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DIPLOMA III PHYSIOTHERAPY STUDY PROGRAM

INSTITUTE OF HEALTH SCIENCE
BAITURRAHIM JAMBI

Serial number : ...... /........ /...........

CLINICAL STATUS REPORT

STUDENT NAME : Sefhia Lestary
NIM : 201951015
PRACTICE PLACE : RSJ Jambi
COACHER : Wanti Hasmar,S.FT,.MOr

Report Date : August 14, 2021

Condition/case : FTA/ FTB/ FTC/ FTD/ FTE

I. GENERAL DESCRIPTION OF SUFFERERS

Name : Mr. Dedy Sianipar
Age : 21 years old

No Reg : 001
Gender : Man

Religion : Christian

Work : Oil palm workers

Address : New city

II. HOSPITAL MEDICAL DATA

a. Medical Diagnosis : Bell's Palsy Sinistra

a. Clinical Notes,
a. Medical Action History, etc. : None

b. Medicine :-
b. Supporting data
a. Lab Results :-
b. X-ray photo c. :-
Etc :-
c. Physiotherapy referral ….. (from whom, fill in the referral)
Please do physiotherapy treatment to Mr. Dedy is 21 years old with a diagnosis
Bell's Palsy
III. ASPECT OF PHYSIOTHERAPY

A. Subjective Examination (Anamnesis)

1.Main Complaint:

The patient complains of numbness, stiffness and tilt on the left side of the face

Complaint Location

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(shows the place/location of the complaint)

3. HISTORY OF PRESENT DISEASE:

About 1 month ago the patient could not close his eyes, then suddenly the patient felt numbness
and stiffness in the left side of his face after doing his daily work in the oil palm plantation.

4. HISTORY OF PREVIOUS DISEASES:

The patient has never had a similar disease

5. HISTORY OF COLLECTING DISEASES

No co-morbidities

6. FAMILY HISTORY:
No family has the same disease

7. PERSONAL HISTORY AND SOCIAL STATUS (Social History and Health Habits)
(Hobby, work environment, place of residence, recreational and leisure activities, social activities) -

B. OBJECTIVE CHECK
1. VITAL SIG EXAMINATION
a) Blood pressure : 130/60mm/hg

b) Pulse : 130 x/minute

c) Respiration : 20 x/minute

d) temperature C

e) Height : 165 cm

f) Weight : 55 kg

2. INSPECTION
a. Static
At rest, the patient's face is asymmetrical

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b. Dynamic

When closing the eyes, the left eye looks imperfect and has difficulty smiling, speaking

3. PALPATION (spasm, tenderness, tone, edema, temperature, etc.):

a. Normal left and right facial temperature
b. No spasm
c. There is tenderness behind the ear

4. PERCUSSION :-
Are not done

5. AUSCULTATION :-
Normal breathing

6. MOTION CHECK
A. Orientation test (determine the location of the complaint)
The patient has difficulty inflating the nostrils, the patient has difficulty smiling symmetrically.

B. Basic Motion Examination

move Ability Symmetrical Asymmetric

+ -
Lifting eyebrows Able
+ -
Close eyes Capable
- +
inflate Can't cover the
nose
- +
Asymmetrical Not capable
smile
Whistling + -
Capable

C. Functional Ability Check (Transfer/Ambulation, ADL, Gait n Balance

Analysis, Tools / not)
The patient is limited to performing basic facial functional abilities such as weakness of the fascia
muscles on the left side of the face, the patient can raise his eyebrows, the patient can close his eyes,
the patient can frown but not perfectly

D. Specific Examination (MMT, ROM, VAS/VDS, Anthropometry, SLR, Mc Murray,

Varus, Spady test, Kats index, Jette index etc)
Examination of functional ability with the Ugo Fisch scale
Position Score
At rest 100% x 20 = 20

Raised eyebrows 70% x 10 = 7

Close eyes 60% x 30 = 18

Smile 30% x 30 = 9
iron 60% x 10 = 6
Amount 60

The Ugo Fisch scale uses 4 ratings:

0% : Asymmetric,No movement
30%: Symmetrical mild, healing tends to asymmetrical and voluntary movement
70%: Symmetrical Moderate, Healing tends to be normal
100% : Normal or Symmetrical
Presentation figures for each position:

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Silent : 20
Raised eyebrows: 10
Closing eyes : 30
Smiling :30
Whistling : 10

Description:
Grade I : Normal (100 points)
Grade II: Mild paralysis (75 – 99 points)
Grade III: Moderate paralysis (50 – 75 points)
Grade IV: Moderate to severe paralysis (25 – 50 points)
Grade V: Severe Paralysis (1-25 Points)
Grade VI: Complete paralysis
Facial Muscle Strength (Facial MMT)

M.Frontalis 3

M. Corrugator superali 3

M.Obricularis oculi 3

M.Nasalis 3

M.Zigomaticum 3

M.Obriccularis oris 3

Pain using the Visual Analogue Scale (VAS)

( Source content/uploads/ : https://med.unhas.ac.id/physiotherapy/wp

2016/12/MEASUREMENT-QUANTITY-PAIN.pdf )
Silent pain : 0
Motion pain : 0
Tenderness: 2

E. COGNITIVE, INTRAPERSONAL AND INTERPERSONAL EXAMINATION

1. Cognitive: the patient is able to know the orientation of time, place and space

2. Intrapersonal: the patient has the spirit to recover

3. Interpersonal: the patient can communicate and cooperate with the therapist

IV. MECHANISM OF PHYSIOTHERAPY PROBLEMS (UNDERLYING)

PROCESS OF PHYSIOTHERAPY)

(Required to include references)

Facial Nerve Disorders

VII

Decreased ability to stimulate

Bell's Palsy
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C. DATA INTERPRETATION
1. IMPAIRMENT
- Decreased facial muscle strength on the left
- Pain behind left ear
- Functional disorders on the face

2. FUNCTIONAL LIMITATION
- Impaired facial expression

- Disturbances in eating and drinking (because food and drink collect in the lesion area)

3. DISABILITY / PARTICIPATION RESTRICTION

The patient complains of feeling less confident when he is first exposed to Bell's Palsy who cannot
socialize in his home environment

4. PHYSIOTHERAPY DIAGNOSIS
Impaired facial expression, pain and weakness of facial muscles on the left side of the face, impaired
expression due to Bell's palsy

D. PHYSIOTHERAPY PROGRAM
1. PURPOSE OF PHYSIOTHERAPY

a. short term: -
Increase muscle strength
- Reduce pain
b. long-term :

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- Improve and maintain functional activity

INTERVENTION TECHNOLOGY
a. Selected / effective (Evidence Based)
- Massage -
Electrical Stimulation
- Infrared
- Mirror Exercise

b. Held
Electrical Stimulation : F : 2x/week

I: patient tolerance
Q: 12 minutes

Massages : F: 2x/week
Q: 1 minute

T : Efflurage

R : 2x repetition

Massages : F: 2x/week
Q: 1 minute

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T : Finger Kneeling
R : 2x repetition

Infrared : F : 2x/week

I: patient tolerance
Q: 12 minutes

T : Faradic

R : 1x repetition
Mirror Exercises: F : 2x/week

I : 5 moves
Q: 8 minutes

T : Mirror Exercise

R : 1x repetition

c. Education:
- Patients are advised to chew gum to increase muscle strength

- Patients are recommended to do therapy regularly

- Use a mask every time you go out
- Patients are advised to reduce the habit of staying up late

V. EVALUATION PLAN
(According to the interpretation of physiotherapy data)
- Functional capabilities with Ugo Ficsh
- Muscle strength with facial MMT
PROGNOSIS (Impairment, Functional Limitation, Disability):
1. Quo Ad Vitam : _________

2. Quo Ad Sanam: _________

3. Quo Ad Function: 4. _________
Quo Ad Cosmetics: a. _________
MANAGEMENT OF PHYSIOTHERAPY:
Implementation of T1

1. Electrical Stimulation
Patient preparation: The therapist's area is free from clothing, metal, sweat and signs of inflammation
Tool Preparation: No exposed wires
Wet pad
Management: Place a pad on the back of the neck and another pad placed on the facial area then move it towards the
patient's chin, cheeks and forehead for 11 minutes.
2. Massage :
Preparation Tools: baby oil
Patient preparation: The patient is supine on the bed
Management: Pour baby oil into the therapist's hand and then wipe the patient's left face for 30 seconds on each part of
the patient's left face for 1 minute and then give the movement. pressure within the patient's tolerance is used to clear
any trigger points found to survive 1 minute with 2 repetitions.

3.Infrared
Patient preparation: The therapist part is free from clothing, metal, sweat
and signs of inflammation

Tool Preparation: No exposed wires

Protective glasses
Management: Point the Infrared to the face on the patient's left set the time for 12 minutes

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4. Mirror Exercise

Patient preparation: The patient is in the most comfortable sitting position possible
Management: First the therapist gives examples of the movements that must be done by the patient then the patient is asked to
imitate these movements, the therapist pays attention and corrects if there are wrong movements. The movements given are:
raising the eyebrows, frowning, bringing the eyebrows closer to the medial, smiling, whistling, and lowering the mouth down.
Therapy is done 8 times repetition of each movement.

T2 Implementation
1. Electrical Stimulation

Patient preparation: The therapist's area is free from clothing, metal, sweat and signs of inflammation
Tool Preparation: No exposed wires Wet pad

Management: Place a pad on the back of the neck and another pad placed on the facial area then move it towards the patient's
chin, cheeks and forehead for 11 minutes.
2. Massage :
Preparation Tools: baby oil
Preparation of the patient: The patient is supine on the
bed Management: Pour baby oil into the therapist's hand then wipe the patient's left face for 30 seconds on each part of the
patient's left face for 1 minute and then give the movement. pressure within the patient's tolerance is used to clear clean any
trigger points found safe 1 minute with 2 repetitions

3.Infrared
Patient preparation: The therapist part is free from clothing, metal, sweat
and signs of inflammation

Tool Preparation: No exposed wires

Protective glasses
Management: Point the Infrared to the face on the patient's left set the time for 12 minutes

4. Mirror Exercise

Patient preparation: The patient is in the most comfortable sitting position possible
Management: First the therapist gives examples of the movements that must be done by the patient then the patient is asked to
imitate these movements, the therapist pays attention and corrects if there are wrong movements. The movements given are:
raising the eyebrows, frowning, bringing the eyebrows closer to the medial, smiling, whistling, and lowering the mouth down.
Therapy is done 8 times repetition of each movement.

Implementation of T3

1. Electrical Stimulation

Patient preparation: The therapist's area is free from clothing, metal, sweat and signs of inflammation
Tool Preparation: No exposed wires
Wet pad

Management: Place a pad on the back of the neck and another pad placed on the facial area then move it towards the patient's
chin, cheeks and forehead for 11 minutes.
2. Massage :
Preparation Tools: baby oil
Preparation of the patient: The patient is supine on the
bed Management: Pour baby oil into the therapist's hand then wipe the patient's left face for 30 seconds on each part of the
patient's left face for 1 minute and then give the movement. pressure within the patient's tolerance is used to clear any trigger
points found to survive 1 minute with 2 repetitions.

3.Infrared
Patient preparation: The therapist's area is free from clothing, metal, sweat
and signs of inflammation

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Tool Preparation: No exposed wires
Protective glasses
Management: Point the Infrared to the face on the patient's left set the time for 12 minutes

4. Mirror Exercise

Patient preparation: The patient is in the most comfortable sitting position possible
Management: First the therapist gives examples of the movements that must be done by the patient then the patient is asked to
imitate these movements, the therapist pays attention and corrects if there are wrong movements. The movements given are:
raising the eyebrows, frowning, bringing the eyebrows closer to the medial, smiling, whistling, and lowering the mouth down.
Therapy is done 8 times repetition of each movement.

Implementation of T4

1. Electrical Stimulation

Patient preparation: The therapist's area is free from clothing, metal, sweat and signs of inflammation
Tool Preparation: No exposed wires
Wet pad
Management: Place a pad on the back of the neck and another pad placed on the facial area then move it towards the patient's
chin, cheeks and forehead for 11 minutes.
2. Massage :
Preparation Tools: baby oil
Preparation of the patient: The patient is supine on the
bed Management: Pour baby oil into the therapist's hand then wipe the patient's left face for 30 seconds on each part of the
patient's left face for 1 minute and then give the movement. pressure within the patient's tolerance is used to clear any trigger
points found to survive 1 minute with 2 repetitions.

3.Infrared
Patient preparation: The therapist part is free from clothing, metal, sweat
and signs of inflammation

Tool Preparation: No exposed wires

Protective glasses
Management: Point the Infrared to the face on the patient's left set the time for 12 minutes

4. Mirror Exercise

Patient preparation: The patient is in the most comfortable sitting position possible
Management: First the therapist gives examples of the movements that must be done by the patient then the patient is asked to
imitate these movements, the therapist pays attention and corrects if there are wrong movements. The movements given are:
raising the eyebrows, frowning, bringing the eyebrows closer to the medial, smiling, whistling, and lowering the mouth down.
Therapy is done 8 times repetition of each movement.

Evaluation (After Therapeutic Action / per date):

1. Subjective
- There is an increase in facial muscle strength after several treatments

- There is a decrease in numbness on the left side of the face after several treatments

2. Objective

Results of Evaluation of Facial Muscle Strength

T
Muscle Name T1 2 T3 T4
m. frontalist 3 3 3 4

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m. super corugator 3 3 4 4

m. orbicularis oculi 2 3 3 3

m. nasalist 3 3 4 4

m. zygomaticum 2 3 3 3

m. orbigularis oris 3 3 4 4

Pain Evaluation Results

Painful T1 T2 T3 T4

Silent
0 0 0 0
pain

Motion
0 0 0 0
pain

2 2 2 1
Tenderness

ugo fisch evaluasi evaluation results

T
Component Which
T T T
In 1 2 3 4
Evaluation

2
Shut up/rest 20 0 20 20

Raised eyebrows 7 7 7 10

Close eyes 18 8 18 18

Smile 9 9 9 9

Whistling 6 6 6 6

3. Action

- Electrical Stimulation can increase facial muscle strength and functional ability
facial muscles
- Massage can relax and reduce pain due to inflammation of the facial nerve
-
Infrared can accelerate blood circulation 4. Planning:
Further therapy is needed
- Mirror Exercise can improve facial nerve function and the healing process.

VI. LAST THERAPY RESULTS:

After the patient has received therapy 4 times, get results

a. There is an increase in functional facial muscles in the form of facial expressions
b. Patient recovery tends to be normal
c. Numbness is gone
d. There is a reduction in tenderness behind the ear.

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- PRACTICE GUIDING NOTES:

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COACHER

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NIP.

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