Patient : Mrs.I/53 y.o.

/116002688/Entrepreneur/Malang
Referred from : Orthopedic department (CF radial head D post back slab)
Resident : VIN/ZEN/IEN
Anamnesis Problem List Diagnosis Planning
Chief Complaint: Pain and stiff in the right Medical: Clinical diagnosis: PDx : USG MSK at shoulder D
shoulder since 1 month ago Frozen shoulder D + CF radial head D Frozen shoulder D + CF radial PTx :
History of Present Illness : mason type I post backslab (3 months) + head D mason type I post • Continue medication from
Pain and stiff in the right shoulder since 1 month overweight backslab (3 months) + overweight orthopedic department
ago Surgical : - Functional diagnosis : Modality :
• Pain was dull, intermittent, radiating to R1 (M) : - Impairment: - USD at GH joint D & elbow D, 1
upper arm, aggravated during activity R2 (A) : - • Pain at the right shoulder Mhz, intensity as patient’s
(NRS 5) and relieved after taking pain R3 (C) : - • Stiffness at the right shoulder tolerance, duration 15 min,
medication (NRS 2) R4 (P) : - • Stiffness at the right elbow 2x/week.
o Pain and stiff was appeared after patient R5 (S) : - Disability : - TENS at shoulder D, high
underwent back slab procedure (3 months R6 (V) : - • Difficulty to carrying heavy intensity 50-100 Hz, intensity
ago). objects as patient’s tolerance,
o Patient didn’t use the left shoulder due to Handicap : duration 15 minutes, 2x/week
pain, 2 months after immobilize, patient felt Exercise :
the right shoulder became stiff. • AROM Exercise UE D/S
o Numbness, tingling sensation and • Gentle stretching at shoulder
muscle weakness were denied D & elbow D
• F : 2-3 day/weeks
• I : stretch to the point of
feeling tightness or slight
discomfort
• T : stretch for 10-30 seconds
• T: static flexibility
• Overhead pulley
• Finger to wall exercise
Patient : Mrs.I/53 y.o./116002688/Entrepreneur/Malang
Referred from : Orthopedic department (CF radial head D post back slab)
Resident : VIN/ZEN/IEN
Anamnesis Problem List Diagnosis Planning
January 2024 P.Mo:
• Patient was fell from chair during gardening, Subjective, NRS, ROM,
the right arm was hit the floor. Shoulder circumference, BMI
• Patient was brought to ER in RSSA and PEd:
underwent x-ray examination, patient was
diagnosed with fracture in the right lower arm - Explain about patient’s
and underwent back slab procedure condition
• Due to current condition, patient used the left - Purpose and benefit of
arm during ADL. PMR therapy
February 2024 - Routine control to PMR
• Back slab was removed. clinic
• Patient still used the left arm during ADL. - Continue Home exercise
April 2024 (finger wall climbing
• Patient was referred to PM&R outpatient clinic exercise, pendulum
at RSSA for further treatment
exercise)
- Icing when pain
- Elevate the right arm 10-15
minutes before sleep with 2-
3 pillows
Patient : Mrs.I/53 y.o./116002688/Entrepreneur/Malang
Referred from : Orthopedic department (CF radial head D post back slab)
Resident : VIN/ZEN/IEN

Anamnesis Problem List Diagnosis Planning

History of Past Illness :
DM (-), HT (-), arthritis (-), Stroke (-),
Malignancy(-)
History of Family Illness :
No family history related to patient’s condition
Medication :
Orthopedic department
• Na diclofenac 2x50 mg
Patient : Mrs.I/53 y.o./116002688/Entrepreneur/Malang
Referred from : Orthopedic department (CF radial head D post back slab)
Resident : VIN/ZEN/IEN
Anamnesis
Functional activity :
• Patient is an entrepreneur
• Patient still able to do all ADL and household task independently
• Patient had difficulty to carrying heavy object
Psycho-Socio-Economic :
• Patient didn’t get depression from her symptom, and had eager to get better
• Patient’s hope : to reduce pain and stiffness on the right shoulder
• Patient lives with her husband (56 y.o).
• They had 1 children (26 y.o,) that lives in the same house
• The patient’s house is 1 floor. There was no ladder In front of his house. From entrance
door to the patient’s room approximately 2 m.
• From the bedroom to toilet about 2 m, with sitting toilet.
• Patient’s daily need was fulfilled by her husband
• Economic status: Middle Class
• Health insurance: BPJS
Barthel Index
2 3

2
20/20 3
Independent
2
2

2
2

2
2
20
Patient : Mrs.I/53 y.o./116002688/Entrepreneur/Malang
Referred from : Orthopedic department (CF radial head D post back slab)
Resident : VIN/ZEN/IEN

Positive Finding
Physical Exam : Physiological Reflex :
GCS : 456 (Compos Mentis) • BPR : +2/+2
BP : 120/85 mmHg • TPR : +2/+2
HR: 86x/m RR: 20x/m SpO2: 97% • KPR : +2/+2
BW : 59 kg BH: 155 cm BMI: 24,5 (Overweight) • APR : +2/+2
Ambulation : Independent Pathological Reflex :
Gait : normal • Hoffman -/-
Cranial Nerve : N. I-XII : Normal • Tromner -/-
Head and Neck : Anemic (-), Jaundice (-), Cyanosis (-) • Babinski -/-
Thorax : • Chaddock -/-
• Cor : S1-S2 single, murmur (-), gallop (-)
• Pulmo : RH -/- WH -/-
• Chest expansion : 3 – 3 –2,7 cm
• Breath count test : 28 – 27 – 27
Abdomen : soefl, hepar & lien unpalpable, pain (-)
Extremities : warm -/- oedema -/-
 NEUROLOGY EXAMINATION
Upper Extremity Lower extremity
D S D S

ROM Full except at shoulder Full Full Full

flexion, abduction,
adduction, internal and
external rotation
MMT 5 5 5 5
Muscle tone normal normal normal normal

Clonus - - - -

Spasticity None None None None

Physiological BPR +2 / TPR +2 BPR +2 / TPR +2 KPR +2 / APR +2 KPR +2 / APR +2

Reflexes
Pathological Reflex Hoffman (-) Hoffman (-) Babinski (-) Babinski (-)
Tromner (-) Tromner (-) Chaddock (-) Chaddock (-)
Sensory Exteroceptive (touch, pressure, temperature, pain): N
Proprioceptive (joint position sense, vibration) : N
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 F (0-300) 5
Lateral bending F/F (0-350) 5/5
Rotation F/F (0-450) 5/5
 Musculoskeletal Examination
SHOULDER AROM PROM End Feel MMT
Flexion L (0-1450)/F(0- L (0-1600)/F(0- Firm 5/5
1800) 1800)
Extension L (0-300)/F (0-600) L (0-500)/F (0-600) Firm 5/5
Abduction L (0-1300)/F (0- L (0-1500)/F (0- Firm 5/5
1800) 1800)
Adduction F/F (0-450) 5/5
Internal rotation L (0-450)/F (0-700) L (0-600)/F (0-700) Firm 5/5
Eksternal rotation L(0-200)/F (0-800) L(0-300)/F (0-800) Firm 5/5

ELBOW AROM PROM End feel MMT

Flexion L (10-1350)/F (0-1500) L (10-1350)/F (0- Firm 5/5
1500)
Extension L (135-100)/F (0- L (135-100)/F (0- Firm 5/5
1500) 1500)
Supination F/F (0-900) 5/5
Pronation F/F (0-900) 5/5
Musculoskeletal Examination
WRIST ROM MMT
Flexion F/F (0-800) 5/5
Extension F/F(0-800) 5/5
Ulnar deviation F/F (0-300) 5/5
Radial deviation F/F (0-200) 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 ROM 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 ROM 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 ROM 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.I/53 y.o./116002688/Entrepreneur/Malang
Referred from : Orthopedic department (CF radial head D post back slab)
Resident : VIN/ZEN/IEN
Positive Finding
A/R Shoulder D Special Test :
Inspection : Painful Arch : (+) at 70˚
• Edema (+) Apley Scratch Test :
• Scar (-) • Flexion, Abduction, external
• Erythema (-) rotation: neck
• Extension, Adduction, internal
• Atrophy (-) rotation: gluteal ipsilateral
Palpation : • Cross chest Adduction: able
• Tenderness (-) Shoulder Apprehension : -
• Warmth (-) Neer’s test: (-)
• Sulcus sign : (-) Hawkin test: (-)
Move : Empty can test ( Jobe’s Test): (-)
• ROM : Limited Drop arm test : (-)
• Pain when move: (+) during Yergason test: (-)
shoulder internal & external Infraspinatus test : (-)
Lift off test: : (-)
rotation
Shoulder ∅ : 28/26 cm
Elbow ∅ : 24/22 cm
Forearm ∅ : 22/22 cm
Elbow x – ray AP/Lat (03-01-24)

Kesimpulan:
• Fraktur transverse complete pada
proximal os. radial kanan, dengan minimal
displacement
• Soft tissue swelling pada regio elbow
kanan
ICF DIAGNOSIS PATIENT CONDITION
Body Function
B280 Sensation of pain Right shoulder pain
B710 Mobility of joint function Right shoulder and elbow stiffness
Body Structure
S739 Structure of upper extremity CF radial head D
Activity and Participation
D430 Lifting and carrying objects Difficulty to carrying object

Environment
E110 Drugs Patient routine consume medicine
E310 Immediate family Family supports her
E580 Health services, systems, and policies BPJS
Personal Factor Female, 55 y.o, Entrepreneur, Javanese, Muslim
Patient : Mrs.I/53 y.o./116002688/Entrepreneur/Malang
Referred from : Orthopedic department (CF radial head D post back slab)
Resident : VIN/ZEN/IEN
Problems Cause Goal Planning
• Right shoulder pain and Frozen shoulder D Reduce pain PTx: Continue medication from orthopedic department
stiffness CF radial head D mason Reduce stiffness Modality :
• Difficulty to carrying type I post backslab (3 - USD at GH joint D & elbow D, 1 Mhz, intensity as patient’s tolerance,
object months) duration 15 min, 2x/week.
- TENS at shoulder D, high intensity 50-100 Hz, intensity as patient’s
tolerance, duration 15 minutes, 2x/week
Exercise :
• AROM Exercise UE D/S
• Gentle stretching at shoulder D & elbow D
• F : 2-3 day/weeks
• I : stretch to the point of feeling tightness or slight discomfort
• T : stretch for 10-30 seconds
• T: static flexibility
• Finger to wall exercise
P.Mo: Subjective, NRS, ROM, Shoulder circumference, BMI
P.Ed:
- Explain about patient’s condition
- Purpose and benefit of PMR therapy
- Routine control to PMR clinic
- Continue Home exercise (finger wall climbing exercise, pendulum
exercise)
- Icing when pain
- Elevate the left arm 10-15 minutes before sleep with 2-3 pillows
Patient : Mrs.I/53 y.o./116002688/Entrepreneur/Malang
Referred from : Orthopedic department (CF radial head D post back slab)
Resident : VIN/ZEN/IEN
Problems Cause Goal Planning
Overweight Reduce physical activity Achieve ideal body weight PTx: consult to nutritionist
P.Ed:
•Reduce calorie intake
•Exercise at home after pain reduce
•Increase physical activity
P.Mo: Subjective, BMI
Prognosis

Ad Vitam • Bonam

Ad Sanationam • Bonam

Ad Functional • Dubia ad Bonam

 Goal

Short Term Mid Term Long Term

• Reduce pain (NRS 5-3) • Reduce pain (NRS 3 to 0) • Able to lift and carrying
• Reduce stiffness object without difficulty
• Reduce acute inflammation