STATUS AMPUTASI

I. Identity
II. Anamnesis
 Chief complain
 History of present illness :
 Etiologi amputasi (vascular/non vascular)
 AGA : ADL
 AGB : transfer, berdiri 1 kaki, ambulasi dng apa
 History of past illness : mencari comorbidity
 HT, DM, cardiac disease, stroke
 Harapan pasien : level ambulasi ; prosthesis kosmetik atau fungsional
III. Physical Examination
a. Status General :
 Ambulasi dng apa (2 kruk, … point gait, swing to/through ; walker)
 Hand dominance
 VS
 Ankle Bracial Index/ABI (terutama pada amputasi krn vascular problem)
 Thorax : Cor & Po
b. Status Muskuloskeletal
 ROM
 MMT (terutama remaining stump)
c. Status Local Regio Amputasi
 Inspeksi :
o Level amputation
o Bentuk stump (bulging, cylindrical, conical)
o Wound
o Redness / Edema
o Dog ear
 Palpasi :
o Warmth
o Sensoris (deficit/hipersensitif)
o Neuroma
o Soft tissue coverage (myoplasty, myodesis)
o Stump pain
o Phantom sensation
o Phantom pain
o Telescoping sensation
o Stump length % (short, standard, long) dengan marker : acromion, olecranon,
greater trochanter, tibial plateau
o Stump diameter
o Pulsasi proximal arteri
  Additional Examination :
 Standing balance one leg (static & dynamic)
 Hopping
 Count test & chest expansion
 Cardiopulmonary endurance
IV. Neurologial Examination
 Cranial nerve :
 Tonus / spasticity :
 DTR :
 Pathological Ref :
 Sensory :
V. Problem List (R1-R7) / ICF
VI. Goal & Prognosis
VII. ASSESMENT
VIII. PDx, PTx, PMx, PEx :