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Case Report
Case Report
Case Report
1.1 Identity
Name : Miss. K
Sex : Female
Age : 21 y.o.
Address : Surabaya
Occupational : Merchant (distributor of snack at DTC Wonokromo)
Religion : Moslem
Ethnic : Javanese
Marital status : Single
Sport recreational : Jogging
Reffered from Orthopaedic out patient clinic with contusio genu dextra susp. ACL lesion.
General Status
Patella 35,5 cm 34 cm
VMO (above superior 40,5 cm 40,5 cm
margin of patella)
Quadriceps (10 cm above 39 cm 39 cm
superior margin of patella)
Barthel Index
Activity Score
Feeding 10
Bathing 5
Grooming 5
Dressing 10
Bowels 10
Bladder 10
Toilet use 10
Transfers 15
Mobility 15
Stairs 5
TOTAL 95 ( Slightly dependent )
II. Diagnosis : Rupture of ACL dextra + Collateral Med. Lig Dextra + Lateral
Meniscus
Functional diagnosis :
Impairment : Right ACL, collateral medial ligament and lateral meniscus
rupture with instability of the right knee.
Disability : cannot praying in a proper position due to the knee pain.
V. Planning
1. Surgical : ACL reconstruction ( from orthopaedic department )
2. Medical : Mefenamic acid 500 mg 3 dd 1.
3. Rehabilitation Medicine
R1 (Ambulation), R2 (ADL), R6 (Vocasional), R7 (Other)
PDx : -
PTx :
Icing genu dextra 20 minutes / session.
High TENS at tender point ( medial tib plateu ) genu D
with frequency 170 Hz, intensity 45 mA, duration 15`.
Isometric strengthening exercise quadriceps dextra as frequent as
possible.
Active NWB ROM exercise genu D minimal 3 times/day @ 10
repetition.
Straight Leg Raising (SLR) exercise.
Bandaging of the right knee
PMx : Clinical sign, symptoms, VAS and ROM knee
PEx : Health education and home exercise program.
R3 (Communication) :-
R4 (Sociological) :-
R5 (Psychological) :
PDx :
PTx : give psychological support to the patient
PMx : Psychological condition
PEx : - Education about her disease
- Encourage her to do exercise more.