IDENTITY :

Mrs. RA, 62 y.o, Christian, live in

tanawangko, manado.
Examination date : september 12th
2014

 patients are stroke patients since 25 years ago, with

weakness in his right extremities.
A few years ago in the patients undergoing medical
rehabilitation therapy several times.
This time the patient can walk on his own without a
walker, can perform ADL independently, including
washing dishes.
This time the patient comes back to chief complaint
tingling in the fingers of his left hand (thumb, index
finger, middle finger and ring finger) since 1 month
ago. The complaints arise in the morning when he just
got up, and slowly disappeared. no complaints of pain.

 History of past illness: hipertention

(+),CVD (-), DM (-).
Socio-economic history: patient is a
retirement from midwife. Patient live
in permanent house with siting toilet.
Hospital fee by BPJS.

Physical Examination:

BP : 120/80 mmHg; Pulse : 80 x/min

Head :conjunctiva anemic (-/-), icteric
(-/-)
Neck : trachea at the midline, lymph
node enlargement (-/-)
Cor: heart sound normal, no murmur,
no gallop
Pulmo: Symmetric thoracic movement,
no ronchi, no wheezing
Abdomen: stoma with colostomy bag
on left side
4

 Local Status at extremity:

Inspection
: atrophy thenar on
the right hand (+).
Palpation : pain (-)
Movement : ROM limitation (-)

Upper extremity

2/3/2/1
Normal

5/5/5/5
Normal

Lower
extremity
Right
Left
Decreas Normal
e
4/4/4/4 5/5/5/5
Normal Normal

Normal

Normal

Normal

Normal

Right
Left
Motoric status
Movement Decrease
Normal
Strength
Muscle
Tone
Physiologi
c reflex
Pathologic
reflex
6

 Provocation Test :
Preyer test
: -/ phalen test
: -/ Tinnel test
:-/+
Compression test : -/+

 Diagnosis :
Clinical Diagnosis: carpal tunnel syndrome
sinistra + hemiparese D
Topical Diagnosis: nervus medianus + right
extremity
Etiologic Diagnosis: entrapment + SNH
Functional Diagnosis:
Impairment : Tingling sensation on the left
hand, weakness on the right extremity
Disability : walking disturnace, limitation
in activity daily living.
Handicap : 8

Problem :
1. Tingling sensation on the left hand
2. Weakness on the right extremity
3. Limitation in ADL
4. Limitation In walking

Program:
US diatermi in carpal tunnel sinistra
IR on the right extremity
ROM exercise on the right extremity
Strengthening exercise on the right
extremity
Resting splint?

Advise:
EMG : lihat kecepatan hantar saraf n.
Medianus apakah kurang dari 50 m/s
dan apakah ada penurunan
amplitudenya.