Professional Documents
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CASE REPORT
IDENTITY
Name : Mr. EH
Age : 72 years old
DOB : May 13th, 1945
Sex : Male
Method of payment : BPJS
Education : Senior High School
lOccupation : retirement
ANAMNESIS
Chief Complaint
Additional complaint
Since 1 year ago, he felt painful on his left knee with visual analog scale 4. He said
there was not swell or any eritema. The pain emerged when he stood for about 30
minutes and relieved by doing some activities. He still belonged to the exercise
program of Poli Klinik Obesitas Rehabilitasi Medik RSCM frequently 2 times per
week.
3 months ago, the patient felt pain on his left shoulder with visual analog scale 2-3. He
felt painful after he lifted a water gallon. He couldnt raise his arm high, but he still can
do his activities as usual. The pain was relieved by having some rest. Because he
thought that the pain didnt become a barrier for him to do his activities and he never
consulted to the doctor.
At this time, the patient still feels painful on both knees with visual analog scale 4 for
right knee and 3 for left knee. The pain is getting better than first onset (visual analog
scale 7 ). Sometimes pain emerges when he stands for 30 minutes until an hour, changes
position from sitting to standing and climbs up or downstairs. The pain is relieved by
having some rest. He feels a dull pain from the inside of his knees. He said that he cant
squat and rise from the floor. The patient has succeeded to lose his weight until 95 kg
now and he admitted that he can wear his old clothes when he was still slim. He also
said that beside having routine exercises at the RSCM, he also goes walking regularly
every morning for 30 minutes around his house for about 2.5 km. He also adjusts his
diet following suggestion from the nutritionist.
Patient has the history of hypertension since 2013 and is currently on medication
(Telmisartan 1x40mg and Amlodipine 1x5mg). His blood pressure is well controlled
as he regularly visited to Internal Medicine Department. He also has hyperuricemia and
is currently on medication (Allopurinol 1x100mg). He takes the allopurinol daily and
his uric acid level is well controlled.
His Father has the history of obesity and passed away because of hepatocarcinoma
There are no histories of hypertension and diabetes mellitus in the patients family.
Functional History
The Patient is a retirement of a private cruise ship company. At present, he is
no longer working, he spends most of his time in his house and with all his family.
The patient always goes walking every day around his housing complex for 2500
meters for about 30 minutes. The patient sometimes helps his neighbor by
delivering his neighbors orders to his customers by a motorbike. Sometimes he
helps his wife clean their house including sweeping the floor and wiping the
windows.
Mobility Activities: Patient can walk independently without any walking aid.
Psychosocial History
The patient married to a woman who is 72 years of age now. From this marriage,
he has a daughter. He is a retirement of a cruise ship company. He had worked
there for almost 30 years and his last title in that ship was as a General Manager.
At this moment, the patient lives in his own house with his wife and his daughter
and also his son-in-law, along with three grandchildren.
The patients daughter is an English teacher in a private Senior High School and
her husband works in a private company as an employee. The patients house is
around 90m square and it is a two-level permanent building. There are two
bedrooms, two bathrooms which is equipped with the squatting closet for each
bathroom. The patients bedroom, kitchen and living room are on the first floor so
the patient doesnt have any necessity to go upstairs to the second room.
The house is provided with electricity from PLN and clean water from PAM.
The patient used to smoke half of the cigarette box in one day and routinely
consumed alcohol less than 1 bottle each day due to his job. After he got retired, he
stopped smoking and drinking alcohols.
There was no history of depression, anxiety, suicidal or other psychological
problems.
Medication and allergies
The patient routinely consumes medicines from the internist for his hypertension
and hiperurisemia ( Telmisartan 1X 40 mg, amlodipine 1x 5mg, allopurinol 1x
100mg). The patient also takes regular medical check ups to the opthalmologist
RSCM for evaluating his eyes function. The patient has a history of dust allergy, if
he gets contaminated by dust particles, he will sneeze and have a runny nose. The
patient has no allergy to certain medicine.
Review of system
Skin: no history of skin rash.
Daily diet
Time Portion and menu Calories
06.30 1 cup of rice 242
1 scrambled egg 237
10.00 1 cup of tea with sugar 25
1 slice of bread with butter 146
12.00 1 cup of rice 242
100 gr of fried fish/chicken/meat 238
1 cup of vegetable soup 100
20.00 1 cup of rice 242
100 gr of fried fish/chicken/meat 238
1 cup of vegetable soup 100
TOTAL 1.810 calories/day
= 1.752,9 cal/day
= 2.774 / 1.752,9
SF-36
Physical functioning : 850 (85%)
HR: 78x/minute
RR: 18x/minute
Temperature: afebris
Nutritional status:
Body Weight: 95 kg
Height: 175 cm
Neck circumference : 41 cm
Gait examination:
Balance :
Static sitting balance : adequate
Dynamic sitting balance : adequate
Romberg test : >30s with opened eyes
>30s with closed eyes
Sharpen Romberg Test : >30s with opened eyes
>30s with closed eyes
Trendelenberg sign : negative/negative
Modified get up and go test : can stand up and sit down without holding to something
(5.45 seconds)
Posture:
Anterior:
- head in midline
- no hyperlordotic lumbal
- no knee recurvatum
Posterior:
- head in midline
- shoulders are symmetrical
- no pelvic obliquity
- no deformity of ankle
4 mm/4 mm
Nose : no septal deviation, normal nasal mucosa, no secretion, no sign of
inflammation.
Oral cavity : symmetrical lips, good oral hygiene
Throat : tonsil T1/T1 and not hyperemic, symmetrical pharyngeal arch, no
deviation of uvula
Neck : trachea in the midline, normal JVP, no thyroid or lymph node
enlargement
Chest :
- Lung :
Functional Examination
Fine Coordination : in normal limit
Neurologic Examination
Higher Function and Mental state :
Cognitive state : Mini Mental State Examination score: 30 (no cognitive impairment)
Mental State
- Affect: normal
Biceps : +2/+2
Triceps : +2/+2
Brachioradialis : +2/+2
Patella : +2/+2
Achilles : +2/+2
Musculoskeletal Examination
CERVICAL
Look : No deformity
No sign of inflammation
CERVICAL
Flexion 0-400 Flexion 5
Special test:
TRUNK
Feel : No Tenderness
No pelvic obliquity
ROM MMT
Thorakolumbal
Flexion 0-600 Flexion 5
Special test:
Patrick : negative/negative
Contra-patrick : negative/negative
Braggard : negative/negative
UPPER EXTREMITIES
Normal sensibility
ROM MMT
Movement Right Left Movement Right Left
SHOULDER
Flexion 0 180 0 160 Flexion 5 5
Extension 0 60 0 60 Extension 5 5
Adduction 0 45 0 45 Adduction 5 5
Abduction 0 180 0 130 Abduction 5 5
Internal 0 80 0 80 Internal 5 5
Rotation
External 0 90 0 90 Rotation
External 5 5
Rotation ELBOW Rotation
Flexion 0 150 0 150 Flexion 5 5
Extension 150 0 150 0 Extension 5 5
FOREARM
Supination 0 90 0 90 Supinatio 5 5
Pronation 0 90 0 90 n
Pronation 5 5
WRIST
Flexion 0 80 0 80 Flexion 5 5
Extension 0 70 0 70 Extension 5 5
Ulnar 0 30 0 30 Ulnar 5 5
deviation
Radial 0 20 0 20 deviation
Radial 5 5
deviation THUMB deviation
Abduction 0 75 0 75 Abductio 5 5
n
ROM MMT
Movement Right Left Movement Right Left
Adduction 0 0 Adductio 5 5
MCP 0 60 0 60 n
MCP 5 5
flexion
IP flexion 0 80 0 80 flexion
IP flexion 5 5
MCP 0 0 MCP 5 5
extension
IP 0 20 0 20 extension
IP 5 5
extension FINGERS extension
Abduction 0 20 0 20 Abductio 5 5
Adduction 0 0 n
Adductio 5 5
MCP 0 90 0 90 n
MCP 5 5
flexion
PIP flexion 0 100 0 100 flexion
PIP 5 5
DIP flexion 0 80 0 80 flexion
DIP 5 5
MCP 0 45 0 45 flexion
MCP 5 5
extension
DIP 0 10 0 10 extension
DIP 5 5
extension extension
LOWER EXTREMITIES
No deformity
No effusion
Tenderness on Medial Right Knee and Pes Anserinus region???
Normotonus
Normal sensibility
ROM MMT
Movement Right Left Movement Right Left
HIP
Flexion 0 120 0 120 Flexion 5 5
Extension 0 30 0 30 Extension 5 5
Adduction 0 30 0 30 Adduction 5 5
Abduction 0 45 0 45 Abduction 5 5
Internal 0 35 0 35 Internal 5 5
Rotation
External 0 45 0 45 Rotation
External 5 5
Rotation KNEERotation
Flexion 0 135 0 135 Flexion 5 5
Extension 0 0 Extension 5 5
ANKLE
Dorsiflexion 0 20 0 20 Dorsiflexion 5 5
Plantarflexio 0 50 0 50 Plantarflexion 5 5
n
Inversion 0 35 0 35 Inversion 5 5
Eversion 0 15 0 15 Eversion 5 5
GREAT TOE
MTP flexion 0 45 0 45 MTP flexion 5 5
IP flexion 0 90 0 90 IP flexion 5 5
MTP 0 60 0 60 MTP extension 5 5
extension
IP extension 0 0 IP extension 5 5
TOES
MTP flexion 0 40 0 40 MTP flexion 5 5
PIP flexion 0 35 0 35 PIP flexion 5 5
DIP flexion 0 60 0 60 DIP flexion 5 5
MTP 0 40 0 40 MTP extension 5 5
extension
Special test for the knee
Patella gridding test : negative/negative
Anterior Drawer Sign : negative/negative
Posterior Drawer Sign : negative/negative
Valgus test : negative/negative
Varus test : negative/negative
McMurray Test : negative/negative
Appley compression test : negative/negative
Appley decompression test : negative/negative
Leg length discrepancy : no leg length discrepancy
SUPPORTIVE FINDINGS
Radiology
Radiography of genu AP and lateral (29122016)
Hipoechoic pada substansi tendon supraspinatus short axis suspek partial tear
Cortical irregularity
Labrum intak
AC joint menyempit
Kesan :
Tenosynovitis bicipitalis
CASE SUMMARY
The patient is male, 72 years of age, from anamnesis on August 8th, 2017, the
patient complained that he got pain on his both knees with visual analog scale 4 for his
right knee and 3 for his left knee. The additional complain was his obesity problem.
The patient said that he kept gaining weight when he still worked for almost 30 years.
Since 4 years ago, he felt terrible pain on his right knee. He said that his knee was
swollen and redden at that time with VAS 7. The patients condition at that time still
could walk slowly. After taking the doctors prescription, His swell was reduce but the
pain still remained. The patient was reffered to Poli Klinik Obesitas Rehabilitasi Medik
RSCM and got TENS therapy and also ergocycle, strengthening and flexibility
exercise. Since last year, his left knee was in pain with visual analog scale 5. The patient
still does exercises 2 times a week at Poli Klinik Obesitas Rehabilitasi Medik RSCM.
3 months ago, the patient felt pain at his left shoulder due to picking up a water gallon,
he could not lift his arms high. At this moment, the patient still feel pain on his both
knees especially when he has to stand still for almost 30 minutes and change position
from sitting to standing. The pain feels dull from the inside of his knee. The patient has
a history of ARMD on his both eyes and had been operated in 2012, prostate cancer
and had taken prostatektomi procedure in 2016. The patient also has a history of
hypertension and hyperuricemia since 2013, they had been controlled. Physical activity
level of patient is 1,58 / sedentary.
On physical examination: BMI 31,02 kg/cm2 (obese grade I), waist
circumference 108 cm, neck circumference 41 cm. On local stase of upper extremity,
there was pain on left shoulder when flexion and abduction movement with limited
range on motion shoulder flexion 0-160 and abdudction 0-130. On lower extremity,
there was tenderness on Medial Right Knee and Pes Anserinus region, also crepitation
in both knees.
From hematology, there were borderline LDL. Radiological finding were
Bilateral knee osteoarthritis grade II. Ultrasonography of bilateral knee and left
shoulder finding were Sprain of Medial Collateral Ligament Dextra, Tendinopathy Pes
Anserinus Dextra, Chronic Partial Tear Tendon Supraspinatus Sinistra, and
Tenosynovitis Bicipitalis Sinistra.
Medical Diagnosis :
Obesity Grade I
Shoulder pain Sinistra ec. Chronic partial tear tendon supraspinatus and
tenosynovitis bicipitalis
Hypertension
Hyperuricemia
Rehabilitation Diagnosis :
Obesity grade I
Shoulder Pain and Limited Range of Motion Shoulder Flexion and Abduction due
to chronic partial tear tendon supraspinatus and tenosynovitis bicipitalis.
Body Functions :
GOALS
Short term goal :
Rehabilitation Program
PROBLEMS TARGET PROGRAMS
Physical exercise:
Hamstring, quadriceps, gastrocnemious stretching
exercise, is done before and after aerobic and
Achieving ideal strengthening exercise.
Aerobic exercise using static cycle
body weight - Astrand test :
Patient start the exercise with initial loading 2 KP
Ideal body weight: for 30 minutes and the frequency is 3 times a week.
- Determine target heart rate: (50-60% HR max) =
82,5 kg
50-60% (200-72) = 64-77x/ minutes. Evaluate the
heart rate during exercise.
- Evaluate BORG scale before and during exercise
- Educate the patient to cease exercise within 11-13
RPE BORG
Strengthening exercise using NK table (see the
description below)
Pharmacotherapy
Orlistat 120 mg, 3 times/day
Maintaining normal Education:
- Encourage patient to have an active life style:
blood pressure and
routine home exercise.
uric acid
Diet Modification:
- Control diet program by consulting to nutritionist.
- Motivation to eat healthy food: reduce salt intake
Physical exercise
Diagnosis
Follow up examination of blood pressure and blood
uric acid.
Prognosis
ad vitam : bonam