Chapter II

CASE REPORT

I. Identity
Name : L.B
Gender / Age : Male / 62 years old
Address : Desa Kolongan Kecamatan Kalawat No. 1
Religion : Christian
Occupational : Businessman
Medical Record : 47 59 76
Examination date : June 13rd 2016

II. Anamnesis (History)

Chief complain:
Low back pain.

History of present illness:

Low back pain has felt for about 2 weeks. Patient has been feeling a great sudden pain
on his lower back after lifting heavy object (stone) approximately 10 kg with bending
position and suddenly heard krek sound from his back. Pain being persistent since 1
week ago. Sharp pain localized at low back (right side), no radiating to buttocks or legs.
Furthermore, the pain occurred intermitten, increasing when the patient working such as
bending forward his back to grab something from the floor, stand from sitting or lying
position, prolonged sitting or standing, squatting and the pain was decreasing when he
lying supine on her bed.
On May 1st 2015, he went to RS Advent and take care of for 1 week. The patient was
reference to Clinic Physical Medicine and Rehabilitation RSUP Prof. Dr. R. D Kandou to
get the further treatment. The diagnosed from neurologist is LBP ec compression fracture
T12.
There is no problem for micturition and defecation. There was no history of weight
loss in the past three months. There was no history of fever. There is no morning
stiffness. There is no weakness on his leg and no numbness in the area of bottom. No
increasing pain while coughing, squeezing or defecation. This is the first time patient has
an experience like this. After this condition, patient has consumed mefenamic acid for
several days, but there was no significant recovery.

History of past illness:

- Hypertension (on treatment)
- Hypercholesterolemia (on treatment)
- Have no history for diabetes.
- Have no history for hyperuricemia.
- Have no history for cancer in the body.
- Have no allergic.

History of psycologic :
Patients are open, communicative, and wise character. Patient was worried for the
disease. Because of back pain, the patient currently leave from his work for last 3 weeks.

History of habitual :
When sleep on the floor, using a mattress foam and one head and bolster pillows. In
connection with his job, patient in work place always sitting for about 5-6 hours,
sometimes walking and sometimes just standing, when sitting sometimes not use seat
back and body position sometimes slight bending, have a room in the second floor so if at
work place must take for about 15 stairs. Sometimes take some work to house and using a
laptop but when sitting not using a seat back. When walking never in a hurry. Patient
smoke cigarette since his age was 30 years old and do not drink alcohol.

History of socioeconomic:
Patient is working as a businessman. Patient lives only with his grandchild 17 years old.
He has 3 children, the first one is 40 years and the third one is 31 years, the second one
was dead. All of his children was married.
Currently the patient did not work because of his health physical condition. For everyday
expenses assisted by their children. He said that this time his life enough. He lives in a
permanent house with 5 rooms 2 floor permanent house. The toilet is sitting toilet. The
source of water is from a well, but patient doesnt need to draw the water from it. They
use PLN (Perusahaan Listrik Negara) as the source of electricity. Patient has Inhealth
Insurance that guarantee his payment for medication.