ijIDENTITY (December 14th, 2022) NDI/SOF/ dr. DW, Sp.K.F.R., Ped.

(K)
Name : Mrs. A
Age : 48 years old
Sex : Female
Religion : Moslem
Marital Status : Married
Address : Surabaya
Occupation : Admistration Officer
Referred from Neurology OPC with Hemiparese sinistra + hemihipoestesia sinistra + suspect stroke infark +
suspect CPSP + sindrom piriformis.

AUTOANAMNESIS
II.1. Chief Complaint: Lemah anggota gerak kiri

II.2. History of Present Illness:

The patient complained about weakness of her left extremities since 4 months ago. At first, she felt
like tingling on her left side of body that gradually become weakness. She realized when she was holding or
grabbing things, they would easily almost fell. Sometimes she had feebly walk, especially whe she was in
headache. She constantly felt headache at the left head. Felt like cekot-cekot. Aggravated in uncertain time.
There was no decrease in consciousness. Sometimes she felt nausea along with the headache, but not
vomiting. WBS 6-7. Relieved when she took medication. WBS 3-4. She also has slurred speech. She felt
slightly heavy and unclear when talking. She has no problem in eating or drinking. Never get choked. No
pocketing. She went to PKM, got medications for weeks. Since there was no improvement, she then reffered
to RSDS for further examination.
She also felt pain on her right and left buttocks (left more than the right) since 3 months ago. Initially
the pain was intermittent but now it is persistent. The pain felt like njarem. It is radiating to the left knee.
Mostly aggavated when she was sitting on the floor for too long. WBS 8. The pain relieved when she took
painkiller. WBS 4. There was also tingling sensation from her left buttock to left sole.

II.3. History of Functional Ability: She is able to do ADL independently. She still went to work like usual
and do household chores like cooking, washing, sweeping. She felt slightly weak when using her left hand to
carry things like glass, plate or wok. No complaint in urination and defecation.

II.4. History of Medication and Rehabilitation: She received medications from Neuro OPC: Capsul of
Paracetamol 400 mg/Diazepam 1mg/ Amitriptyline 12,5 mg 2 times a day and vitamins. She is planned to
have head ct scan at January 5th 2023.

II.5. History of Past Illness: History of Hyepertension, Cardiovascular disease, Diabetes Mellitus and trauma
were denied. Hyperthyroid (+) 15 years ago.

II.6. History of Hobby and Work: She is a high school graduate working as an administration officer.
Working 6 days a week. 8 hours each day. No spesific Hobby.

II.7. History of Psycho-Social-Economic: She lives in 1 storey-house with his husband (50 yo,unemployed),
first daughter (20 yo) and second daughter (19 yo, a student). They have squatting toilet.

II.8. Family History: There was no history the same ilness in her family.

II.9. Patient’s Expectation: She wants her left hand to be normal again and pain free.

PHYSICAL EXAMINATION
III.1. General Status
GCS E4 V5 M6
BP: 120/70 mmHg, MAP: 103 mmHg, HR: 97x/min, RR: 20x/min, Temp: 36.5oC, SpO2: 98%
Height: 154, Weight: 53, BMI: 23.04 (Normoweight).
Dominant extremity: Righthanded. Ambulation: independent.

Conjunctiva anemia (-|-), icterus (-|-), cyanosis (-), enlargement lymph node (-)
Cor : S1-S2 normal, regular, murmur (-), gallop (-)
Pulmo : Vesicular (+|+), wheezing (-|-), ronchi (-|-)
Abdomen : Soefl, peristaltic (+), tenderness (-)
Extremities : Warm acral (+|+), cyanosis (-), edema (-|-)

III.2. Head/Neck/Trunk,
Look : deformity (-|-), swelling (-|-) knock sign (-), doorbell sign (-),
Feel : tender point (-|-), warmth (-|-), edema (-|-)
Move : pain when move (-)
Sensoric : Normal
Region Joint Movement Muscles Strength
Range of Motion MMT
Neck Full 5
Trunk Full 5
Special test : SLR -/-, braggard -/-, Sicard -/-, piriformis test +/+ , freiberg +/+, pace manuver -/-
Sensory : wnl

Neuromuscular :
Cranial Nerve Right Left Reflex / Special Test
Cranial Nerve I Normal Normal
Cranial Nerve II Normal Normal Direct Light Reflex (+|+)
Indirect Light Reflex (+|+)
Cranial Nerve III Normal Normal
Cranial Nerve IV Normal Normal
Cranial Nerve V Normal Normal
Cranial Nerve VI Normal Normal
Cranial Nerve VII Normal Normal
Cranial Nerve VIII Normal Normal Fukuda Test (-)
Cranial Nerve IX Gag reflex (+) Normal
Cranial Nerve X Gag reflex (+) Normal
Cranial Nerve XI Normal Normal
Cranial Nerve XII Normal Normal Nerve lingual palsy (+)

III.3. Upper Extremities Region

Look : redness (-|-), edema (-|-), no shoulder subluxation.
Feel : warmth (-|-), tender point (-|-), crepitation (-|-)
Move : pain when move (-|-)

Neuromuscular :
- Spasticity :-
- Deep Tendon Reflex: BPR (+2|+3), TPR (+2|+3)
- Pathological reflex : Hoffmann (-|-), Tromner (-|-)
- Sensorics :
Exteroceptive: deficit sensory 20-40% at left arm and forearm
Proprioception: good|good

Region Movement ROM Movement MMT

Shoulder Flexion(0-1800) F/F Flexor 5/4
Extension (0-600) F/F Extensor 5/4
Abduction(0-1800) F/F Abductor 5/4
Adduction(0-450) F/F Adductor 5/4
Internal Rotation (0-900) F/F Internal Rotator 5/4
External Rotation (0-700) F/F External Rotator 5/4
 Elbow Flexion(0-1350) F/F Flexor 5/4
Extension (135º-0) F/F Extensor 5/4
Pronation (0-900) F/F Pronator 5/4
Supination(0-900) F/F Supinator 5/4
Wrist Flexion (0-800) F/F Flexor 5/4
Extension (0-700) F/F Extensor 5/4
Radial deviation (0-200) F/F Radial Deviator 5/4
Ulnar deviation (0-350) F/F Ulnar Deviator 5/4
Fingers Flexion F/F Flexor 5/4
Extension F/F Extensor 5/4
Abduction F/F Abductor 5/4
Adduction F/F Adductor 5/4
Hand Function: Grasp F/WF, Cylindrical F/F, Spherical F/WF, Hook F/F, Pinch F/F, Lateral Tip
F/WF

III.4. Lower Extremities Region.

Look : redness (-|-)
Feel : warmth (-|-), crepitation (-|-), Tender point at left buttock (+)
Move : pain when move (-|-)
Neuromuscular :
- Spasticity :-
- Deep Tendon Reflex: KPR +2|+3; APR +2|+3
- Pathological reflex : Babinski (-|-), Chaddock (-|-)
- Sensorics :
Exteroceptive : deficit sensory 10-30% at left cruris
proprioception : good|good
Region Movement ROM Movement MMT
Hip Flexion(0-1250) F/F Flexor 5/4
Extension (0-300) F/F Extensor 5/4
Abduction (0-450) F/F Abductor 5/4
Adduction (0-200) F/F Adductor 5/4
Internal Rotation (0-450) F/F Internal Rotator 5/4
External Rotation (0-450) F/F External Rotator 5/4
Knee Flexion (0-1350) F/F Flexor 5/4
Extension (135º-0) F/F Extensor 5/4
Ankle Dorsiflexion (0-200) F/F Dorsiflexor 5/4
Plantarflexion (0-500) F/F Plantarflexor 5/4
Eversion (0-150) F/F Evertor 5/4
Inversion (0-350) F/F Invertor 5/4
Big Toes Flexion F/F Flexor 5/4
Extension F/F Extensor 5/4
Toes Flexion F/F Flexor 5/4
Extension F/F Extensor 5/4

III.5. Functional Status

Balance : Sitting balance (static and dynamic) good, standing balance (static and
dynamic) good
Mobilization : Lying to sitting able, sitting to standing able
Count test : 23
Chest expansion : 3 cm/3 cm/3 cm
Coordination : Finger to nose able, dysdiadochokinesia (-)
Extinction Phenomenon :-
Hemineglect :-
Communication : Fluent +, comprehension good, repetition good, naming good.
Orientation
 Place : good
 Time : good
  People : good
MocaINA : 30/30 (No Cognitive disturbance)
Barthel Index : 100

Feeding 10/10 Bladder 10/10

Grooming 5/5 Toilet use 10/10
Bathing 5/5 Mobility 15/15
Dressing 10/10 Transfer 15/15
Bowel 10/10 Stairs 10/10

SUPPORTING EXAMINATION
USG Gluteus kanan kiri (December 12th, 2022):
Temuan di atas curiga suatu scitic neuritis kanan kiri (kiri lebih berat) disertai penebalan m. piriformis kiri
minimal

PROBLEM LIST
o Left hemiparesis
o Balance disturbance
o Post Stroke Thrombotic 1st attack
o Bilateral buttock pain
o Decrease of count test and chest expansion

ICF
Body Function:
b265.Touch function (Sensory deficit)
b280. Sensation of pain (right and left buttock pain)
b730. Muscle Power Function (Left hemiparesis)
b440. Respiration function (Decrease of chest expansion and count test)
b730. Muscle power functions (Left extremity muscle weakness)
Body Structure:
s110. Structure of brain (Post stroke thrombotic)
s730. Structure of upper extremity (Left upper extremity weakness)
s750. Structure of lower extremity (Left lower extremity weakness)
s760. Structure of trunk (Piriformis syndrome)
Activities and Participation:
d415. Maintaining Body Position (Balance disturbance)
Environmental Factors:
e310. Immediate family (Families support)
e580. Health Services, System and Policy (Patient covered by BPJS)

ASSESSMENT
Left Hemiparesis et Balance Disturbance ec Suspect Stroke Infarct 1st Attack (4 Months) + Suspect CPSP +
Bilateral Buttock Pain ec Piriformis Syndrome

PROGNOSIS
Ad vitam : Bonam
Ad sanactionam : Bonam
Ad functionam :
- Transfer : Independent
- Ambulation : Independent
- Other ADL : Independent

Goals:
Short Term Goals:
1. Reduce pain
2. Improved left upper and lower extremity muscle weakness
3. Improved balance
4. Improved respiratory function until reaches normal count test and chest expansion

Long Term Goals:

1. Control risk factor and prevent recurrency of stroke
2. Able to do ADL independently
3. Improve quality of life

Planning
PDx:
Review the head CT Scan result (January 5th, 2023)
LOTCA

PTx:
Medicamentosa: continue medication from Neurology OPC
Modalities:
USD 1 MHz 2 watt/cm2 at the right and left piriformis muscle for 10 minutes followed by gentle stretching
to hip internal rotation.
Thera Exercise:
 AROM exercise right and left UE LE
 Balance training with tandem walking followed by perturbation woble board
 If pain is decreased, gentle stretching of piriformis muscle to hip internal roatation.
 Breathing exercise active with diaphragmatic breathing and relaxation positioning when the pain is
occurred
 Sensory reeducation
 Endurance exercise:
F:3-5x/week
I: 40-60% HRR + HR Rest
T: 30 minutes
T: static cycle
PMx: Vital sign, Clinical, MMT, WBS, Balance, Barthel index, Cardiopulmonary endurance
PEx:
 Explain about her condition, rehab planning and goals
 Continue exercises at home
 Stimulation on both side especially on the left side
 Articlation exercise
 Routine control to Neurologic OPC