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  • Hari/Ta Nggal Subject Object Assasment Planning Jum'at, 23-02-17

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    The patient presented with neck pain radiating to both shoulders and arms, neck stiffness, numbness and tingling in both hands, and headache. Examination revealed reduced range of motion and sensation in the C5-C6 dermatomes. The patient was diagnosed with cervical radiculopathy at C5-C6 and received conservative treatment including neck traction, proper positioning, and medications. Over time the symptoms improved with reduced neck stiffness, numbness, tingling, pain, and headache.

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    The patient presented with neck pain radiating to both shoulders and arms, neck stiffness, numbness and tingling in both hands, and headache. Examination revealed reduced range of motion and sensation in the C5-C6 dermatomes. The patient was diagnosed with cervical radiculopathy at C5-C6 and received conservative treatment including neck traction, proper positioning, and medications. Over time the symptoms improved with reduced neck stiffness, numbness, tingling, pain, and headache.

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    10 views6 pages

    Hari/Ta Nggal Subject Object Assasment Planning Jum'at, 23-02-17

    Uploaded by

    avif
    The patient presented with neck pain radiating to both shoulders and arms, neck stiffness, numbness and tingling in both hands, and headache. Examination revealed reduced range of motion and sensation in the C5-C6 dermatomes. The patient was diagnosed with cervical radiculopathy at C5-C6 and received conservative treatment including neck traction, proper positioning, and medications. Over time the symptoms improved with reduced neck stiffness, numbness, tingling, pain, and headache.

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    © All Rights Reserved
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    of 6

    Hari/Ta

    Subject Object Assasment Planning


    nggal
    Jumat, Nyeri leher Ku: cukup Diagnosa Klinis: MWD
    23-02-17 yang menjalar Vital sign: radikulopati cervicalis
    ke bahu kanan TD: 130/70 servikalis Proper neck
    dan kiri N: 82 x/menit potition
    RR: 20 x/mnt Diagnosa topis: Traksi leher
    Leher kaku
    VAS : 8 vertebrae
    Tangan Tes Provokasi cervikalis C5-C6
    kanan dan kiri Tes spurling(+)
    terasa kebas Tes distraksi (+) Diagnosa
    dan kesemutan Tes valsafah (+) Etiologis:

    Nyeri kepala Tes nafzigger (-) cervical root


    Kekuatan: syndrome

    Dermato
    D S Diagnosa
    m
    C5 4 4 Fungsional:
    C6 4 4
    C7 5 5 disabilitas ringan
    C8 5 5
    T1 5 5

    Sensorik

    Dermato
    D S
    m
    C5 1 1
    C6 1 1
    C7 2 2
    C8 2 2
    T1 2 2

    ROM:
    Wrist: DBN
    Elbow: DBN
    Shoulder: DBN
    Cervical:

    G ROM
    N P
    Fleksi 50 40
    Ekstensi 60 60
    Left 45 45
    Right 45 40
    Left 80 80
    rotation
    Right 80 60
    rotation
    Sabtu, Nyeri leher Ku: cukup Diagnosa Klinis: MWD
    24-02-17 yang menjalar Vital sign: radikulopati cervicalis
    ke bahu kanan TD: 140/80 servikalis Proper neck
    dan kiri N: 82 x/menit potition
    RR: 20 x/mnt Diagnosa topis: Traksi leher
    Leher kaku
    VAS : 7 vertebrae
    Tangan Tes Provokasi cervikalis C5-C6
    kesemutan Tes spurling(+)
    Nyeri kepala Tes distraksi (+) Diagnosa
    Tes valsafah (+) Etiologis:
    Tes nafzigger (-) cervical root
    Kekuatan: syndrome

    Dermato
    D S Diagnosa
    m
    C5 4 4 Fungsional:
    C6 4 4
    C7 5 5 disabilitas ringan
    C8 5 5
    T1 5 5

    Sensorik

    Dermato
    D S
    m
    C5 1 1
    C6 1 1
    C7 2 2
    C8 2 2
    T1 2 2

    ROM:
    Wrist: DBN
    Elbow: DBN
    Shoulder: DBN
    Cervical:

    G ROM
    N P
    Fleksi 50 40
    Ekstensi 60 60
    Left 45 45
    Right 45 40
    Left 80 80
    rotation
    Right 80 60
    rotation
    Senin, Leher kaku Ku: cukup Diagnosa Klinis: MWD
    26-02-17 berkurang Vital sign: radikulopati cervicalis
    TD: 140/80 servikalis Proper neck
    Tangan
    N: 78x/menit potition
    kesemutan RR: 20 x/mnt Diagnosa topis: Traksi leher
    berkurang VAS : 5 vertebrae
    Tes Provokasi cervikalis C5-C6
    Nyeri kepala
    Tes spurling(+)
    Tes distraksi (+) Diagnosa
    Tes valsafah (-) Etiologis:
    Tes nafzigger (-) cervical root
    Kekuatan: syndrome

    Dermato
    D S Diagnosa
    m
    C5 5 5 Fungsional:
    C6 5 5
    C7 5 5 disabilitas ringan
    C8 5 5
    T1 5 5

    Sensorik

    Dermato
    D S
    m
    C5 1 1
    C6 1 1
    C7 2 2
    C8 2 2
    T1 2 2

    ROM:
    Wrist: DBN
    Elbow: DBN
    Shoulder: DBN
    Cervical:

    G ROM
    N P
    Fleksi 50 40
    Ekstensi 60 60
    Left 45 45
    Right 45 40
    Left 80 80
    rotation
    Right 80 60
    rotation
    Rabu, Leher kaku Ku: cukup Diagnosa Klinis: MWD
    28-02-17 berkurang Vital sign: radikulopati cervicalis
    TD: 130/70 servikalis Proper neck
    Tangan
    N: 80 x/menit potition
    kesemutan
    RR: 20 x/mnt Diagnosa topis: Traksi leher
    berkurang
    VAS : 5 vertebrae
    Nyeri kepala Tes Provokasi cervikalis C5-C6
    Tes spurling(+)
    Tes distraksi (+) Diagnosa
    Tes valsafah (-) Etiologis:
    Tes nafzigger (-) cervical root
    Kekuatan: syndrome

    Dermato
    D S Diagnosa
    m
    C5 5 5 Fungsional:
    C6 5 5
    C7 5 5 disabilitas ringan
    C8 5 5
    T1 5 5

    Sensorik

    Dermato
    D S
    m
    C5 1 1
    C6 1 1
    C7 2 2
    C8 2 2
    T1 2 2

    ROM:
    Wrist: DBN
    Elbow: DBN
    Shoulder: DBN
    Cervical:

    G ROM
    N P
    Fleksi 50 40
    Ekstensi 60 60
    Left 45 45
    Right 45 40
    Left 80 80
    rotation
    Right 80 60
    rotation
    Jumat, Leher kaku Ku: cukup Diagnosa Klinis: MWD
    02-03-17 berkurang Vital sign: radikulopati cervicalis
    TD: 130/80 servikalis Proper neck
    Tangan
    N: 84 x/menit potition
    kesemutan
    RR: 21 x/mnt Diagnosa topis: Traksi leher
    berkurang
    VAS : 5 vertebrae
    Nyeri kepala Tes Provokasi cervikalis C5-C6
    Tes spurling(+)
    Tes distraksi (+) Diagnosa
    Tes valsafah (-) Etiologis:
    Tes nafzigger (-) cervical root
    Kekuatan: syndrome

    Dermato
    D S Diagnosa
    m
    C5 5 5 Fungsional:
    C6 5 5
    C7 5 5 disabilitas ringan
    C8 5 5
    T1 5 5

    Sensorik

    Dermato
    D S
    m
    C5 1 1
    C6 1 1
    C7 2 2
    C8 2 2
    T1 2 2

    ROM:
    Wrist: DBN
    Elbow: DBN
    Shoulder: DBN
    Cervical:

    G ROM
    N P
    Fleksi 50 40
    Ekstensi 60 60
    Left 45 45
    Right 45 40
    Left 80 80
    rotation
    Right 80 60
    rotation
    Senin, Leher kaku Ku: cukup Diagnosa Klinis: MWD
    05-03-17 berkurang Vital sign: radikulopati cervicalis
    TD: 130780 servikalis Proper neck
    Tangan
    N: 82 x/menit potition
    kesemutan
    RR: 20 x/mnt Diagnosa topis: Traksi leher
    berkurang
    VAS : 5 vertebrae
    Nyeri kepala Tes Provokasi cervikalis C5-C6
    Tes spurling(+)
    Tes distraksi (+) Diagnosa
    Tes valsafah (-) Etiologis:
    Tes nafzigger (-) cervical root
    Kekuatan: syndrome

    Dermato D S
    m Diagnosa
    C5 5 5 Fungsional:
    C6 5 5
    C7 5 5 disabilitas ringan
    C8 5 5
    T1 5 5

    Sensorik

    Dermato
    D S
    m
    C5 1 1
    C6 1 1
    C7 2 2
    C8 2 2
    T1 2 2

    ROM:
    Wrist: DBN
    Elbow: DBN
    Shoulder: DBN
    Cervical:

    G ROM
    N P
    Fleksi 50 50
    Ekstensi 60 60
    Left 45 45
    Right 45 40
    Left 80 80
    rotation
    Right 80 60
    rotation

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