Cervicalgia ec spondilosys unco cervicalis + spondiloarthrosis VC4,5 + paracervical muscle spasm + upper trapezius muscle spasm + fraktur humerus sinistra post ORIF (7 months) + Obese grade II Iin Muslihah Database June, 23rd 2020 Patient Identity Name : Mrs. I Sex : Female Age : 27 y.o. Marital Status Religion : Married : Moslem Occupational : Housewife Education : junior high scool Referred from neurologic outpatient clinic with diagnosis cervicogenic headache Chief Complaint : Nyeri leher kanan History of present illness Neck pain on the right side since 3 years ago, described as “pegal” and dullness pain, also radiated to her right arm. She wakes up at the middle of night because of the pain. No tingling or numbness, increases when she bowed her head (with a cell phone) WBS 7 & and reduced when lying on her left side. she also took zelona (diclofenac sodium) and applied balm or koyo to reduce pain(WBS 1). History of present illness Weakness on her upper extremity (-). Daily activity limitation (-). Never carry heavy objects on her shoulders or head she had message for her neck and back, use heel History of Past illness No History of Hypertension. No history of diabetes mellitus No history of cardiac problem No hystory of tumor/malignancy November 2019, she got motorcycle accident and she suffered fracture of her left humerus and fracture of left patella. She hospitalized for 5 days and undergoing have surgery (ORIF) for her humerus. History of socioeconomic She is a housewife she lives with her husband and her daughter. Her husband is a fisherman. History of Medication • In past 7 months, she consumed zelona ( sodium diclofenac) from Tuban Hospital. • She also got paracetamol 500 mg+ Diazepam 2 mg 2x1, amitriptilin 10 mg 1x1, mecobalamin 1x1 from neurologic outpatient clinic dr. Soetomo’s Hospital. Review of system ■ General State: general condition was good but she complain about her neck ■ Cardiopulmonary system: there was no complaint of palpitation or shortness of breath. ■ Gastrointestinal system: no difficulty of swallowing, vomiting, and defecation. ■ Genitourinary system: There was no complaint about urinating. ■ Nervous system: There was no complaint of smelling, dizziness, vertigo, deaffness, and turning head and neck. ■ Integumentum system: there was no nodule, rash and itching Physical Examination June, 16th 2020 General Status Compos mentis Independent ambulation Right handed dominant Normal Gait Postur : forward head and rounded shoulder BP : 110/70 mmHg HR : 70 bpm/reguler RR : 20 x/minutes T: 36,4 0 C Weight : 79 kg, Height : 153cm, BMI : 32,4 kg/m2 (obese II) General Status Head Chest Heart Lung Abdomen Extremities : No anemia, no jaundice , no cyanosis : Simetris, no retraction : S1S2 single, no murmur nor gallop Right upper border: ICS II right parasternal line Right lower border: ICS IV right parasternal line Left upper border: ICS II left parasternal line Left lower border: ICS V left midclavicular line Ictus cordis : ICS V left midclavicular line : ves/ves, rh -/ rh -, whz-/whz: soefl, hepar and lien unpalpable. Peristaltic sound was normal : scar tissue at anterior humerus sinistra (+) warm, CRT < 2’’, edema (-), Musculoskeletal Status NECK ROM MMT Flexion F (0-450) 5 Extension F (0-450) 5 Lateral bending F/F (0-450) 5/5 Rotation F/F (0-600) 5/5 TRUNK ROM MMT Flexion F (0-800) 5 Extension F (0-300) 5 Lateral bending F/F (0-350) 5/5 Rotation F/F (0-450) 5/5 SHOULDER ROM MMT Flexion F/F (0-1800) 5/5 Extension F/F (0-600) 5/5 Abduction F/F (0-1800) 5/5 Adduction F/F (0-450) 5/5 Internal rotation F/F (0-700) 5/5 External rotation F/F (0-900) 5/5 ELBOW ROM MMT Flexion F/F (0-1500) 5/5 Extension F/F (1500-0) 5/5 Supination F/F (0-900) 5/5 Pronation F/F (0-900) 5/5 WRIST ROM MMT Flexion F/F (0-800) 5/5 Extension F/F (0-700) 5/5 Ulnar deviation F/F (0-300) 5/5 Radial deviation F/F (0-200) 5/5 THUMB ROM MMT Flexion MCP F/F (0-900) 5/5 IP F/F (0-800) 5/5 Extension F/F (0-300) 5/5 Abduction F/F (0-700) 5/5 Adduction F/F (700-0) 5/5 Opposition F/F 5/5 FINGERS ROM MMT Flexion MCP F/F (0-900) 5/5 PIP F/F (0-1000) 5/5 DIP F/F (0-900) 5/5 Extension F/F (0-300) 5/5 Abduction F/F (0-200) 5/5 Adduction F/F (200-0) 5/5 Opposition F/F 5/5 HIP ROM MMT Flexion F/F (0-1200) 5/5 Extension F/F (0-300) 5/5 Abduction F/F (0-450) 5/5 Adduction F/F (0-300) 5/5 Internal rotation F/F (0-450) 5/5 External rotation F/F (0-350) 5/5 KNEE ROM MMT Flexion F/F (0-1350) 5/5 Extension F/F (1350-0) 5/5 ANKLE ROM MMT Dorsoflexion F/F (0-200) 5/5 Plantarflexion F/F (0-500) 5/5 Inversion F/F (0-350) 5/5 Eversion F/F (0-150) 5/5 BIG TOE ROM MMT Flexion Extension TOES MTP F/F (0-300) 5/5 IP F/F (0-500) 5/5 F/F (0-800) 5/5 ROM MMT Flexion Extension MTP F/F (0-250) 5/5 IP F/F (0-250) 5/5 F/F (0-800) 5/5 MMT Dextra MMT Sinistra 5 C5 abduction) (shoulder 5 5 C6 (elbow flexion) 5 5 C7 (finger extension) 5 5 C8 (finger flexor) 5 5 T1 (finger abduction) 5 Neurological Status Cranial Nerve I –XII : Normal Deep Tendon Reflexes : BPR++/++ TPR++/++ KPR ++/++ APR++/++ Pathological Reflexes : Babinski -/-, Hoffman -/-, Tromner -/- Sensory : Dextra Dermatom sensory Sinistra 100 % C5 100 % 100 % C6 100 % 100 % C7 100 % 100 % C8 100 % 100 % T1 100 % Status localis cervical Inspection : swelling (-), redness (-), deformity (-) Palpation : Warmth (-), , Tender point at paracervical dextra (+) paracervical muscle spasm (+) Special test: Compression test (-) Distraction (-) Spurling test (-/-) TOS I (-/-) TOS II (-/-) TOS III (-/-) Status localis Shoulder Inspection : simetri (+) swelling (-), redness (-), deformity (- ) Palpation : Warmth (-), upper trapezius muscle spasm(+/-) Special test: Apprehension test (-/-) Sulcus sign (-/-) Neer test (-/-) Hawkin test (-/-) Empty can (-/-) Infraspinatus test (-/-) Lift off (-/-) Belly test (-/-) Drop arm test (-/-) yergason test (-/-) Cross chest test (-/-) Additional Examination Chest expansion Count test : 24 T2/ T4/ T6 : 3cm / 3cm / 3 cm Balance Static and dynamic sitting balance : good Static and dynamic standing balance : good Barthel index Feeding = 10 Grooming =5 Bathing =5 Dressing = 10 Bowels = 10 Bladder = 10 Toilet use = 10 Transfer = 15 Mobility = 15 Stairs = 10 Total 100 X ray cervical AP/Lateral /oblique kanan kiri Curve melurus Trabekulasi tulang normal Superior dan inferior endplate baik Tampak osteophyte di unco cervicalis dan processus articularis VC 4,5 yang tidak menyebabkan penyempitan foramen intervertebralis VC 3-4, 4-5 sisi kanan. Corpus, pedicle dan spatium intervertebralis tampak baik. Tak tampak soft tissue mass/swelling Retrofarieal dan retrotracheal space normal. Trachea tampak di tengah, airway paten. Kesan: spondylosis unco cervicalis dan spondyloarthrosis VC 4,5 yang tidak menyebabkan penyempitan foramen intervertebralis Vc 3-4, , 4-5 sisi kanan. Paracervical muscle spasm. PROBLEM LIST Body Structure Activities and Participation S710 structure of head and neck _ Environmental factor Body Function b280 sensation of pain b530 weight maintenance function - Assessment : Cervicalgia ec spondilosys unco cervicalis + spondiloarthrosis VC4,5 + paracervical muscle spasm + upper trapezius muscle spasm + fraktur humerus sinistra post ORIF 7 months + Obese grade II Planning PDx Goal : Consult to nutritionist : Decrease the pain Decrease muscle spasm Correct posture Decrease body weight Planing Theraphy Modalitas: SWD 27,12 MHz coplanar at area paracervical +upper trapezius dextra for 15 minutes. Thera EXC: AROM ExerciseUpper Extremiti Dextra and Sinistra Gentle Stretching area paracervical and upper trapezius Dextra Correct the posture Neck Cailliet Exercise PMx : Clinical condition, vital sign, WBFS, BMI, MMT, ROM PEx : 1. Explain to patient about his condition 2. Continue exercise at home 3. Icing if she felt pain, duration 15 min, every 2 hours. 4. Correcting the posture 5. Reduce body weight, with walking in the morning 6. Avoid message using heel. 7. Borg scale, pulses count summary Female 27 years old with chief complain: nyeri leher kanan since 3 years ogo . She felt also right headache and since the last 1 year, pain radiating to the right arm. There is no tingling or numbness. BMI 32,4. paracervical muscle spasm (+), upper trapezius muscle spasm (+), MMT 5, Full ROM and there is no sensory deficit. X ray cervical: spondylosis unco cervicalis dan spondyloarthrosis VC 4,5, Paracervical muscle spasm. Theraphy: SWD and Exercise. Monitoring: Clinical condition, vital sign, WBFS, BMI, MMT, ROM We educate patient: Explain to patient about his condition, Continue exercise at home, Icing if she felt pain, duration 15 min, every 2 hours, Correcting the posture, Reduce body weight, Avoid message using heel. THANK YOU
