8/13/2019 Spondilitis Tuberkulosis ucha

1/28

TUBERCULOUS SPONDYLITIS

Case

8/13/2019 Spondilitis Tuberkulosis ucha

2/28

Identity

Name : Mr. B

Gender : Man

Age : 58 years Occupation : Farmer

Address : Kijang Jaya, kampar

MR Number : 827925

came to AA Hospital on 30 Sept 2013

Anamnesis autoanamnesa andalloanamnesa

with patients family

8/13/2019 Spondilitis Tuberkulosis ucha

3/28

Chief Complain

Abdominal bloating since 1 month before

admitted to hospital.

8/13/2019 Spondilitis Tuberkulosis ucha

4/28

Present Illness History

The patient are referrad by Santa Maria

Hospital.

1 month before addmited to hospital patient

complained abdomen bloating. Nausea and

vomiting (-). Diarhhea (+).

1 years before addmited to hospital patient

complained weakness on the dextra andsinistra extremity inferior. Patient can not

walk. Patient also complained flatulance at all

regio abdomen. Patients went to an

alternative treatment but not cured. Nausea

8/13/2019 Spondilitis Tuberkulosis ucha

5/28

4 years before addmited to hospital,

patient complained back pain and pain atthe right leg. Pain is continous and

moderate pain.

15 years before addmited to hospitalpatient complained left leg could not be

moved. Patient went to an alternative

treatment but not cured.

Patient also complained of high fever at

night, and shivering.

8/13/2019 Spondilitis Tuberkulosis ucha

6/28

Past Illness History

Take medications regularly (-)

Long cough (-)

8/13/2019 Spondilitis Tuberkulosis ucha

7/28

Family illness history

no history same illness of familys patient

8/13/2019 Spondilitis Tuberkulosis ucha

8/28

Physical Examination

Generalized status :

Generalized condition : moderateillness

Conciousness : composmentis

Nutritional state : deficient

Vital sign

BB : 100/60 mmHg

P : 102x/minutes

RR : 22x/minutes

T : 36,90

C

8/13/2019 Spondilitis Tuberkulosis ucha

9/28

8/13/2019 Spondilitis Tuberkulosis ucha

10/28

Dextra Sinistra

Sense of

smell

Normal Normal Normal

N. I (Olfactorius )

N.II (Opticus)

Dextra Sinistra

Power of vision

Field of view

Color test

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

8/13/2019 Spondilitis Tuberkulosis ucha

11/28

Dextra Sinistra

PtosisPupil

Shaped

Size

Eye Movement

Pupil reflexDirect and

indirect

(-)round

2mm

Normal

(+)

(+)

(-)round

2mm

Normal

(+)

(+)

NormalNormal

Normal

Normal

Normal

Normal

N.III (Oculomotorius)

Dextra Sinistra Keterangan

Eye movement Normal Normal Normal

N. IV (Trokhlearis)

8/13/2019 Spondilitis Tuberkulosis ucha

12/28

Dextra Sinistra

Motoric

Sensibilitas

Cornea reflex

(+)

(+)

(+)

(+)

(+)

(+)

Normal

Normal

Normal

N. V (Trigeminus)

Dextra Sinistra

Eye Movement

Strabismus

Deviasi

(+)

(-)

(-)

(+)

(-)

(-)

Normal

Normal

Normal

N. VI (Abduscens)

8/13/2019 Spondilitis Tuberkulosis ucha

13/28

Dextra Sinistra

Tic

Motoric

Sense of taste

chvostek

(-)

(+)

(+)

(-)

(-)

(+)

(+)

(-)

Normal

Normal

Normal

Normal

N. VII (Facialis)

Dextra Sinistra

Audio (+) (+) Normal

N. VIII (Akustikus)

8/13/2019 Spondilitis Tuberkulosis ucha

14/28

Dextra Sinistra

Arcus farings

Sense of taste

Vomite reflex

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

N. IX (Glossofaringeus)

Dextra Sinistra

Arcus farings

Dysfonia

Normal

(-)

Normal

(-)

Normal

Normal

N. X (Vagus)

8/13/2019 Spondilitis Tuberkulosis ucha

15/28

Dextra Sinistra

Motoric Normal Normal Normal

N. XI (Assesorius)

Dextra Sinistra

Motoric

Trofi

Tremor

Disartri

Normal

Eutrofi

(-)

(-)

Normal

Eutrofi

(-)

(-)

Normal

Eutrofi

Normal

Normal

N. XII (Hipoglossus)

8/13/2019 Spondilitis Tuberkulosis ucha

16/28

Neurologic status

GCS : 15

Extremity superior Extremity inferior

dextra sinistra dextra sinistra

Sensoric normal normal Normal Normal

Motoric 5 5 1 1

Otonom Normal

Phisiologicreflex

+/+ (decresed)

Phatologicreflex

-/-

8/13/2019 Spondilitis Tuberkulosis ucha

17/28

Vetebrea examination

Inspection : no ulcer

Palpation : no pain

8/13/2019 Spondilitis Tuberkulosis ucha

18/28

Genitourinarius examination: normal

8/13/2019 Spondilitis Tuberkulosis ucha

19/28

Working Diagnosis

Paraplegia suspect spondylitis

8/13/2019 Spondilitis Tuberkulosis ucha

20/28

Differential diagnostic

Stroke Haemorrhagic

Medulla spinalis tumour

Metastatic cancer

8/13/2019 Spondilitis Tuberkulosis ucha

21/28

Suggested examination

Routine blood test

CRP Test

X-ray thoraks X-ray vetebra thorakolumbal AP and

lateral

MRI

8/13/2019 Spondilitis Tuberkulosis ucha

22/28

Routine Blood Test

Hb : 11,2 g/dl

Ht : 33,6% WBC : 14900/l

PLT : 445000/l

CRP : Reactive 6,8 / dll

X R th

8/13/2019 Spondilitis Tuberkulosis ucha

23/28

X-Ray thorax

8/13/2019 Spondilitis Tuberkulosis ucha

24/28

Rontgen vetebra thorakolumbal

8/13/2019 Spondilitis Tuberkulosis ucha

25/28

MRI

8/13/2019 Spondilitis Tuberkulosis ucha

26/28

8/13/2019 Spondilitis Tuberkulosis ucha

27/28

Definitive Diagnosis

Spondylitis tuberculosa with furtherdestruction stage and neurological disorders4 degrees.

8/13/2019 Spondilitis Tuberkulosis ucha

28/28

Therapy

OAT Therapy

Operative