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Formulir Fisioterapi
Formulir Fisioterapi
Formulir Fisioterapi
Physical Therapy F r! Name of Phisical therapist : Deisy Nursifa Identify Room recording medical number : 2312-30- ! : "ctober th 2013 Room Date :
I" Pa#ie$# I%e$#i#y &S' #ull Name (irth ,ge ,ddress .ast grade of education &ob 0obby $edical Diagnostic de3tra : $r% Imam Prasetya &uma'an : Padang) "ctober 1*th 1+* : 2*rd : anoname street no% 2 Depo: /1 : athlet football : tra1elling : Post /urgery Posterior 2ruciatum .igament
II" (is# ry
) pa#ie$#
$a4or Problem : pain post surgical opration patient can5t mo1e his right leg) th Recent of 0istory : on /ept 13 2013 Patient got accident) he lost his consciousness and his -nee 'as bleeding% ,fter that 0e 'ent to hospital by ambulance% Doctor cured his 'ound % 6hree hours after the doctor told imam5s 'ife there 'as fracture in imam5s leg) so the doctor recommend to chec- it 'ith rontgent% (ut the result sho' there is not any fracture% ,fter accident) patient couldn5t balance his step and he felt his -nee 'as too mobile% 6hen he consult to orthopedic and suggest to $RI) as the result there 'as rupture at imam5s -nee5s ligament% ,nd he should fi3 the ligament 'ith surgical operation% "n sept 1! th 2013 his -nee had been surgery and opname for 3 day% Doctor suggest to phisical therapy but patient did not go there% 6hree 'ee- later he felt painful no disappear and it5s so hard to mo1e% 0e can5t 'al- normal and he lost his 4ob) can5t do his hobby and the acti1ityis disturbed% ,nother 0istory #amily 0istory : 7nothing8 : 7nothing8
Phsycococial 0istory : li1e 'ith his 'ife and don5t ha1e child 7patient not 'or-ing since accident) patient5s 'ife 'or- as model8
III" Asses!e$# &O' a% 9eneral gait a'areness : :sing crutches : 2ompos $entis
2ooperati1e ;non-cooperatiti1e (lood Pressure 0igh =eight I$6 0eart Rate : 1*0;+0 mmhg
b% specially Inspection : Palpation : $o1e : $o1ing pain on -nee R"$ o ,cti1e -nee fle3i : *0o ?nee e3tend : 1!o o Passi1e /pasme on $% 0amstrings pressure pain in -nee hypotonus on $% >uadriceps local temperature afebris using crutches non 'eigth bearing No oedema .oo-ing e3 surgery ,trophy $% >uadriceps
,ntropometry
IV" Physi #herapis# Pr *le! a% Physical 6herapist problem based on priority 1% ?nee pain 2% /pasme on $% 0amstrings 3% hypotonus on $% >uadriceps % limitation of R"$
b% Physical 6herapy Diagnostics .imit of 'al- ability because -nee pain) spasm on $% hamstring) hypotonus on $% >uadricep) and limitation of R"$ related post surgery posterior cruciatum ligament de3tra%
V" I$#er+e$#i $ a% 9oals 1% /hort 6erm 9oals .ost the pain Reduce the spasm Incerase the tonus Increase range of mo1ement
N 1
Me#h % /tretching
N #e 6o stretch hamstring muscle% $aintenance strengh of mucle and range of motion) reduce the pain% Increase the strength of muscle) increase the tonus%
Passi1e A3cercise
P: .ost the pain Reduce the spasm Incerase the tonus Increase range of mo1ement