    (-)

    (+)

    (+)

    (+)

    (+)

    (-)

    (-)

    (-)

    (-)

    (+)

    (+)

    (+)

    (+)

    Refleks
    Fisiologis
    Refleks
    Patologis
    Sensibilitas

    TEST

    DEKSTRA

    SINISTRA

    Laseque

    Kernique

    Sicard

    (-)

    (-)

    Bragard
    Patrick
    Kontra

    (-)
    (-)

    (-)
    (-)

    (-)

    (+)

    Naffziger

    (+)

    (+)

    Valsava

    (+)

    Patrick

    Pemeriksaan Darah
    Pemeriksaa
    n

    Hb

    Hasil

    Nilai normal

    12,9 gr%

    1216 gr%

    Hematokrit

    42,3 %

    3244 %

    Leukosit

    7.020 /mmk

    4.000

    Trombosit

    224.000/mm

    10.000/mm3
    150

    LED 1 jam

    k
    13 mm/jam

    400rb/mm3
    0 -15 mm/jam

    LED 2 jam

    28 mm/jam

    Diff count
    Eosinophyl

    5%

    1-13 %

    Basophyl

    0%

    0-1 %

    Stab

    0%

    2-6 %

    Segmen

    52 %

    50-70 %

    Lymphocyte

    40 %

    20-40 %

    Monocyte

    2-6 %

    Assesment :
    -LBP
    DD/ suspek HNP
    3/3/
    2014

    Keluhan: Keluhan: nyeri punggung sampai tungkai kiri.

    - Infus RL 20

    KU: sadar, kesakitan (+), nafas spontan (+).

    tetes/menit
    - Inj. Dexametason
    3x1 amp
    -Na diclofenac 2x1tab
    -Ranitidin 3x1 tab
    - Diazepam 2x1 tab

    TV: TD: 130/80 mmHg


    Nadi: 84 x, reguler, isi dan tegangan cukup
    RR: 22x/menit

    Evaluasi KU, TV,

    t: 36,50C axilla

    nyeri punggung

    Status Internus : dbn


    Status Neurologis :
    Pemeriksaan
    Gerakan
    Kekuatan
    Otot
    Tonus Otot

    Superior
    Dekstra
    Sinistra
    (+)
    (+)

    Inferior
    Dekstra
    Sinistra
    (+)
    (+)

    5/5/5/5

    5/5/5/5

    5/5/5/5

    5/5/5/5

    normotonus

    normotonus

    normotonus

    normotonus

    Atrofi Otot
    Refleks
    Fisiologis
    Refleks
    Patologis
    Sensibilitas

    (-)

    (-)

    (-)

    (-)

    (+)

    (+)

    (+)

    (+)

    (-)

    (-)

    (-)

    (-)

    (+)

    (+)

    (+)

    (+)

    TEST

    DEKSTRA

    SINISTRA

    Laseque

    Kernique

    Sicard

    (-)

    (-)

    Bragard
    Patrick

    (-)
    (-)

    (-)
    (-)

    Kontra

    (-)

    (+)

    Patrick
    Naffziger

    (+)

    (+)

    Valsava

    (+)

    Foto Vertebrae

    Lumbosacral Ap/Lat

    Osteofit (+)

    Permukaan inferior dan superior VL4-5

    Kesan : Spondyloartrosis VL4-5


    Assesment :
    -LBP
    DD/ suspek HNP

    4/3/
    2014

    Keluhan: nyeri punggung sampai tungkai kiri berkurang.

    - Infus RL 20

    KU: sadar, kesakitan (+), nafas spontan (+).

    tetes/menit
    - Inj. Dexametason
    3x1 amp
    -Na diclofenac 2x1tab
    -Ranitidin 3x1 tab
    - Diazepam 2x1 tab

    TV: TD: 120/70 mmHg


    Nadi: 82 x, reguler, isi dan tegangan cukup
    RR: 22x/menit

    Evaluasi KU, TV,

    t: 37,00C axilla

    nyeri punggung

    Status Internus : dbn


    Status Neurologis :
    Pemeriksaan
    Gerakan
    Kekuatan

    Superior
    Dekstra
    Sinistra
    (+)
    (+)

    Inferior
    Dekstra
    Sinistra
    (+)
    (+)

    Otot
    Tonus Otot

    5/5/5/5

    5/5/5/5

    5/5/5/5

    5/5/5/5

    normotonus

    normotonus

    normotonus

    normotonus

    Atrofi Otot

    (-)

    (-)

    (-)

    (-)

    (+)

    (+)

    (+)

    (+)

    (-)

    (-)

    (-)

    (-)

    (+)

    (+)

    (+)

    (+)

    Refleks
    Fisiologis
    Refleks
    Patologis
    Sensibilitas

    TEST

    DEKSTRA

    SINISTRA

    Laseque

    Kernique

    Sicard

    (-)

    (-)

    Bragard
    Patrick
    Kontra

    (-)
    (-)

    (-)
    (-)

    (-)

    (+)

    Naffziger

    (+)

    (+)

    Valsava

    (+)

    Patrick

    Assesment :
    -LBP
    DD/ suspek HNP

    5/3/
    2014

    Keluhan: nyeri punggung sampai tungkai kiri berkurang.

    - Infus RL 20

    KU: sadar, kesakitan (+), nafas spontan (+).

    tetes/menit
    - Inj. Dexametason
    3x1 amp
    -Na diclofenac 2x1tab
    -Ranitidin 3x1 tab
    - Diazepam 2x1 tab

    TV: TD: 130/80 mmHg


    Nadi: 82x/ menit, reguler, isi dan tegangan cukup
    RR: 22x/menit

    Evaluasi KU, TV,

    t: 36,80C axilla

    nyeri punggung
    Konsul RM

    Status Internus : dbn


    Status Neurologis :
    Pemeriksaan
    Gerakan
    Kekuatan

    Superior
    Dekstra
    Sinistra
    (+)
    (+)

    Inferior
    Dekstra
    Sinistra
    (+)
    (+)

    Otot
    Tonus Otot

    5/5/5/5

    5/5/5/5

    5/5/5/5

    5/5/5/5

    normotonus

    normotonus

    normotonus

    normotonus

    Atrofi Otot

    (-)

    (-)

    (-)

    (-)

    (+)

    (+)

    (+)

    (+)

    (-)

    (-)

    (-)

    (-)

    (+)

    (+)

    (+)

    (+)

    Refleks
    Fisiologis
    Refleks
    Patologis
    Sensibilitas

    TEST

    DEKSTRA

    SINISTRA

    Laseque

    Kernique

    Sicard

    (-)

    (-)

    Bragard
    Patrick
    Kontra

    (-)
    (-)

    (-)
    (-)

    (-)

    (+)

    Naffziger

    (+)

    (+)

    Valsava

    (+)

    Patrick

    Assesment :
    -LBP
    DD/ suspek HNP

    6/3/
    2014

    Keluhan: nyeri punggung sampai tungkai kiri berkurang.

    Aff infus.

    KU: sadar, kesakitan (+), nafas spontan (+).

    Metil prednisolon

    3x1 tab
    Paracetanol 3x1tab
    Na diclofenac

    2x1tab
    Ranitidin 3x1tab
    Diazepam 2x1tab

    TV: TD: 120/80 mmHg


    Nadi: 84x/ menit, reguler, isi dan tegangan cukup
    RR: 22x/menit
    t: 37,40C axilla
    Status Internus : dbn

    Evaluasi KU, TV,

    Status Neurologis :

    nyeri punggung
    Boleh Pulang

    Pemeriksaan
    Gerakan
    Kekuatan

    Superior
    Dekstra
    Sinistra
    (+)
    (+)

    Inferior
    Dekstra
    Sinistra
    (+)
    (+)

    Otot
    Tonus Otot

    5/5/5/5

    5/5/5/5

    5/5/5/5

    5/5/5/5

    normotonus

    normotonus

    normotonus

    normotonus

    Atrofi Otot

    (-)

    (-)

    (-)

    (-)

    (+)

    (+)

    (+)

    (+)

    (-)

    (-)

    (-)

    (-)

    (+)

    (+)

    (+)

    (+)

    Refleks
    Fisiologis
    Refleks
    Patologis
    Sensibilitas

    TEST

    DEKSTRA

    SINISTRA

    Laseque

    Kernique

    Sicard

    (-)

    (-)

    Bragard
    Patrick
    Kontra

    (-)
    (-)

    (-)
    (-)

    (-)

    (+)

    Naffziger

    (+)

    (+)

    Valsava

    (+)

    Patrick

    Hasil konsul RM :
    Program : US piriformis sinistra (di titik nyeri)
    TENS sepanjang n. ischiadicus sinistra
    Assesment :

    -LBP
    DD/ suspek HNP

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