Patient : Mrs. R/76 y.

o /11609486/retired marine civilian/Kedungkandang

Referred From : Neurology Outpatient Clinic (CVA Thrombosis Brainstem + HT Stage II)
Resident : TYO/OGE/RIT
Anamnesis Problem List Diagnosis Planning

Chief Complaint: Right eye can't open
since 2 weeks ago
History of Present Illness :
The complaint of not being able to open
your right eye has been felt since 2 weeks
ago.
• The complaint began with the
patient feeling severe pain in the
right eye until the patient could
not sleep and had fainted. (NRS 8)
• After the patient regained
consciousness (15 minutes), the
patient was then taken to
Kepanjen Eye Center and referred
directly to RSSA eye clinic.
• After arriving at the eye clinic, the
patient was referred to the
neurology clinic due to suspicion
of vascular blockage.
• The patient underwent CT scan and
laboratory examination by the
neurology department.
• The patient was given medication
from the neurology clinic and the
patient was referred to the
medical rehabilitation clinic due to
complaints that the right eyelid
could not be opened.
Medical: Clinical diagnosis: PTx : Continue medication from neurologist
• CVA non-hemorrhagic LACI subacute phase (2 CVA non-hemorrhagic LACI subacute Modality :
weeks) phase (2 weeks) + HT uncontrolled + • NMES at eyelid D (levator palpebrae D)
• HT uncontrolled Geriatric Problem (Cognitive pulse duration 300-600 msec, 70 – 85
Surgical: - Impairment) pulses per second, on time 10-15 second
R1 (M) : - range, off times 50 second range, off times
R2 (A) : - Impairment: 50 second, 2x/week
R3 (C) : - • Parese N. II, III, IV, VI OD Exercise :
R4 (P) : Discomfort to meeting other people dt. • Hypertension • AROM exercise UE/ LE D/S
her appearance • Mild cognitive impairment • Endurance exercise
R5 (S) : - • Reduce breathing capacity F : 3-5d/w
R6 (V) : Disability : I : 40-59% HRR
• Difficulty to open right eye T : 30 minute
R7 (O):
Handicap : T: ergocycle
• Difficulty to open right eye
• - • Active breathing exercise (deep breathing,
• Mild cognitive impairment chest expansion exercise)
• Decreased breathing count test & chest OT :
expansion • Cognitive training
PMo:
• Subjective, muscle power eyelid, BCT, CET,
cognitive hamilton
PEd:
• Explain about patient’s condition
• Purpose and benefit of PMR therapy
• Routine control to PMR clinic
• Continue exercise at home
• Continue medication from internist and
neurologist
• Raising eyebrow, placing finger underneath
palpebrae and holding for several seconds
5x/day.
Patient : Mrs. R/76 y.o /11609486/retired marine civilian/Kedungkandang
Referred From : Neurology Outpatient Clinic (CVA Thrombosis Brainstem + HT Stage II)
Resident : TYO/OGE/RIT

Anamnesis Problem List Diagnosis Planning

History of Past Illness :
History of Trauma (-) CVA(-)
History of Comorbid:
HT (+) uncontrolled DM (-) Malignancy (-)
smoking (-) dyslipidemia (+)
History of Family Illness :
No family history related to patient’s condition
History of medication & rehabilitation
From neurologist:
• ASA 1x80mg
• Amlodipin 1x10mg
• Simvastatin

Patient never had any rehabilitation before

Patient : Mrs. R/76 y.o /11609486/retired marine civilian/Kedungkandang
Referred From : Neurology Outpatient Clinic (CVA Thrombosis Brainstem + HT Stage II)
Resident : TYO/OGE/RIT
Anamnesis
Functional activity :
• Mobility: patient able to walk to walk independently
• Activity daily living: patient able to do ADL independently.
• Patient daily activity is go to the rice field to farm daily.
• Patient didn’t have any particular hobby

Psycho-Socio-Economic :
• Patient felt worried about her condition, especially her right eyelid.
• Patient’s hope : able to open her right eyes again.
• Patient is a widow. Lives alone at her house.
• Patient lives in a house with 1 storey. From door to patient’s bedroom was approx. 3m.
From her bedroom to the bathroom was approx. 10m with squatting closet.
• Patient’s daily expenses was fulfilled by herself.
• Economic status: middle class
• Health insurance: BPJS
Barthel Index
2 3

2
20/20 3
Independent
1
2

2
2

2
1
20
Patient : Mrs. R/76 y.o /11609486/retired marine civilian/Kedungkandang
Referred From : Neurology Outpatient Clinic (CVA Thrombosis Brainstem + HT Stage II)
Resident : TYO/OGE/RIT

Positive Finding
Physical Exam :
GCS : E4V5M6 (Compos Mentis) Physiological Reflex :
BP : 153/100 mmHg • BPR : +2/+2
HR: 82x/m RR: 20x/m SpO2: 98% • TPR : +2/+2
BW : 53 kg BH: 160 cm BMI: 20,7 (normoweight) • KPR : +2/+2
Ambulation : Independent • APR : +2/+2
Gait : normal Pathological Reflex :
• Hoffman -/-
Head and Neck : Anemic (-), Jaundice (-), Cyanosis (-) • Tromner -/-
Thorax : • Babinski -/-
• Cor : S1-S2 single, murmur (-), gallop (-) • Chaddock -/-
• Pulmo : RH -/- WH -/-
• Chest expansion : 3-3-3 cm
• Breath count test : 10-10-10
Abdomen : soefl, hepar & lien not palpable, pain (-)
Extremities : warm -/- oedema-/-
Patient : Mrs. R/76 y.o /11609486/retired marine civilian/Kedungkandang
Referred From : Neurology Outpatient Clinic (CVA Thrombosis Brainstem + HT Stage II)
Resident : TYO/OGE/RIT

Positive Finding
Local Status:
Face symmetrical (+)
Oedem (-/-)
Hematom (-/-)
Entropion (-/-)
Ektropion (-/-)
Conjungtiva anemi (-/-)
Icteric Sclera (-/-)
Secret (-/-)
Ptosis (+/-)
 Cranial Nerve Examination
I (Olfactory) Smell function (Normal)
II (Opticus) Visus (>3/60 OD/OS) visual field (normal) Pupillary reflex (-/+) OD pupil midriatic
III (Occulomotor) Eye movement Superior (-/+), Inferior (-/+) Medial (-/+)

IV (Trochlear) Eye movement inferotemporal : (-/+)

V (Trigeminal) Mastication muscle (normal), mid face sensory (normal), cornea reflex (+)
VI (Abducens) Eye movement lateral (-/+)
VII (Facialis) symmetrical face, smile symmetrical (normal), 2/3 anterior tongue (normal), schimmer test
(not tested)

VIII (Vestibulotrochlear) Hearing (Normal), hallpike manuvere (not tested)

IX (Hypoglosus), X (Vagus) 1/3 posterior tongue sensory (Normal), voice quality (Normal), uvula centered, pharynx
arcus (DFE), gag reflex (Normal), Dry swallowing test (5x/30s), BSST (NT)
XI (Asesorius) Trapezius, sternocloidomastoideus muscle (Normal)
XII (Glossopharingeal) Dysarthria (-), tongue movement ( functional)
 NEUROLOGY EXAMINATION
Upper Extremity Lower extremity
D S D S

ROM Full Full Full Full

MMT 5 5 5 5
Muscle tone Normal normal normal normal

Clonus - - - -

Spasticity None None None None

Physiological Reflexes BPR +2/ TPR +2 BPR + 2/ TPR +2 KPR +3 / APR +3 KPR +2 / APR +2

Pathological Reflex Hoffman (-) Hoffman (-) Babinski (-) Babinski (-)
Tromner (-) Tromner (-) Chaddock (-) Chaddock (-)
Sensory Exteroceptive (touch, pressure, temperature, pain): normal
Proprioceptive (joint position sense, vibration) : normal
Cranial Nerve
Examination
Cranial Nerve Examination
Cranial Nerve Examination
Musculoskeletal Examination
NECK ROM 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 ROM MMT

Flexion F (0-800) 5/5
Extension F (0-300) 5/5
Lateral bending F/F (0-350) 5/5
Rotation F/F (0-450) 5/5
Musculoskeletal Examination
SHOULDER AROM MMT
Flexion F/F (0-1800) 5/5
Extension F/F (0-600) 5/5
Abduction F/F (0-1800) 5/5
Adduction F/F (0-450) 5/5
Internal rotation F/ F (0-700) 5/5
Eksternal rotation F/F (0-900) 5/5

ELBOW ROM MMT

Flexion F/F (0-1500) 5/5
Extension F/F (1500-0) 5/5
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 ROM 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 ROM 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
 FUNCTIONAL EXAMINATION
Transfer Balance
Lying to sitting : able Sitting Balance
Sitting to standing : able Static : good
Transfer to chair : able Dynamic: good
Gait pattern : normal Sitting Tolerance : > 1 hour
Standing Balance
Static : good
Dynamic: good
Communication function

Speech : dysarthria (-), dysphonia (-)

Language : fluency (good) comprehension (good) repetition (good) naming (good), writing (good), Reading (good)
 FUNCTIONAL
Cerebellar function EXAMINATION
Cerebral function
▪ Stereognosis : able
Coordination :
▪ Dysdiadokokinesia : able
▪ Graphesthesia : able
▪ Finger to nose (dysmetria) : Able
▪ Sensory extinction : able
▪ Heel to shin : Able
▪ Barognosia : able
▪ Two point tactile : able

Balance :
Romberg test : able
Tandem walking test : able
Video Functional Examination
Video Functional Examination
 Functional Examination

Hand Function :
• Cylindrical : F/F
• Grasp : F/F
• Lateral tip : F/F
• Spherical : F/F
• Hook : F/F
• Pinch : F/F
Hand grip: 17.2/14.7 (normal/normal)
Supporting Examination
Head CT Scan (08-03-2024)
Supporting Examination
Laboratory (07-03-2024)
ICF DIAGNOSIS
Body Function
B420 Blood Pressure functions
B440 Respiration functions
B730 Muscle power functions
B163 Cognitive function
Body Structure
S110 Structure of brain
S220 Structure of eyeball
S230 Structue around eye
Activity and Participation
D230 Carrying out daily routine
D910 Community life
Environment
E310 Immediate family
E580 Health services, systems, and policies
Personal Factor
PATIENT’S CONDITION
Hypertension Uncontrolled
Decrease breathing capacity
Unable to open right eye
Mild Cognitive Impairment
CVA Non-Hemorrhagic LACI subacute phase (2 weeks)
Parese N. II, III, IV, VI OD
Pupillary Mydriasis OD
Ptosis OD
Discomfort to do daily routine dt. her condition
Discomfort to meeting other people dt. her appearance
Her family supports her
BPJS
Female, 76 y.o, retired marine civillian, Javanese, Muslim
Prognosis

Ad Vitam • Dubia ad bonam

Ad Sanationam • Dubia

Ad Functional • Dubia ad bonam

Goal
Short Term Mid Term Long Term
• Improve muscle power • Improve muscle power -

of eyelid of eyelid
• Improve breathing
capacity
• Improve cognitive
Patient : Mrs. R/76 y.o /11609486/retired marine civilian/Kedungkandang
Referred From : Neurology Outpatient Clinic (CVA Thrombosis Brainstem + HT Stage II)
Resident : TYO/OGE/RIT
No. Problems Target Programs Time Setting
1 • Difficulty to open right eyelid • Improve muscle power of PTx : -
• Discomfort to do daily routine right eyelid. Modality :
• NMES at eyelid (levator palpebrae) pulse duration 300-600
msec, 70 – 85 pulses per second, on time 10-15 second
range, off times 50 second range, off times 50 second, 1-3 months:
2x/week Modality (NMES) for 3 months
Exercise :
• AROM exercise UE/ LE D/S (MMT ≥3 )
• Endurance exercise
F : 3-5d/w
I : 40-59% HRR 1-6 months
T : 30 minute
T: ergocycle

PMo: Subjective, muscle power eyelid

PEd:
• Explain about patient’s condition
• Purpose and benefit of PMR therapy
• Routine control to PMR clinic 1-6 months
• Continue exercise at home 3-6 months
• Continue medication from internist and neurologist
• Raising eyebrow, placing finger underneath palpebrae and
holding for several seconds 5x/day.
 Patient : Mrs. R/76 y.o /11609486/retired marine civilian/Kedungkandang
Referred From : Neurology Outpatient Clinic (CVA Thrombosis Brainstem + HT Stage II)
Resident : TYO/OGE/RIT
No. Problems Target Programs Time Setting
2. Reduce breathing capacity Improve breathing capacity PTx: -
PDx: -
Exercise :
Active breathing exercise (deep breathing, 3-6 months
chest expansion exercise)
P.Mo:
• Subjective, Breath count test, chest
expansion
P.Ed:
• Explain patient’s condition
• Educate patient and family to measure RR
at home
• Continue exercise at home
3. Mild Cognitive impairment Improve cognitive function PTx: -
PDx: -
OT :
• Cognitive training
PMo:
• Subjective,cognitive hamilton 3-6 months:
PEd: Cognitive training
• Explain patient’s condition
• Purpose & benefit PMR therapy
• Routine visit to PMR outpatient clinic
• Continue exercise at home