Report of Scenario B Block IX

CHAPTER I
INTRODUCTION
1.1. Background
Neuromusculoskeletal block is the ninth block in the third semester of
the Curriculum Based on Medical Education Competency, Faculty of
Medicine, Palembang Muhammadiyah University.
On this occasion a case study tutorial was carried out as a learning
material to deal with the actual tutorial on future opportunities. The author this
time explained the case given regarding scenario titled “ Pinched Shoulder”.
1.2. Purpose of the report

The purpose of this case study tutorial report is:
1. As a tutorial group assignment report which is part of the KBK learning
system at the Palembang Faculty of Medicine, Muhammadiyah
University.
2. Can solve the case given in the scenario with the analysis method and
group
discussion learning.
3. The achievement of the objectives of the tutorial learning method.
1|Report of Scenario B Block IX

CHAPTER II
DISCUSSION
2.1 Data Tutorial

Tutor : dr. Mitayani, M.Si. Med
Moderator : M. Ilham Dendy Pratama
Secretary of the desk : Vera Novita Sari
Secretary of the board : Erwin Dwitama
Time : Monday, 29 Oktober 2018
Wednesday, 31 Oktober 2018
2.2 Regulation of Tutorial

1. Not allowed to use handphone when the tutorial takes place
2. Say hello and introduce yourself before asking
3. Not allowed to interrupt when a friend gives an opinion
4. Using the english language is good and right

2.3 Scenario B of Block IX
” Pinched Shoulder “
Jojo a 20 years old Karateka, came to emergency department with a
chief complain of pain and inability to move his right shoulder since 2
hours ago. The symptom occurs during his full body contact karate match,
when his opponent kick Jojo’s shoulder from the side. After the incident,
Jojo’s right shoulder began to ache and immoveable. The symptom
followed by some swelling and the pain is getting more intense if he tries
to move it. Jojo complains that he can’t move his right shoulder and
sustains his ached arm with his left hand. Jojo was rushed to emergency
department immediately.
Physical Examination
General Appearance:
Consciousness: compos mentis; Respiratory rate 26 x/m; Pulse rate 102
x/m; the fill and it tension is nomal; Blood pressure 130/80 mmHg;
Temperature 37,0 C. VAS 7.
Spesific Examination:
Height: 160 cm, Weight: 57 kg
Head: anemic conjungtive (-), icteric sclera (-)
Thoraks: heart and lung is normal
Abdomen: flat, supple, hepar and lien are not palpable
Upper extremities: right shoulder regio
Look:
 Asymmetric, swollen, shoulder contour are dimmminishing
 Hematome (+)
 Open wound (-), active bleedeing (-)
Feel: Tenderness (+),Crepitation (-), Right shoulder skins was tense if
Palpated
Move: Pain if the right shoulder was moved (+)

ROM: Shoulder joints range of motion was undertermined due to the
pain
Radialis artery pulsation was palpable
Left shoulder regio: within normal limits
Lower extremities: within normal limits
Additional Examination:
Blood chemistry: Hb: 14 gr%, Leukocytes 9.000 /mm³, platelets 150x109/L
Radiological Examination:
Clarification of Term
Pain The feeling of disstressed suffering

or agany cause by stimulation of
specialized nerve endings
Swelling Abnormal increased fluid
intercellular body
Hematome A localized of extravasated blood,
usually cloted intra organ space or
tissue
Tenderness A very sensitive condition of touch
and pressure
Crepitation There is a sound if we move the
fracture bone
Asymmetric The condition of the part of the
body or the orgn of the body

ROM Range of joints motion
VAS Visual analog scale
2.4 Identification of Problem

1. Jojo a 20 years old Karateka, came to
emergency department with a chief complain of pain and inability to
move his right shoulder since 2 hours ago. The symptom occurs during
his full body contact karate match, when his opponent kick Jojo’s
shoulder from the side.
2. After the incident, Jojo’s right shoulder
began to ache and immoveable. The symptom followed by some
swelling and the pain is getting more intense if he tries to move it.
3. Jojo complains that he can’t move his right
shoulder and sustains his ached arm with his left hand. Jojo was rushed
to emergency department immediately.
4. Physical Examination
General Appearance:
Look:
 Hematome (+)

Palpated
pain
5. Additional Examination:
Blood chemistry: Hb: 14 gr%, Leukocytes 9.000 /mm³, platelets
150x109/L
6. Radiological Examination:

2.5 Problem Analyzed
1. Jojo a 20 years old Karateka, came to
emergency department with a chief complain of pain and inability to
move his right shoulder since 2 hours ago. The symptom occurs during
his full body contact karate match, when his opponent kick Jojo’s
shoulder from the side.
1a. What is anatomy, fisiology, and histology of superior extremity?

Answer:

Osseous structures of interest are the scapula, humerus and clavicle. In
the specific anatomy of that such as :
 Acromion
 Spina scapulae
 Tuberculum Mayus
 Tuberkulum Minus
 Capsula articularis
 Lig. Coracoclavicular
 Lig. Coracoacromial
 Lig. Coracohumeral
 Lig. Glenohumeral superius
 Lig. Glenohumeral medium
 Lig. Glenohumeral inferius
 Lig. Transversum scapulae
 Scapulothoracic joint
 Acromioclavicular joint
 Glenohumeral joint
 Proc. Coracodeus
 Cavitas glenoidalis
 Labrum glenoidale
 M. Supraspinatus
 M. subscapularis
 M. Biceps brachii
 M. Infraspinatus
 M. Teres minor
 M. Pectoralis mayor
 M. Pectoralis minor
 M. Deltoideus
 M. Bicep brachii
 M. Tricep brachii
 M. Brachioradialis
 M. Brachialis
 N. Medianus
 N. Intercostabrachialis
 N. Cutaneous antebrachii
 N. Cutaneous brachii median
 N. Musculocutaneus

Superior extremity
The innervation of superior extremities comes from the brachial

plexus. Brachial Plexus is formed by Rr. Anterior spinal nerve
segment of the cervical spinal cord under da thoracalata (C5-T1).
Vascularity
1. A. axillaris
2. A. subscapularis
3. A. thoraoacromalis
4. A. brachialis
5. A. circumflexa posterior humeri
6. A. circumflexa anterior humeri

7. A. profundal brachii
8. A. collateralis media
9. A. collateralis radialis
10. inferior ulnar collateralis
11. A. radialis
12. A. recurrens radialis
13. A. interossea recurrent
14. A. interossea communis
15. A. princeps pollicis
16. A. radialis indicis
17. Aa. Digitales palmares communes
18. Aa. Digitales palmares propriae
Joints are divided into 3 types, namely:

Fibrous: the relationship between joints by fibrous tissue
Cartilage / cartilage: the intercellular space binds to cartilage.
Synovial / synovial joint: there is joint space and ligament to
maintain joints. Jointed in superior extremity, namely: Which is in
art. Humeri can occur abduction and adduction movements, in ar.
Cubiti can occur flexion and extension, on ar. Radicarpalis and
pronation and suppression movements occur, ar. Interphalange
proximal occurs flexion and extension movements ( Paulsen. F and
Waschke. J, 2010).
Histology of bone, bone growth is devided into two types

1. Immature bone (non-lamelar bone, wpofen bone, fiber bone)
formed in embryonic development and at the age of one year no
longer seen. Immature bone contains collagen tissue
2. Mature bone (mature bone, lamelar bone)
(Noor. Z, 2016)
10 | R e p o r t o f S c e n a r i o B B l o c k I X
1b. What is the meaning Jojo a 20 years old Karateka, came to emergency
department with a chief complain of pain and inability to move his
right
shoulder since 2 hours ago?
Answer:
Feel pain and inability to move right shoulder means Jojo
experiencing somatic pain where this pain refers to pain originating
from muscles, tendons, ligaments, bones, joints and arteries ( Price and
Wilson, 2005).
1c. What is classification of pain?

Answer:
Considering the durations of symptoms, pain can be divided into
groups:
• Acute pain: duration < 3 months, acts as a warning defensive (post-

operative pain, traumatic, associated with medical procedures).
• Chronic pain: duration > 3 months, does not fulfill the role of warning
and defensive, due to the nature and symptoms of the disease is
considered in itself, and requires a multitherapeutic activities.
• Survived pain: most often occurs as a result of improper treatment of

acute pain,persists despite the healed tissue, the damage to which
resulted in acute pain.
Pain can be classified in various ways, namely:

1. By type: nociceptic pain, neurogenic pain, and pain psychogenic
2. According to the onset of pain: acute pain and chronic pain
3. According to the causes: oncologic pain and non-oncologic pain
4. According to the degree of pain: mild, moderate and severe pain
(Sweiboda. P, 2013).
1d. What is relation of age and gender with his complain?

Answer:
Frequent shoulder joint dislocation found in adults, rarely
found in children (Apley,2010). There are 71.8% of men who has
dislocation,46,8% between 15-29 years, 48.3% result from trauma
like in sports activities. More dislocation can be refers to women
who has aged >60year,. The most common cause is 58.8% due to
falling. Cases of 16% joint component fracture occur in cases of
joint dislocation shoulder (Zachilli and Owens, 2010).
1e. What is pathophysiology of pain and inability to move?

Answer:
Inflammation due to physical injury excessive emphasis
on bones  pressure> bone strength prostaglandin synthesis
nociceptive receptors transduction from peripheral to posterior
cornua spinal cord endogenous analgesic interactions occur
suppress pain impulses in the posterior horn of the spinal cord
the impulse is channeled to the somatosensory thalamus in the
cerebral cortex pain perception pain pain when in
motionlimited / unmovable movement
1f. What is the meaning the symptom occurs daring his full body
contact karate match?
Answer:
The meaning is experience pain and inability to move his
right shoulder because of mechanical trauma. mechanical trauma
refers to bodily injury or a surprise produced by a sudden physical
injury. In this case mechanical trauma that he got from kicked his
shoulder by his opponent (Kneale Julia D and Peter S Davis, 2011).
1g. What is etiology of pain?

Answer:
Pain accurs through seceral stimuli such as :
 mechanical stimuli
 temperature
 chemical (bradykinin, serotonin, histamine, potassium ions,
acids, asetylcholine, and proteolytic enzymes).
Pain can also be caused by other influences such as infection, tissue
ischemia, tissue contusions, and muscles spasm (Guyton. A.C and
Hall. J.E, 2007).
2. After the incident, Jojo’s right shoulder

began to ache and immoveable. The symptom followed by some
swelling and the pain is getting more intense if he tries to move it.
2a. What is the meaning Jojo’s right shoulder began to ache and
immoveable?
Answer:
The meaning of After the inCident, his Right shouDer began to
ache is a sign of inflammation and the meaning immoveable is the
dislocation of his humeral bone.
2b. What is the meaning The symptom followed by some swelling
and the pain is getting more intense if he tries to move it?
Answer:
The meaning is experiencing inflammation due to
dislocation of the shoulder joint. The symptoms of the
inflammatory process are :
1.Reddish (rubor)
The occurrence of this redness is because the arteries that circulate

blood to the area are dilated so that there is an increase in blood
flow to the site of injury.
2.Hot feeling (heat)
Heat and redness occur simultaneously. Where the feeling of heat

is caused by more blood in the inflammation than in other areas
around the inflammation. This hot phenomenon occurs when it
occurs on the surface of the skin. Whereas if it happens deep in the
body we cannot see and feel.
3.Pain (dolor)
Inflammation pain can be caused by several things:
(1) tissue stretching due to edema resulting in an increase in local

pressure that can cause pain, (2) the release of chemicals or pain
mediators such as prostaglandin, histamine, bradykinin which can
stimulate the nerves - peripheral nerves around inflammation so
that it is felt pain.
4.swelling (tumor)
The most obvious symptom of inflammation is swelling caused by

an increase in capillary permeability, an increase in blood flow and
fluid to the injured tissue so that plasma proteins can exit the blood
vessels into the interstitium space.
5.Fungsiolaesa
Fungsiolaesa is a functional disorder of the tissues affected by

inflammation and its surroundings due to the inflammatory process.
Release Histamin, Bradikin adn PGE2 have vasodilator

effect and increased vascular permeability. These cause local
edema, increased tissue preasure and stimulate Nociceptor. So
Nociceptor can make the pain is getting more intense. Vasodilator
effect and increased vascular permeability cause many blood fluid
send to injury area, that cause seeps out from capillary to interstitial
space, and then swelling was happened (Corwin. E..J, 2008).
2c. What is the range of pain?

Answer:
Various methods are used to measure the degree of pain, a simple
way to determine the degree of pain qualitatively as follows:
1. Mild pain is pain that arises, especially when doing daily
activities and lost during sleep
2. Moderate pain is continuous pain, activity is disturbed,
which only disappears when the patient sleeps
3. Severe pain is pain that persists continuously throughout
the day, the patient cannot sleep or is often awake by pain during
sleep.
Measurement of Pain Degree
There are several ways to help find out the consequences of pain
using a unidimensional (single) or multidimensional pain
assessment scale.
1. Unidimensional:
- Only measures pain intensity
- Suitable for acute pain
- The scale commonly used for evaluating analgesics
This unidimensional pain assessment scale includes:
A. Visual Analog Scale (VAS)

Analog visual scale (VAS) visualizes the gradation of the level
of pain that a patient may experience. The pain range is
represented as a line 10 cm long. Signs at both ends of this line
can be numbers or descriptive statements.
To evaluate intensity, visual or analogue scales are used to
compare pain with the strongest pain which the patient ever
suffered. In practice, most popular scale divides pain into very
strong, strong, moderate, weak and no pain. The visual analogue
scale is used to assess pain by an increasing score: from 0 –
meaning no pain, to 10 – meaning the strongest pain endured in
life.
B. Verbal Rating Scale (VRS)
This scale uses the numbers 0 to 10 to describe the level of
pain. This verbal numerical scale is more useful in the
postoperative period, because naturally verbal / words do not rely
too much on visual and motor coordination.
C. Wong Baker Pain Rating Scale

Used in adult and children> 3 years old patients who cannot
describe the intensity of pain with numbers
2. Multidimensional
- Measuring intensity and pain (unpleasantness)
- Applied for chronic pain
- Can be used for clinical assessment
This multidimensional scale includes:
A. McGill Pain Questionnaire (MPQ)

It consists of four parts:
 pain images
 pain index (PRI)
 question questions about past pain and location
 pain intensity index experienced at this time
B. The Brief Pain Inventory (BPI)

Is a medical questionnaire used to assess pain. Initially it was
used to diagnose cancer pain, but it was also validated for
chronic
pain assessment.
C. Memorial Pain Assessment Card

Is an instrument that is quite valid for evaluating the
effectiveness and treatment of chronic pain subjectively.
Consists of 4 components of assessment about pain including
pain intensity, description of pain, reduction of pain and mood
(Mardana, I.K.R.P and Aryasa. T, 2017).
2d. What is the pathophysiology of swelling?

Answer:
Injury -> Blood clots and Inflamation were happened -> Release of
Bradikinin, Histamin and PGE2 -> Vasodilation, Increase Vascular
Permeability -> Many Blood Fluid send to the injury area -> Seeps out
from capillary to interstitial space -> Swelling (Silbernagl, 2016).
2e. What is etiology of swelling?

Answer:
The etiology of the causes of edema can be classified into four
general categories:
 Decreasing plasma protein concentration causes a decrease in

osmotic pressure plasma. This decrease causes filtration of the fluid
coming out of the vessels higher, while the amount of liquid
reabsorbed is less than normal. Thus there is additional liquid left
in the rooms interstitial. Edema caused by a decrease in plasma
protein concentration can occur in several ways: a. Excessive
release of plasma protein in the urine due to kidney disease b.
decreased plasma protein synthesis c. due to liver disease (liver
synthesizes almost all plasma proteins); d. foods that contain less
protein e. release of protein due to extensive burns.
 Increased venous pressure, such as blood blocked in the vein, will

be accompanied increase in capillary blood pressure, because
capillary drains its contents into vein. This increase in pressure
towards the capillary wall mainly plays a role in edema that occurs
in congestive heart failure. Regional edema can also occurs due to
local venous return restriction. One example is swelling in the legs
and feet that often occurs during pregnancy. An enlarged uterus
compresses the veins - large veins that drain blood from lower
extremity when the veins enter the abdominal cavity. Blood
blocking in this vein causes the foot to push regional edema in the
lower extremities.
 Increasing the permeability of capillary walls causes plasma

proteins getting out of the capillary into the surrounding interstitial
fluid. As for example, through dilation of capillary pores triggered
by histamine on tissue injury or allergic reaction. There is a
decrease in colloid osmotic pressure the plasma decreases inward
while increasing osmotic pressure Colloid interstitial fluid
produced by excess protein in the liquid the interstitium increases
the pressure outwards. this imbalance comes along play a role in
causing local edema related to injury (for example, blisters) and
allergic response for.
 Blockage of lymph vessels causes edema, because of excess fluid

filtered out retained in interstitial fluid and cannot be returned to
blood through the lymph system. Protein accumulation in the
interstitial fluid becomes heavier problem through its osmotic
effect. Local lymph blockage can occur, for example in a woman's
arm in her lymph drainage from the blocked arm due to removal of
lymph glands during surgery for breast cancer. More widespread
lymph blockage occurs in filariasis, a mosquito-borne parasitic
disease that is mainly found in tropical regions. Whatever the cause
of edema, the important consequence is a decrease in the exchange
of ingredients between blood and cells. Often with interstitial fluid
accumulation, the distance between cells and blood that must be
reached by nutrients, O2, and residual substances widen so that the
diffusion speed decreases. Thus, cells in edematous tissue may lack
blood supply (Price. Sylvia A, 2003).
3. Jojo complains that he can’t move his right

shoulder and sustains his ached arm with his left hand. Jojo was rushed
to emergency department immediately.
3a. What is the meaning Jojo complains that he can’t move his right
shoulder and sustains his ached arm with his left hand?
Answer:
This is one of clinical characteristic of dislocation in glenohumeral
joint. The chief complain are pain in shoulder and cant move it. Cant
move shoulder is caused by dislocation. This Dislocation is most often
that happened, because the role of ligamentosa and bone of caput
humeri movement are strengthless. Mostly patients prevent internal
rotation movement, elbow flexion, and lower arm is helped by other
hand (Noor, Z. 2016).
3b. What is possible disease in this case?

Answer:
Injury from musculoskeletal trauma such as:
Contusion: is injury in soft tissue that caused by blunt trauma

directly affects the tissue, such as hit, kick and fall down,
disconnected of small blood vessels effect bleeding in soft tissue
with characteristic being ekimosis and bruise. Hematom can
happen if a lot of bleeding until followed by blood accumulation.
Local symptom such as pain, swelling, and discoloration often can
control easily with cold compress and will lost after 1-2 weeks.
Strain: is muscle pull cause excessive use, over stretch or over

local stress. Strain is microscopic rip that incomplete with bleeding
in tissue. Patients often complain sudden pain with being local
tenderness of muscle use.
Sprain : is injury of ligament structure around joint, cause

clamping and turning movement, ligament has function as
protection of stability, but still capable to do mobility. Rip ligament
will lost of stability. Blood vessels will disconnected and edema
will happened, joints feel painful and joint movement feel very
painful.
Dislocation: is a condition where happen lost of normal connection
between two of joint surface with completed.
Fractur: is lost of bone dan cartilago continuity, both of total or in

part.
Ruptur: iss lost of tendon continyity, both of total or in part.
(Noor. Z, 2016)
4. Physical Examination
General Appearance:
Look:
 Hematome (+)
Palpated
pain
4a. What is interpretation of physical examination?
Answer:
Physical Check up Result Interpretation
General  RR 26 x/m  Takipnea
appearance  VAS 7  severe pain
Spesific  MTB: 22,6

Examinatio  right shoulder regio
n - assymetric, -abnormal
- swollen -inflamation react
- shoulder contour are -abnormal
dimminishing -internal
- hematome (+) bleeding(abnormal)
 Feel : right shoulder skin  Abnormal

palpable
 Move : pain when the  Dislocation
right shoulder was
moved  abnormal
 ROM : shoulder joint
range of motion was
undetermined due to the
pain
4b. What is pathophysiology abnormal of physical examination?

Answer:
Hematoma
Mechanical trauma > damage to blood vessel walls > extravasation of
blood in tissue > hemaoma.
Swelling
Physical trauma > breakdown of blood supply causing damage to

tissue > release of histamine by mast cells in damaged areas >
increased local capillary permeability extravasation plasma proteins
from capillaries > accumulation of plasma proteins intertisium fluid >
local edema or swelling.
Pain
Trauma causes nosiseptor issue subtanse P, which activate the

ascending pain pathway wich provides input to the thalamus, the
perception of pain in the thalamus, then leads to the somatosensory
cortex as localization of pain and to the limbic system will experience
behavioral and emotional responses to pain.
Visual Analog Scale (VASs)

The method most often used to measure pain. This method which is
10 cm long does not exist to a very great level. The patient sees the
right number felt. The advantages of using this method are sensitive to
regulating, easy to understand and work on, and can be used in a
variety of clinical conditions. The disadvantage is that it cannot be
done for children under 8 years and maybe people who use therapy in
severe pain.
Interperation :
1-4 = mild pain
5-6 = moderate pain
7-10 = severe pain.
4c. How to identify of Range of Motion?

Answer:
Range of Motion (ROM) is one of the physical indicators related to
the function of movement. ROM can be interpreted as maximum
movement that is possible in a joint without causing pain.
ROM training is an exercise that moves the joints as optimally and
as broadly as possible according to the ability of a person who does
not cause pain in the joints that are moved. The movement of the
joints will cause an increase in blood flow into the joint capsule. The
decrease in ROM is caused by lack of activity and to maintain ROM
normality, the joints and muscles must be moved to the maximum and
carried out regularly. Static stretching exercises in adulthood can also
increase joint flexibility.
Measurement of joint flexibility by measuring ROM, using
goniometer. Joint flexibility measurement is done before, after 3
weeks and 6 weeks of ROM exercise. Factors affecting ROM are age
and sex, namely ROM in old age is lower than in young age and
women are better than men (Ulliya, 2007)
5. Additional Examination: Blood chemistry: Hb: 14 gr%, Leukocytes

9.000 /mm³, platelets 150x109/L
5a. What is the interpretation of additional examination?

Answer:
Hb: 14 gr% : Normal (13-18 gr%)
Leukocytes : 9000/mm3 : Normal (5000-10000/mm3)
Platelets : 150x109/L : Normal (150-400x109/L)
6. Radiological Examination:
6a. What is the interpretation of radiological examination?
Answer:
The interpretation is glenohumeral dislocation. From the
radiological examination shows that caput humerus is pulled out from
the fossa glenoid.
6b. What are the function of radiological examination?

Answer:
The function of radiological examination are for evaluation
the patient with abnormal musculoskeletal. x-rays in the bones
describe bone density, texture, erosion, and changes in bone
relationships. Multiple X-rays are used for a complete review of the
structure being examined. X-ray bone texture shows widening,
constriction, and irregularity. X-rays in the joint can show fluid,
irregularity, constriction, and changes in joint structure (Noor. Z,
2016).
6c. What are clasification of radiological examination?
Answer:
1. Photo X-rays
X-rays are important for evaluating patients with
musculoskeletal disorders. X-rays in the bones represent bone
density, texture, erosion, and changes in bone relationships.
2. Magneting Resinnce Imaging (MRI)

Magneting Resinnce Imaging (MRI) is a special, noninvasive
imaging technique that uses magnetic fields, radio waves, and
computers to show soft tissue abnormalities, such as muscles,
tendons, and cartilage.
3. Computed Tomogarphy Scan

Computed Tomogarphy Scan (CT Scan) shows details of
certain areas of abnormal bone and can show soft tissue tumors or
injury to ligaments and tendons.
4. Angiography
Angiography is the study of vascular structures (arterial
system). This examination is very useful for assessing arterial
perfusion and can be used for the level of amputation to be
performed.
5. Venogram
Venogram is an assessment of the venous system that is often
used to detect venous thrombosis.
6. Myelography
Injecting contrast material into the lumbar spinal subarachnoid
cavity is performed to see disc herniation, dpinal stenosis, or the
presence of a tumor.
7. Atrography
Artrography is the injection of radiopaque material or air into
the joints to see the soft tissue structure and joint contours.
(Noor. Z, 2016)
6d. What are steps of radiological examination for each examination?

Answer:
Protection of officers and people accompanying patients:
 Found behind the control panel when X rays are being exposed.
 If the patient needs to be taken, make sure the lead-coated apron
has been used by the person who helped.
 Do not allow others to be in the examination room whenever
possible. If other people must be in the examination room, make
sure they are behind the control panel when X-rays are being
exposed.
 If available, always use film badges (measuring the dose of
radiation received). Check badge films regularly.
Protection of patients:
Radiation risk for patients undergoing X-ray examination is
very small because of the rare frequency of exposure and only a
small part of the body of patients exposed to X-rays. Therefore, X-
ray examinations are justified and should always be done if there
are clinical reasons. Even so, always try to get all details at the first
inspection so there is no need for X-ray exposure for the second
time.
Guiding rules for radiographic examination are the ALARA
principle:
The radiation dose for each individual in an X-ray room or an
individual who is in the range of active X-rays must be as low
maybe that is still acceptable or As Low As Reasonably Achieved
(ALARA) by paying attention to social and economic factors.
These rules will be implemented if you obey the things that have
been stated in general principles above, and if you comply with the
instructions for inspection presented in this manual. X-rays are
formed in x-ray tubes emitted out and penetrate the body tissues to
be examined and then captured by the film (Sandstorm, 2011).
7. What is diagnosis in this case?

Answer:
Anamnesis
Complaint of pain and inability to move his right shouldet since 2 hours
ago. After the incident, jojo's right shoulder began to Ache And
immoveable. It followed some swelling and the pain getting intense
when it moves.
Physical Examination
VAS 7
Upper extremities: right shoulder hand
Look: assymetric and swollen, hematome (+)
Feel: tenderness, right shoulder skins was tense is palpated
ROM: shoulder joint range of motion was undetermined due to the pain
Radiological Examination
X-ray examination of the anterior posterior will show

overlapping shadows between the hvaput humerus and the glenoid
fossa, the caput usually located below and medial to the joint bowl.
Lateral photographs directed at the leaf of the scapula will show the
humeral head coming out of the joint bowl.
8. What is differential diagnosis in this case?

Answer:
Dislocation: is a condition where happen lost of normal connection
between two of joint surface with completed.
Sprain : is injury of ligament structure around joint, cause

clamping and turning movement, ligament has function as
protection of stability, but still capable to do mobility. Rip ligament
will lost of stability. Blood vessels will disconnected and edema
will happened, joints feel painful and joint movement feel very
painful.
Strain: is muscle pull cause excessive use, over stretch or over

local stress. Strain is microscopic rip that incomplete with bleeding
in tissue. Patients often complain sudden pain with being local
tenderness of muscle use (Noor. Z, 2016).
9. What is supporting examination in this case?

Jawab:
There is no supporting examination because, we can make the
diagnose from X-Ray.
10. What is working diagnosis in this case?

Answer:
Dislocation of gleno-humeral joint et causa mechanical trauma.
11. How to treat the patient ?

Answer:
Basically, the Three Step Analgesic Ladder Principle can be
applied to chronic pain or acute pain, namely: 12
1. In chronic pain Consider steps up to 1-2-3.
2. In the acute stage, on the contrary, do the steps down the stairs 3-
2-1.
Gambar 9. Three Step Analgesic Ladder WHO
1. Non-opioid analgesic drugs

MEDICINE DOSE SUPPLY
NAME
Paracetamol Tablet Adult: 3-4 x 500 mg daily, Children 500 mg tablet,
6-12 years: 3-4 x 250-500 mg daily syrup 120mg / 5ml
Syrup Child 0-1th: 2.5ml; 1-2th: 5ml; 2-6th:
5-10ml; 6-9 years: 10-15ml; 9-12: 15-20ml.
Ibuprofen Adult &> 12 years old: 3-4x200mg tab Tablet 400mg &
Children 6-12 years old: 3-4x100mg tab 200mg
100mg / 5ml syrup
Asam Adults & children> 14 years old Initial dose: Caplet 500mg,
Mefenamat 500 mg then 250 mg every 6 hours as needed Capsule 250mg,
Syrup 50mg / 5ml
Ketorolac Adults: 10 mg followed by an increase in the IV: 10 or 30mg /
dose of 10-30 mg every 4-6 hours if needed ml
(Max dose 90mg / ml).
2. Therapy
Dislocation reduction must be done as soon as possible. some
interventions in carrying out shoulder reduction include the following:
1. Stimson manuever. This intervention is carried out by setting the
position and giving burden. The patient is set to a prone position with the
arm hanging on the side of the bed with a 90 ° shoulder angle and forward
flexion. Then the wrist is given a load of 15-20 minutes until a reduction
occurs.
2. Manipulation of the scapula. Positions can be carried out in an express
or sitting manner In the prone position, the operator presses the scapula
and the assistant pulls the arm like traction with the load on the stimson
maneuver. In a sitting position, the assistant pushes the scapula and the
operator draws the arm.
3. Traction and contraction methods. Interventions can be carried out by
having to be sedated or anesthetized and in a supine position. Pull slowly
on the arm with the shoulder slightly reduced, while the assistant performs
strong traction on the body (a towel wrapped around the patient's chest)
Post-x-ray reduction is performed to ensure reduction does not cause
fracture. When the patient is fully conscious, active abduction is slowly
tested to rule out an axillary nerve injury. The arm is rested in a sling cloth
for one or two weeks and the active movement then begins, but the
combination of abduction and lateral rotation should be avoided for at
least 3 weeks. During this period, elbow and finger movements are
practiced every day (Noor. Z, 2016).
12. What is the complications in this case?

Answer:
There are 2 complications :
1. Early complications
a. nerve injury. Axillary nerves can be injured; the patient cannot

contract the deltoid muscle and there may be a small area of
numbness in the muscle. This is usually a neurapraxia that resolves
spontaneously after several weeks or several months. sometimes
the posterior brachial plexus cord is injured.
b. Vascular injury. The axillary artery can be damaged. It should
always be checked to look for signs of ischemia.
c. Fracut-dislocation. If there is also a fracture in the proximal part of
the humerus, open reduction and internal fixation may be needed.
2. Advanced complications.
a. Shoulder stiffness. Long immobilization can lead to shoulder

stiffness, especially in patients over the age of 40 years. Loss of
lateral rotation occurs, which automatically limits abduction.
b. Repeated dislocation. If anterior discoloration rips the shoulder
capsule, repair occurs spontaneously and the dislocation does not
recur; but if the glenoi labrum is torn or the capsule is dislodged
from the front of the glenoid neck, chances are that the repair does
not occur and the dislocation often recurs (Noor. Z, 2016).
13. What is prognosis in this case?

Answer:
Quo ad vitam : Bonam
Quo Ad Functionam : Dubia ad bonam
Quo ad sanationam : Bonam
14. What is the General Practitoners Competency Level in this case?

Answer:
3A: doctor graaduates are able to make clinical diagnose and
provide preliminary therapy in emergency situations. Doctor
graduates are able to determine the most appropriate referral and
are able to follow up after returning from the referral.
15. What is the Islamic values in this case?

Answer:
Al-Mu’minunun : 14 :
“ Then we made the semen of blood, and then a lump of blood We

made a lump of meat, and a lump of meat We made the bones, then
the bones We warp with the flesh. Then we made him another
( shaped ) creature. So Glorious is Allah, the most excellent creator
”
“No believer is struck by a calmamity of pain, which are not

healed, tired, painful, anxieties,which are overthrown but his sins
are forgiven” HR : muslim 2573
2.6 Conclusion
Jojo, a 20 years old karateka has complain of pain, swelling, and inability
to move his right shoulder caused dislocation of gleno-humeral joint et
causa mechanical trauma.
2.7 Conceptual Framework
3
Mechanical Trauma
(Kick on right
shoulder)
Inability to Dislocation
move glenohumral joint
Injury
DAFTAR PUSTAKA
Corwin, E.J. 2008. Handbook Of Pathophysiology, Third Edition. Columbus: The

Ohio State University.
Guyton, A.C and Hall, J.E. 2007. Buku Ajar Fisiologi Kedokteran Edisi 11.
Jakarta: EGC.
Kneale Julia D dan Peter S Davis. 2011. Perawatan Orthopedi dan Trauma.
Jakarta: EKG.
Mardana, I.K.R.P dan Aryasa, T. 2017. Penilaian Nyeri. Denpasar: FK

Universitas Udayana.
Noor, Z. 2016. Buku Ajar Gangguan Muskuloskeleter Ed- 2. Jakarta: Salemba

Medika.
Paulsen, F and Waschke, J. 2010. Sobotta Atlas Anatomi Manusia Edisi 23 Jilid 1.
Jakarta: EGC.
Price, S.A. and Wilson, L. M. 2005. Patofisiologi: Konsep Klinis Proses-Proses

Penyakit Edisi 6. Jakarta : EGC.
Price, Sylvia A. 2003. Patofisiologi Vol.II Ed 6. Jakarta: EGC.
Sandstorm. 2011. The WHO Manual of Diagnostic Imaging (radiographic

Technique and Projections). Jakarta: EGC.
Silbernagl, S and Florian Lang. 2016. Teks dan Atlas Berwarna Patofisiologi Ed
3. Jerman: Wurzburg and Tubingen.
Sweiboda, P, et all. 2013. Article Assessment of pain: types, mechanism and

treatment. Poland: Department of Internal Medicine, Medical University, Lublin.
Ulliya, S. 2007. Effect of Range of Motion (ROM) Exercise on Knee Joint

Flexibility in the Elderly at the Home Wreda Wening Wardoyo Ungaran Vol. 1
No. 2. Yogyakarta: FK UNDIP.
Zachilli, M. A., Owens, B. D., 2010. Epidemiology of shoulder dislocation. Bone
Joint Surgery. www.ncbi.nlm.nih.gov/pubmed/20194311.

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CHAPTER I

1.2. Purpose of the report

1|Report of Scenario B Block IX

2.1 Data Tutorial

2.2 Regulation of Tutorial

2|Report of Scenario B Block IX

3|Report of Scenario B Block IX

Pain The feeling of disstressed suffering

4|Report of Scenario B Block IX

2.4 Identification of Problem

5|Report of Scenario B Block IX

6|Report of Scenario B Block IX

1a. What is anatomy, fisiology, and histology of superior extremity?

7|Report of Scenario B Block IX

8|Report of Scenario B Block IX

The innervation of superior extremities comes from the brachial

9|Report of Scenario B Block IX

Joints are divided into 3 types, namely:

Histology of bone, bone growth is devided into two types

1c. What is classification of pain?

• Acute pain: duration < 3 months, acts as a warning defensive (post-

• Survived pain: most often occurs as a result of improper treatment of

Pain can be classified in various ways, namely:

1d. What is relation of age and gender with his complain?

1e. What is pathophysiology of pain and inability to move?

1g. What is etiology of pain?

2. After the incident, Jojo’s right shoulder

The occurrence of this redness is because the arteries that circulate

2.Hot feeling (heat)

Heat and redness occur simultaneously. Where the feeling of heat

Inflammation pain can be caused by several things:

(1) tissue stretching due to edema resulting in an increase in local

The most obvious symptom of inflammation is swelling caused by

Fungsiolaesa is a functional disorder of the tissues affected by

Release Histamin, Bradikin adn PGE2 have vasodilator

2c. What is the range of pain?

A. Visual Analog Scale (VAS)

C. Wong Baker Pain Rating Scale

A. McGill Pain Questionnaire (MPQ)

B. The Brief Pain Inventory (BPI)

C. Memorial Pain Assessment Card

2d. What is the pathophysiology of swelling?

2e. What is etiology of swelling?

 Decreasing plasma protein concentration causes a decrease in

 Increased venous pressure, such as blood blocked in the vein, will

 Increasing the permeability of capillary walls causes plasma

 Blockage of lymph vessels causes edema, because of excess fluid

3. Jojo complains that he can’t move his right

3b. What is possible disease in this case?

Contusion: is injury in soft tissue that caused by blunt trauma

Strain: is muscle pull cause excessive use, over stretch or over

Sprain : is injury of ligament structure around joint, cause

Fractur: is lost of bone dan cartilago continuity, both of total or in

Ruptur: iss lost of tendon continyity, both of total or in part.

Spesific  MTB: 22,6

 Feel : right shoulder skin  Abnormal

4b. What is pathophysiology abnormal of physical examination?

Physical trauma > breakdown of blood supply causing damage to

Trauma causes nosiseptor issue subtanse P, which activate the

Visual Analog Scale (VASs)

4c. How to identify of Range of Motion?

5. Additional Examination: Blood chemistry: Hb: 14 gr%, Leukocytes