Munawarah, Female, 60

y.o
Chief Complain
weakness at her lower extremity since 2 months ago
History of Present Illness
2 months ago,patient complains for numbness and mild weakness on both
legs , with pain, suddenly occured without history of trauma, fever or
chronic cough. Patient still able to walk, so the patient didnt take any
medication, but the complains didnt resolve and getting worse. Urination
and defecation both normal.
1 year before, she found mass at her back. The mass is hard and doesnt
get bigger. The mass didnt make any complain before.
2 month ago, the patient started the treatment at Internist and Orthopaedi
unit at Ulin Hospital, the patient felt that the weakness become worse, and
she had no problem of defecation and urination. The bodyweight also
decreased about 3kg. There is no history of prolong cough, night sweating
or fever. The patient then hospitalized in orthopaedy ward. And start
Tuberculosis medication. Now the patient has taken Tuberculosis
medication for more than one month but her leg didnt resolve. She also
got her DM type II medication from internist.
History of Past Disease
Diabetes (+), hypertension(+), no history of allergy or asthma

Physical Examination
Compos mentis, BP : 140/70 mmHg, HR : 80x /min, RR :
16x/min
Eye : No anemic conjunctiva, No icteric sclerae
Thorax : No bruises, symmetric on both sides when
inspiration and expiration
Lungs : Vesicular on both sides, No Rhales nor
Wheezing
Heart : Normal Heart sounds, no murmur nor gallop
Abdomen : flat, No pain on palpation, liver and spleen
wasnt enlarged, no muscular defense, normal bowel
sounds
Extremity : Warm, CRT <2

Local State of Spine

Look
Deformity (+), gibus (+), no
sinus drain
Feel
No Tenderness, muscle spasm
(-), step off (+)
Move
Spinal ROM limited due to
pain

Physical Examination
Reflexes

Right

Left

Patellar tendon (L4)

++

++

Autonom
Achilles tendon (S1)

++

++

Babinsky group

Clonus

Right

Left

C5

C6

C7

Urinary incontinence (-)

Fecal incontinence (-)

Right

Left

C5

C6

C7

C8

C8

T1

T1

Physical Examination
Right

Left

Right

Left

L2

L2

L3

L3

L4

L4

L5

L5

S1

S1

Lumbosacral
AP and Lateral, 2016
Pre
Op X Ray

Sagital
Sagittal MRI
AprilMRI
2014

Axial
MRI
Axial MRI

MRI
Sagittal Coronal
MRI April
2014

th
Thorax
AP,
October
6
Sagittal MRI April 2014 2016

th
EKG,
October
6
2016
Sagittal MRI April 2014

Laboratory

CBC : 11.4/32.2/5500/328000
PT : 9.6
aPTT : 21.9
AST / ALT : 14/33
Ur / Cr : 36/1.2
Fasting blood glucose/2HPP BG :
108/194
Electrolyte :146/4.6/115

Assessment
Diagnosis
TB spine L1
List of Problems
Infection
Instability
Pain
Deformity
Pathologic fracture
Neurological deficit
Socioeconomic

Performed
TOTAL TREATMENT 4
Basic TB treatment:
Anti TB drugs
Orthoses (TLSO)
Bedrest

Surgical:
Debridement, posterior
stabilization

Sari Murni, Female, 62

y.o
Chief Complain
weakness at her lower extremities since 3 months ago
History of Present Illness
3 months ago ,patient complains for numbness and mild weakness on both
legs, with no pain, suddenly occured without history of trauma, fever or
chronic cough. At first, patient still able to walk, but the complains didnt
resolve. Urination and defecation both at first was normal. Days before, she
just felt pain at her chest below her breast, the pain was continuously
appear and she did some examination at Jakarta but the result was normal.
2 weeks ago, the patients complain got worse, she cant even stand. Then
she started the treatment at Neurology and Orthopaedi unit at Ulin
Hospital, she had a problem of defecation and urination. The bodyweight
also decreased about 5kg. There is no history of prolong cough, night
sweating or fever. The patient then hospitalized in Anggrek ward.
History of Past Disease
Hypertension (+) No history of diabetes, allergy or asthma

Physical Examination
Compos mentis, BP : 130/70 mmHg, HR : 109x /min,
RR : 27x/min
Eye : No anemic conjunctiva, No icteric sclerae
Thorax : No bruises, symmetric on both sides when
inspiration and expiration
Lungs : Vesicular on both sides, No Rhales nor
Wheezing
Heart : Normal Heart sounds, no murmur nor gallop
Abdomen : flat, No pain on palpation, liver and spleen
wasnt enlarged, no muscular defense, normal bowel
sounds
Extremity : Warm, CRT <2

Local State of Spine

Look
No deformity, no gibus, no
sinus drain
Feel
No Tenderness, muscle spasm
(-), step off (-)
Move
Spinal ROM limited due to
weakness

Physical Examination
Reflexes

Right

Left

Patellar tendon (L4)

Autonom
Achilles tendon (S1)

Babinsky group

Clonus

Right

Left

C5

C6

C7

Urinary incontinence (catheter)

Fecal incontinence (-)

Right

Left

C5

C6

C7

C8

C8

T1

T1

Physical Examination
Right

Left

Right

Left

L2

L2

L3

L3

L4

L4

L5

L5

S1

S1

SagitalMRI
MRIApril
October2016
Sagittal
2014

Axial
MRI
October2016
Axial MRI

CoronalMRI
MRIApril
October2016
Sagittal
2014

Laboratory

CBC : 11.3/33.0/9500/201.000
PT : 10.6
aPTT : 23.4
AST / ALT : 27/16
Ur / Cr : 24/019
Fasting blood glucose : 111
Electrolyte :146/4/115

BMA
Conclusion:
Monoclonal gammopaty (s.multiple
myeloma)

Assessment
Diagnosis

Performed

Myelodenopaty
vertebrae Thoracal
6&7 MBD dd MM
List of Problems
Instability
Deformity
Neurological deficit

Surgical:
Decompression
Stabilization
Tumor removal