Patient: Mrs.

T/45 yo/11607748/Housewife/Malang
Referred from : Oncology department: Ca mammae post op
Resident: ZUL/SAN/AIK
Anamnesis Problem List Diagnosis Planning
Chief Complaint: stiffness at left shoulder since Medical: Clinical diagnosis: PDx: -
1 month ago Frozen shoulder S ec Ca mammae Frozen shoulder S ec Ca PTx : Continue medication from
History of Present Illness : S post MRM (1 month) mammae S post MRM (1 oncology
o The patient complained stiffness at rleft Surgical: - month)
shoulder since 1 month ago Modality :
R1 (M): - - TENS at Shoulder S, high
• The patient had difficulty to move her R2 (A): - Functional diagnosis : intensity 50-100 Hz, intensity
shoulder to do overhead activity R3 (C): - Impairment: as patient’s tolerance,
when reach something R4 (P): - • ROM Limitation of Shoulder duration 15 minutes, 2x/week
o The stiffness accompanied with right S - Cryotherapy at shoulder S,
R5 (S): - • Reduce breathing capacity start from low level, intensity
shoulder pain
• Pain was dull, intermittent, and didn’t R6 (V): Difficulty to work and • Improper posture as patient tolerance, 3 minute,
radiated household task Disability : 2x/week
• Pain worsens by moving the shoulder R7 (O): • Difficulty to lifting heavy Exercise :
(flexion, abduction and external • ROM Limitation of Shoulder S object •AROM exercise at UE D/S
rotation)(NRS 4) and lift object and • Reduce breathing capacity • Difficulty to do household • Pendulum Exercise
relieved by rest (NRS 0) • Improper posture task • Wall climbing exercise
• Difficulty to lifting heavy object •Stretching at shoulder S
• There were no tingling and numbness Handicap: • Frequency: 2-3x/week
sensation on the right shoulder were • Difficulty to work • Intensity: To the point of
denied feeling tightness or slight
o there were no history of trauma, fever, and discomfort
reduce body weight • Time: 15 s hold for static
stretching
• Type: static
• Posture correction with
kinesthetic awareness
• Active Breathing exercise
Patient: Mrs.T/45 yo/11607748/Housewife/Malang
Referred from : Oncology department: Ca mammae post op
Resident: ZUL/SAN/AIK

Anamnesis Problem List Diagnosis Planning

PMo: Subjective, NRS, ROM,

History of Past Illness :
breathing capacity, posture
Ca mammae (+) since 1 year HT (-) , DM (-),
Heart Disease (-), Trauma (-) PEd:
-Explain about patient’s
History of Family Illness : condition
No family history of related to the patient -Purpose and benefit of PMR
conditions.
Medication : therapy
- -Routine control to PMR clinic
-Continue exercise at home
-Icing when in pain
Patient: Mrs.T/45 yo/11607748/Housewife/Malang
Referred from : Oncology department: Ca mammae post op
Resident: ZUL/SAN/AIK
Anamnesis
Functional activity :
• Patient is a housewife. Due to her current condition Patient had difficulty to lift object and
do household task
• Patient able to do ADL without difficulty
• Patient didn’t have any particular hobby

History of Hobby and Work :

Patient has no particular hobby.

Psycho-Socio-Economic
• Patient did not worry nor stress about her condition
• The patient is married, lives with her family
• Husband– 45 y.o – Farmer
• son – 14 y.o – junior high School
• Current expenses for daily living were covered by her husband
• Patient lives in a 1-storey house. There were no stairs in entrance of the house. From the
door to patient’s bedroom was approx. 3 m. The bathroom distance to patient’s bedroom
was approx. 3 m with sitting closet.
• Economic status: low Class
• Health payment: BPJS
Patient hope/wish:
She hope the stiffness relieved and able to do household task without difficulty.
Barthel Index
2 3

2
20/20 3
Independent
1
2

2
2

2
1
20
Patient: Mrs.T/45 yo/11607748/Housewife/Malang
Referred from : Oncology department: Ca mammae post op
Resident: ZUL/SAN/AIK

Positive Finding
Physical Exam : Physiological Reflex :
GCS : 456 (Compos Mentis) • BPR : +2/+2
BP : 120/82 mmHg • TPR : +2/+2
HR: 79x/m RR: 18x/m SpO2: 98% • KPR : +2/+2
BW : 44 kg BH: 150 cm BMI: 19,5 ( normoweight) • APR : +2/+2
Ambulation : independent Pathological Reflex :
Cranial Nerve : N. I-XII : Normal • Hoffman -/-
Head and Neck : Anemic (-), Jaundice (-), Cyanosis (-) • Tromner -/-
Thorax : • Babinski -/-
• Cor : S1-S2 single, murmur (-), gallop (-) • Chaddock -/-
• Pulmo : RH -/- WH -/-
• Chest expansion : 2,5 – 2,5– 2,5 cm
• Breath count test : 25– 22 – 23
Abdomen : soefl, hepar & lien unpalpable, pain (-)
Extremities : warm +/+ oedema -/-
Skin: normal
Musculoskeletal Examination
NECK AROM MMT
Flexion F (0-450) 5/5
Extension F (0-450) 5/5
Lateral bending F/F (0-450) 5/5

Rotation F/F (0-600) 5/5

TRUNK AROM MMT

Flexion F (0-800) 5
Extension NT NT
Lateral bending F/F (0-350) 5/5
Rotation F/F (0-450) 5/5
 Musculoskeletal Examination
SHOULDER AROM PROM END FEEL MMT

Flexion F (0-180°) /(0-80°) F (0-180°) /(0-90°) Firm 5/2

Extension F/F 0-60° F/F 0-60° - 5/5

Abduction F (0-180°)/ (0-30°) F (0-180°)/ (0-45°) Firm 5/2

Adduction F/F (0-45°) F/F (0-45°) - 5/5

Internal rotation F/F (0-70°) F/F (0-70°) - 5/5

Eksternal rotation F/ F (0-70°) F/ F (0-70°) - 5/5

 Musculoskeletal Examination
ELBOW AROM MMT WRIST ROM MMT
Flexion F/F (0-1500) 5/5 Flexion F/F (0-800) 5/5
Extension F/F(0-800) 5/5
Extension F/F (1500-0) 5/5
Ulnar deviation F/F (0-300) 5/5
Supination F/F (0-900) 5/5 Radial deviation F/F (0-200) 5/5
Pronation F/F (0-900) 5/5

THUMB ROM MMT

Flexion
MCP F/F (0-500) 5/5
IP F/F (0-900) 5/5
Extension F/F (0-200) 5/5
Abduction F/F (0-700) 5/5
Adduction F/F (700-0) 5/5
Opposition F/F 5/5
Musculoskeletal Examination
FINGERS AROM MMT
Flexion
MCP F/F (0-900) 5/5
PIP F/F (0-1000) 5/5
DIP F/F (0-900) 5/5
Extension F/F (0-300) 5/5
Abduction F/F (0-200) 5/5
Adduction F/F (200-0) 5/5
Musculoskeletal Examination
HIP AROM MMT
Flexion F/F (0-1200) 5/5
Extension F/F (0-300) 5/5
Abduction F/F (0-450) 5/5
Adduction F/F (0-300) 5/5
Internal rotation F/F (0-350) 5/5
External rotation F/F (0-450) 5/5

KNEE AROM MMT

Flexion F/F (0-1350) 5/5
Extension F/F (1350-0) 5/5
Musculoskeletal Examination
ANKLE AROM MMT
Dorsoflexion F/(0-500) 5/5
Plantarflexion F/(0-500) 5/5
Inversion F/(0-300) 5/5
Eversion F/(0-150) 5/5

TOES AROM MMT

Flexion
MTP F/F (0-250) 5/5
IP F/F (0-300) 5/5
Extension F/F (0-800) 5/5
Patient: Mrs.T/45 yo/11607748/Housewife/Malang
Referred from : Oncology department: Ca mammae post op
Resident: ZUL/SAN/AIK

Physical Examination
A/r Shoulder (D): Special Test at Shoulder (D/S):
Inspection: • Painful Arc test : at 120/80
● Deformity (-/-) degree
● Edema (+/-) • Apley Scratch Test Shoulder S:
● Scar (-/-) - Flexion, Abduction, ext
● Erythema (-/-) rotation : at level C7
● Atrophy (+/+) - Extension, Adduction, int
Palpation: rotation : Medial inferior
● Tenderness (-) contralateral
● Warmth (-) • Cross chest Adduction : -/-
Movement : • Shoulder Apprehension : -/-
● ROM Limitation • Sulcus sign : -/-
● Pain at movement (+) • Neer’s test: -/-
(abduction, flexion) • Hawkin test: -/-
• Empty can test ( Jobe’s Test): -/-
• Speed test -/-
• Drop arm test : -/-
• Tes Yergason: -/-
Arm ∅ : 36/35 cm
Forearm ∅ : 28/27 cm
Wrist ∅ : 22/21 cm
 TAMPAK DEPAN
Kesegarisan Kepala ❑ Sentral
❑ Tilt (miring) lateral kiri atau kanan
❑ Rotasi kiri atau kanan
Bahu ❑ Setingkat
❑ Elevasi kiri atau kanan
❑ Protraksi kiri atau kanan
❑ Retraksi kiri atau kanan
Jarak lengan ke ❑ Simetris
tubuh ❑ Tidak simetris
Lipatan Kulit ❑ Seimbang (sama)
Pinggang ❑ Fleksi miring kiri atau kanan
Pelvic Obliquity ❑ Sejajar
❑ Elevasi kiri atau kanan
Patella ❑ Sejajar
❑ Elevasi kiri atau kanan
❑ Terposisi medial
❑ Terposisi lateral kiri atau kanan
Ankle ❑ Netral
❑ Valgus
❑ Varus
Kaki ❑ Netral
❑ Dalam posisi lateral kiri atau kanan
❑ Dalam posisi medial kiri atau kanan
❑ Datar kiri atau kanan
 TAMPAK BELAKANG
Kesegarisan Kepala ❑ Sentral
❑ Tilt (miring) lateral kanan
❑ Rotasi kiri atau kanan
Bahu ❑ Setingkat
❑ Elevasi kanan
Inferior skapula ❑ Sejajar
❑ Elevasi kiri atau kanan
❑ Abduksi kiri atau kanan
❑ Aduksi kiri atau kanan
❑ Winging kiri atau kanan

Vertebra toraks ❑ Netral

❑ Skoliosis
Vertebra lumbar ❑ Netral
❑ Skoliosis
Jarak lengan ke tubuh ❑ Simetris
❑ Tidak simetris
Lipatan kulit pinggang ❑ Sejajar
❑ Elevasi kiri atau kanan
Pelvic obliquity ❑ Sejajar
❑ Elevasi kiri atau kanan
Posisi lutut ❑ Sejajar
❑ Elevasi kiri atau kanan
Ankle ❑ Netral
❑ Valgus
❑ Varus
Kaki (menopang beban) ❑ Sama besar
❑ Berkurang pada kiri atau kanan
 TAMPAK SAMPING KANAN
Head ❑ Netral
❑ Forward
❑ Backward
Bahu ❑ Protraksi kiri atau kanan
❑ Retraksi kiri atau kanan
Vertebra thorax ❑ Normal
❑ Hipokifotik
❑ Hiperkifotik
❑ Datar
Vertebra Lumbal ❑ Normal
❑ Hipolordotik
❑ Hiperlordotik
❑ Datar
Hip ❑ Netral
❑ Anterior tilt
❑ Posterior tilt
Posisi Lutut ❑ Netral
❑ Recurvatum
❑ Hiperekstensi kanan atau kiri
❑ Fleksi kanan atau kiri
Ankle dan kaki ❑ Netral
❑ Deformitas
❑ Jari mencengkram
 TAMPAK SAMPING KIRI
Head ❑ Netral
❑ Forward
❑ Backward
Bahu ❑ Protraksi kiri atau kanan
❑ Retraksi kiri atau kanan
Vertebra thorax ❑ Normal
❑ Hipokifotik
❑ Hiperkifotik
❑ Datar
Vertebra Lumbal ❑ Normal
❑ Hipolordotik
❑ Hiperlordotik
❑ Datar
Hip ❑ Netral
❑ Anterior tilt
❑ Posterior tilt
Posisi Lutut ❑ Netral
❑ Recurvatum
❑ Hiperekstensi kanan atau kiri
❑ Fleksi kanan atau kiri
Ankle dan kaki ❑ Netral
❑ Deformitas
❑ Jari mencengkram
ICF DIAGNOSIS PATIENT’S CONDITION

Body Function
B280 Sensation of pain Pain at Shoulder S
B440 Respiratory functions Reduce breathing capacity
B710 Mobility of joint functions Limitation ROM at shoulder S

Body Structure
S730 Structure of Upper extremity Frozen shoulder S
S760 Structure of trunk Improper posture

Activity and Participation

D430 lifting and carrying object Difficulty to lift object
D649 Household task Difficulty to household task
D859 Work & employment Difficulty to work

Environment
E310 Immediate family Family supports her
E580 Health services, systems, and policies BPJS

Personal Factor Female, 45 y.o, housewife, Javanese, Muslim

Prognosis
Ad Vitam • Dubia

Ad Sanationam • Bonam

Ad Functional • Dubia ad Bonam

Goal
Short Term Mid Term Long Term
• Reduce pain • Improve breathing • Able to do household task
• Prevent further function without difficulty
complication (contracture, • Able to lift object without
muscle atrophy) difficulty
• Improve ROM of shoulder
• Improve posture
Patient:
Patient:Mrs.T/45 yo/11607748/Housewife/Malang
Ch. I / 29 months old / 11557936 / Malang
Referred from : Oncology department: Ca mammae post op
Referred from: Pediatric Outpatient Department (GDD + epilepsy on treatment)
Resident: ZUL/SAN/AIK
Resident: ACE/AIK/LIS
Problems Goal Planning Time setting

• Reduce pain at Shoulder PDx: - 1-3 months

● Difficulty to lift up D PTx : Continue medication from neurologist oncology
an object • Improve ROM shoulder D Modality :
● Difficulty to do • Able to lift objects - TENS at Shoulder D, high intensity 50-100 Hz, intensity as patient’s
without difficulty tolerance, duration 15 minutes, 2x/week
household task
● Difficulty to work • Able to do household
task without difficulty Exercise :
• able to work without •AROM exercise at UE D/S
• Pendulum Exercise
difficulty • Wall climbing exercise
• Overhead Pulley exercise
• Stretching at shoulder D
• Frequency: 2-3x/week
• Intensity: To the point of feeling tightness or slight discomfort
• Time: 15 s hold for static stretching
• Type: static
Pmo: Subjective, ROM, NRS
Education:
• Home exercise
• Warm compress
Patient: Mrs.T/45 yo/11607748/Housewife/Malang
Referred from : Oncology department: Ca mammae post op
Resident: ZUL/SAN/AIK

Problems Goals Planning Time setting

Reduced Improve Exercise: 1-3 months

breathing breathing Active breathing exercise (deep breathing and chest expansion
capacity capacity exercise)
P.Mo:
Breath count test, Chest expansion
P.Ed:
Continue exercise at home

Improper • Good P.Tx : Posture correction with kinesthetic awareness 1-3 months
posture posture P.Mo: Posture

P.Ed:
Continue exercise at home