I. IDENTITY (April 6th, 2023) DRE/SAR/dr. AL, Sp.K.F.R., M.S.

(K)
Name : Mrs. R
Age : 59 yo
Sex : Female
Marrital Status : Married
Religion : Catholic
Address : Mojokerto
Occupation : Administration Staff
Referred from Internal Medicine OPC with Spondylarthritis Axial + Suspek Massa Paru

II. HISTORY TAKING

Chief Complaint : Nyeri punggung bawah

History of Present Illness:

The patient complained of low back pain since 3 weeks ago, after she fell in a sitting position when she
was about to sit on a chair. The pain was felt in the middle buttock area around the tailbone (WBS 8).
The pain is local and does not radiate, there is no tingling, numbness, no weakness. Pain is worse when
the patient sits on a hard surface, pain improves in a lying position. The pain made it difficult for her to
walk. The pain did not improve so she was taken to the RKZ ER, then referred to RSDS for further
treatment. Patient admitted to Kemuning Room RSDS from 27 March - 3 April 2023, she received a
rehabilitation program.

Three months earlier, the patient complained of swollen legs. As the days went by, her legs and hands
became increasingly stiff, making it difficult for her to walk and grip. The patient walked by holding on to
surrounding objects or was assisted by her daughter.

In the last 1 week, the patient's condition was getting weaker, so she only lay in bed. Pain in the low
back area was still felt with WBS 3 (felt "kemeng"). She was able to rolling right/left, but unable to
change position from lying to sitting by herself. She defecates and urinates using diapers. She could not
walk due to weakness and stiffness. She is able to eat by herself or be fed by her daughter. She is a
vegetarian since more than 10 years ago. There is no complain of cough or shortness of breath. There is
no complaint of night sweats and prolonged fever. Her bodyweight is decreasing since 3 months ago.

History of Functional Ability:

The patient is bedridden. She is able to feed herself or be fed by her child. The patient bathes with
wiping, dresses with the help of her daughter. She can feel if she is going to defecate and urinate,
defecate and urinate using diapers. She needs help to change position from lying to sitting. She is unable
to sit without backrest, stand up and walk by herself.

History of Medication and Rehabilitation:

 Internal Medicine: Asam Folat 2x1, Paracetamol 500 mg if pain, Albumin 3x2 caps, Vit D3 1x1
 Pulmonary: planning of thorax CT-Scan next week.
 PMR: received PMR program in Kemuning RSDS.

History of Past Illness:

Diabetes Mellitus, Hypertension, Stroke, Tumor, and Cardiology problem were denied.
Trauma (+) 20 years ago, neglected fracture of the right wrist, but able to do ADL.
History of Work/Hobby:
She worked as an administrative staff at PT Dirgantara, still working until just before her illness. Her job
involves a lot of sitting. There is no specific hobby.

History of Psycho-socio-economic:
The patient is originally from Mojokerto, while working in Surabaya the patient lived in her own
boarding house. The patient has a daughter (27 years old, social media parttimer, bachelor degree) living
in Mojokerto. Since the patient became ill, her daughter has accompanied her to the boarding house in
Surabaya.

Family History:
No family history of disease or complaints similar to the patient's.

Patient’s Expectation:
She can walk again

III. PHYSICAL EXAMINATION

III.1 General Status
GCS: 456 BP: 100/70 mmHg HR: 80x/min, regular T: 37,0°C SpO2: 98%
BMI: impression underweight
Posture: DTE
Ambulation: wheelchair, at home: bedridden
Dominant Extremity: Right-handed

Head and neck : Conjunctiva anemia (+|+), icterus (-|-), cyanosis (-), enlargement lymph node (-)
Cor : S1-S2 normal, regular, murmur (-), gallop (-)
Pulmo : Vesicular (+|+), wheezing (-|-), ronchi (-|-)
Abdomen : supple, peristaltic (+), tenderness (-)
Extremities : Warm acral (+|+), edema (-|-), CRT < 2 seconds, atrophy muscle of UE and LE (+/+)

III.2. Head/Neck/Trunk
Look : deformity (-), sweeling (-), bruises (+) at sacrum area
Feel : tender point (+) at sacrum area, paralumbal muscle spasm (-/-)
Move : pain when move (+) at sacrum area
Sensoric : no deficit
Propioceptive : Normal
Special Test : SLR -/-, Bragard -/-, Siccard -/-, Thomas -/-, Patrick -/-, Contra patrick -/-, Pelvic
compression -/-, Hamstring tightness +/+

Movement ROM Muscles MMT

Neck Flexion (0-450) F Flexor 5
Extension (0-450) F Extensor 5
Lateral flexion (0-450) F Lateral flexor 5
Rotation (0-600) F Rotator 5
Trunk Flexion(0-850) Flexor
Extension (0-300) Extensor
NE Impression <= 3
Lateral flexion (0-350) Lateral flexor
Rotation (0-450) Rotator
III.3. Upper Extremities Region
Look : redness (-|-), swelling (-|-), atrophy intrinsic muscles of hand (+/+), deformity (+)
neglected fracture of right wrist
Feel : warmth (-|-), tender point (-|-), crepitation (-|-)
Move : pain (-|-)
Neuromuscular :
- Muscle tone : normal
- Deep Tendon Reflex : BPR (+2|+2), TPR (+2|+2)
- Pathological reflex : Hoffmann (-|-), Tromner (-|-)
- Sensorics : normal
- Propioceptive : normal
- Special test :-
Region Movement ROM Movement MMT
0
Shoulder Flexion(0-180 ) F/F Flexor 4/4
Extension (0-600) F/F Extensor 4/4
Abduction(0-1800) F/F Abductor 4/4
0
Adduction(0-45 ) F/F Adductor 4/4
Internal Rotation (0-900) F/F Internal Rotator 4/4
0
External Rotation (0-70 ) F/F External Rotator 4/4
Elbow Flexion(0-1350) F/F Flexor 4/4
Extension (135º-0) F/F Extensor 4/4
0
Pronation (0-90 ) F/F Pronator 4/4
Supination(0-900) F/F Supinator 4/4
0
Wrist Flexion (0-80 ) F/F Flexor 4/4
Extension (0-700) F/F Extensor 4/4
Radial deviation (0-200) F/F Radial Deviator 4/4
0
Ulnar deviation (0-35 ) F/F Ulnar Deviator 4/4
Fingers Flexion F/F Flexor 4/4
Extension F/F Extensor 4/4
Abduction F/F Abductor 4/4
Adduction F/F Adductor 4/4

III.4. Lower Extremities Region.

Look : atrophy (+|+), redness (-|-), swelling (-|-), deformity High arch (+/+), Claw toes (+/-)
Feel : decreased muscle tone (+|+) of lower extremity, warmth (-|-), crepitation (-|-),
tenderness (-|-)
Move : pain when move (-|-)
Neuromuscular :
- Tonus : decreased tone (+/+)
- Deep Tendon Reflex : KPR +2 | +2 ; APR +2 | +2
- Pathological reflex : Babinski (-|-) Chaddock (-|-)
- Sensorics : deficit L5-S1 50%
- Propioceptive : normal
- Special Test : Hamstring tightness (+|+)
- ALL : 90/90 cm
- TLL: Femur: 45/45 cm, Cruris: 37/37 cm
 Region Movement ROM Movement MMT
Hip Flexion(0-1250) F/F Flexor 3/3
Extension (0-300) F/F Extensor 3/3
Abduction (0-450) F/F Abductor 3/3
Adduction (0-200) F/F Adductor 3/3
Internal Rotation (0-450) F/F Internal Rotator 3/3
External Rotation (0-450) F/F External Rotator 3/3
Knee Flexion (0-1350) F/F Flexor 4/4
Extension (1350-0) F/F Extensor 4/4
Ankle Dorsiflexion (0-200) 0° end feel hard Dorsiflexor
/0-10° end feel
springy
Plantarflexion (0-500) 0-5° end feel Plantarflexor
hard /0-20° end 1/2
feel springy 1/2
Eversion (0-150) 0° end feel Evertor 1/2
hard /0-10° end 1/2
feel springy
Inversion (0-350) 0° end feel Invertor
hard /0-10° end
feel springy
Big Toes Flexion F/F Flexor 2/2
Extension F/F Extensor 2/2
Toes Flexion F/F Flexor 2/2
Extension F/F Extensor 2/2

Sensoric MMT Dermatome and Myotome MMT Sensorics

s
100% 3 L2 3 100%
100% 4 L3 4 100%
100% 1 L4 2 100%
50% 2 L5 2 50%
50% 1 S1 2 50%

III.5. Functional Status

Balance : sitting (static and dynamic) poor, standing not tested
Balance Test : not tested
Transfer : Lying to sitting able with support, sitting to standing not tested
Coordination : Dysdiadokokinesia: -|-, finger to nose: +|+
Count test : 10
Chest expansion : 2/2/2cm

Feeding 5/10 Bladder 5/10

Grooming 5/5 Toilet use 0/10
Bathing 0/5 Mobility 0/15
Dressing 5/10 Transfer 0/15
 Bowel 5/10 Stairs 0/10
Barthel Index : 25 (severe dependency)

SUPPORTING EXAMINATION
Thorax X-ray AP/Lateral (RSDS, 27/3/2023)
- Multiple nodul ukuran bervariasi batas tidak tegas dengan ukuran terbesar -/+ 4cm di parahilar
kanan sisi posterolateral disertai dengan penebalan fissure minor kesan subpleural dapat
merupakan proses metastase (mohon evaluasi lebih lanjut)
- Curiga pneumothorax
- Loculated pleural effusion kanan

Lumbosacral X-ray AP/Lateral (RSDS, 27/3/2023)

- Osteopenia
- Tak tampak proses metastase pada tulang-tulang yang tervisualisasi

PROBLEM LIST
 Low back pain
 Prolonged immobilization
 Suspect spondyloarthropathy
 Suspect lung metastase
 ADL dependent
 Unable to transfer from lying to sitting
 Poor sitting balance
 weakness lower extremities
 ROM limitation of bilateral ankle
 Bilateral pes cavus
 Suspect Charcot Marie Tooth
 Decubitus ulcer region sacrum
 Reduced cardiopulmonary status
 Underweight impression

ICF
Body Function
b280 Sensation of pain (pain at sacrum area, WBS 3)
b440 Respiration functions (decreased count test and chest expansion test)
b530 Weight maintenance functions (impression of underweight)
b710 Mobility of joint functions (limited ROM of both ankle)
b730 Muscle power functions (weakness of trunk, upper and lower extremities)
b735 Muscle tone functions (decreased tone of upper and lower extremities)
b740 Muscle endurance functions (unable sitting without support)
Body Structure
s730 Structure of upper extremity (neglected fracture of right wrist)
s750 Structure of lower extremity (muscle atrophy, contracture of ankle joint)
s810 Structure of areas of skin (bruise at sacrum area)
Activity and Participation
d230 Carrying out daily routine (bedridden)
d410 Changing basic body position (unable to change from lying to sitting, sitting to standing)
d415 Maintaining a body position (unable to sit without back support, unable to stand)
d440 Fine hand use (difficulty in grasping and handling object because of stiffness and weakness)
d450 Walking (unable to walk because of weakness)
d510 Washing oneself (bedridden, wipe by her daughter)
d530 Toileting (using diaper)
d540 Dressing (being helped by her daughter)
d850 Remunerative employment (cannot go to work due to health condition)
Environmental Factor
e310 Immediate family (supportive daughter)
e355 Health professionals (treated by internal medicine, pulmonary, and PMR doctors)
e580 Health services, systems and policies (covered by BPJS)

ASSESSMENT
Low Back Pain et Prolonged Immobilization ec Suspect Spondyloarthropathy + Suspect Lung Metastase +
Lower Extremity Weakness et Bilateral Pes Cavus ec Suspect Charcot Marie Tooth + Ulcus Decubitus
Regio Sacrum (Improved) + Underweight Impression.

PROGNOSIS
Ad vitam : Dubia ad Bonam
Ad sanactionam : Dubia ad Malam
Ad functionam :
- Transfer : bed mobility, lying to sitting, sitting to standing independent
- Ambulation : independent walking with or without assistive device
- Other ADL : minimal dependent with Barthel Index >90

GOALS
Short term:
1. Established the diagnosis
2. Reduced further complication of prolong immobilization (pain, atrophy, weakness, contracture)
3. Reduced back pain (from WBS 3 to 0-1)
4. Independent transfer from lying to sitting
5. Good sitting balance and tolerance
6. Improved muscle strength of upper and lower extremities (MMT improved 1 level)
7. Improved sensory function (10-20%)
8. Improved respiratory function (CT >20, CE 2,5/2,5/2,5)

Long term:
1. Prevented worsening of condition
2. Achieved good posture
3. Improved respiratory function (CT >25, CE 3/3/3)
4. Improved ADL (BI from severe to mild dependent)
5. Normal sensory function
6. Improved bodyweight
7. Safe transfer and ambulation with proper assistive device
8. Better quality of life.

PLAN
PDx: EMG-NCV (pending until review Thorax CT Scan), evaluate HDRS, suggest consult to nutritionist
PTx:
Modality:
 NMES Galvanic Current at bilateral ankle plantar flexor and dorsiflexor until visible muscle
contraction for 20 minutes.

Therapeutic Exercise: precaution : avoid fatigue

 Bed mobility exercise
 Transfer exercise from lying to sitting
 Gradual passive sitting mobilization as patient tolerance
 Posture correction
 Active breathing exercise with deep breathing
 Chest expansion exercise
 Cores strengthening exercise with abdominal drawing in
 ROM exercise of bilateral upper and lower extremities according to ADL (AROM if MMT >=3,
AAROM if MMT 2, and PROM if MMT 0-1)
 Strengthening exercise bilateral upper and lower extremities as patient tolerance
 Gentle stretching of bilateral ankle to dorsiflexion
 Sensory resensitization

PMx: vital sign, clinical findings, WBS, ROM, MMT, decubitus ulcer, count test, chest expansion, sensory
function, transfer ability

PEdx:
1. Explain patient condition, prognosis, rehabilitation program she will get, and goal of the
rehabilitation program.
2. Proper positioning when supine and sitting
3. Continue exercise at home : breathing exercise, ROM exercise, bed mobility exercise, SLR
modified exercise, axial loading exercise both lower extremity, endurance exercise by lifting
water bottle with Borg scale 11-12
4. Turning to the left and right every 2 hours while lying on bed
5. Icing when pain, duration: 20 minutes, at tender area, can be repeated every 4 hours
6. Continue control to internal medicine and pulmonary OPC.