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TUBERCULOUS SPONDYLITIS
Case
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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
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Chief Complain
Abdominal bloating since 1 month before
admitted to hospital.
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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
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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.
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Past Illness History
Take medications regularly (-)
Long cough (-)
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Family illness history
no history same illness of familys patient
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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
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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
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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)
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Dextra Sinistra
Motoric
Sensibilitas
Cornea reflex
(+)
(+)
(+)
(+)
(+)
(+)
Normal
Normal
Normal
N. V (Trigeminus)
Dextra Sinistra
Eye Movement
Strabismus
Deviasi
(+)
(-)
(-)
(+)
(-)
(-)
Normal
Normal
Normal
N. VI (Abduscens)
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Dextra Sinistra
Tic
Motoric
Sense of taste
chvostek
(-)
(+)
(+)
(-)
(-)
(+)
(+)
(-)
Normal
Normal
Normal
Normal
N. VII (Facialis)
Dextra Sinistra
Audio (+) (+) Normal
N. VIII (Akustikus)
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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)
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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)
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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
-/-
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Vetebrea examination
Inspection : no ulcer
Palpation : no pain
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Genitourinarius examination: normal
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Working Diagnosis
Paraplegia suspect spondylitis
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Differential diagnostic
Stroke Haemorrhagic
Medulla spinalis tumour
Metastatic cancer
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Suggested examination
Routine blood test
CRP Test
X-ray thoraks X-ray vetebra thorakolumbal AP and
lateral
MRI
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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
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X-Ray thorax
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Rontgen vetebra thorakolumbal
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MRI
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Definitive Diagnosis
Spondylitis tuberculosa with furtherdestruction stage and neurological disorders4 degrees.
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Therapy
OAT Therapy
Operative