Case

TUBERCULOUS SPONDYLITIS

Identity

: Mr. B : Man : 58 years : Farmer : Kijang Jaya, kampar : 827925 came to AA Hospital on 30 Sept 2013 Anamnesis autoanamnesa and alloanamnesa with patients family

Name Gender Age Occupation Address MR Number

Chief Complain
Abdominal bloating since 1 month before

admitted to hospital.

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 and sinistra extremity inferior. Patient can not walk. Patient also complained flatulance at all regio abdomen. Patients went to an alternative treatment but not cured. Nausea

 4 years before addmited to hospital,

patient complained back pain and pain at the right leg. Pain is continous and moderate pain. 15 years before addmited to hospital patient 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.

Past Illness History

Take medications regularly (-) Long cough (-)

Family illness history no history same illness of familys patient

Physical Examination
Generalized status : Generalized condition illness Conciousness Nutritional state Vital sign

: moderate : composmentis : deficient

BB P RR T

: 100/60 mmHg : 102x/minutes : 22x/minutes : 36,90C

Physical Examination
Head and Neck

: conjuntival was anemia (+/+) sclera was not icteric (-/-) mucosa of mouth and lips dry Chest : normal Abdomen : normal Extremity : warm, CRT < 2 seconds, edema (-)

N. I (Olfactorius ) Dextra Sense of Normal Sinistra Normal Normal

smell
N.II (Opticus)
Dextra Sinistra

Power of vision
Field of view Color test

Normal Normal Normal

Normal Normal Normal Normal Normal Normal

N.III (Oculomotorius)
Dextra Ptosis Pupil Shaped Size (-) round 2mm Normal Sinistra (-) round 2mm Normal Normal Normal Normal Normal

Eye Movement
Pupil reflex Direct and indirect

(+)
(+)

(+)
(+)

Normal
Normal

N. IV (Trokhlearis)
Dextra
Eye movement Normal

Sinistra
Normal

Keterangan
Normal

N. V (Trigeminus)
Dextra
Motoric Sensibilitas Cornea reflex (+) (+) (+)

Sinistra
(+) (+) (+) Normal Normal Normal

N. VI (Abduscens)
Dextra Eye Movement Strabismus Deviasi (+) (-) (-) Sinistra (+) (-) (-) Normal Normal Normal

N. VII (Facialis)
Dextra
Tic Motoric Sense of taste chvostek (-) (+) (+) (-)

Sinistra
(-) (+) (+) (-) Normal Normal Normal Normal

N. VIII (Akustikus)
Dextra Audio (+) Sinistra (+) Normal

N. IX (Glossofaringeus)
Dextra Arcus farings Sense of taste Vomite reflex Normal Normal Normal Sinistra Normal Normal Normal Normal Normal Normal

N. X (Vagus)
Dextra Arcus farings Dysfonia Normal (-) Sinistra Normal (-) Normal Normal

N. XI (Assesorius)
Dextra Motoric Normal Sinistra Normal Normal

N. XII (Hipoglossus)

Dextra Motoric Trofi Tremor Disartri Normal Eutrofi (-) (-)

Sinistra Normal Eutrofi (-) (-) Normal Eutrofi Normal Normal

 Neurologic status GCS : 15

Extremity superior dextra Sensoric Motoric Otonom Phisiologic reflex Phatologic reflex normal 5 Normal +/+ (decresed) -/sinistra normal 5 Extremity inferior dextra Normal 1 sinistra Normal 1

 Vetebrea examination

Inspection : no ulcer Palpation : no pain

 Genitourinarius examination: normal

Working Diagnosis
Paraplegia suspect spondylitis

Differential diagnostic
Stroke Haemorrhagic Medulla spinalis tumour Metastatic cancer

Suggested examination
Routine blood test CRP Test X-ray thoraks X-ray vetebra thorakolumbal AP and

lateral MRI

 Routine Blood Test Hb Ht WBC PLT CRP

: 11,2 g/dl : 33,6% : 14900/l : 445000/l : Reactive 6,8l / dl

 X-Ray thorax

 Rontgen vetebra thorakolumbal

 MRI

Definitive Diagnosis
Spondylitis tuberculosa with further

destruction stage and neurological disorders 4 degrees.

Therapy
OAT Therapy Operative