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CHAPTER II

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

Taken on August 8th, 2017 by autoanamnesis.

Chief Complaint

Knee pain on both sides when he stands too long.

Additional complaint

Shoulder pain on his left shoulder.

History of Present Illness


The patient has felt painful on his right knee since 4 years ago. He felt a dull pain from
the inside of his right knee with visual analog scale about 7. The pain emerged every
time he stood for about 30 minutes and walked for about 100 meters and more
intensified when he walked incline and decline or changed position from sitting to
standing. The pain was relieved by having some rest. There was no morning stiffness.
He said that at the time his right knee was swollen and reddish but he could still walk
slowly. The swell was relieved by taking medicine which given by the internist, but the
pain was still felt. Patient has no record of any trauma or injury on his knees. Besides
that the patients has gained weight since he was still working at a private cruise ship
company. Due to entertaining his guests, he couldnt control his intake as the result
his weight reached 106 kilograms. He was referred to POLI KLINIK OBESITAS
REHABILITASI MEDIK RSCM and diagnosed as Knee Osteoarthritis and Obesity
Grade I. After that, he got some treatments such as TENS therapy and exercises
including ergocycling, strengthening and fleksibility exercise, 2 times per week. The
pain reduced after treatment with visual analog scale 5.

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.

History of Past Medical Condition


The patient has the history of Prostate Cancer and has undergone prostatectomy
procedure on February 2016.
He also suffered from Age Related Macula Degenerative on both his eyes and has
undergone an operation procedure in 2012 that causes him suffer field of vision
impairment.
Patient has no history of diabetes, stroke or heart disease.

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.

History of Family Illness

His Father has the history of obesity and passed away because of hepatocarcinoma

His Mother passed away because of heart disease.

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.

Activities of daily living: Patient was fully independent in feeding, grooming,


dressing, bathing, and toileting Activities
Community activities: Patient is still active in his community activities, such as
going to Church weekly.
Cognition: Patient has adequate orientation, memory skills, judgment and
capacity of abstract thought.
Communication: Patient has no problem in verbal communication.

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.

Cardiopulmonary status: no history of asthma, pulmonary or heart disease

Gastrointestinal status: no history of nausea, constipation and darkened stool.


She defecates regularly.
Genitourinary status: He has record of Prostate Cancer and has prostatectomy
procedure on February 2016.
Nutritional status: obesity gr I

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

Daily Physical Activity

Time Physical activity METS


05.00 Wake up 0.9
05.00-06.00 Walking around House 3.6
06.00-06.30 Bathing 1.5
06.30-07.30 Eating 1st breakfast 1.5
07.30-10.00 Helping His Neighbor 3.5
10.00-10.15 Eating snack 1.5
10.15-12.00 Watching television 1.3
12.00-12.30 Eating lunch 1.5
12.30-15.00 Taking a nap 1.8
15.00-16.30 Helping his wife cleaning house 3.5
16.30-16.45 Bathing 1.5
16.45-18.00 Playing with his grandchildren 2.0
18.00-20.00 Watching television/chatting with his daughter 1.3
20.00-20.15 Eating dinner 1.5
20.15-21.00 Watching television/chatting with his wife 1.3
21.00-05.00 Sleeping 1.0
TOTAL 29.2

Total Energy Expenditure


BW x METs in 24 hour = 95 x 29,2 = 2.774 cal/day

BMR using Harris Bennedict formula


BMR = 66 + ( 13.7 x weight in kilos ) + ( 5 x height in cm ) - ( 6.8 x age in years )

= 66 + (13.7 x 95) + ( 5 x 175) (6.8 x 72)

= 1.752,9 cal/day

Physical Activity Level


= TEE / BMR

= 2.774 / 1.752,9

= 1,58 (limited activity)

SF-36
Physical functioning : 850 (85%)

Role limitations due to physical health : 400 (100%)

Role limitations due to emotional problems : 300 (100%)

Energy/ fatigue : 300 (75%)

Emotional well being : 360 (72%)

Social functioning : 200 (100%)

Pain : 155 (77.5%)

General health : 400 (80%)


PHYSICAL EXAMINATION
General Physical Examination
Level of Consciousness: compos mentis
Vital sign:
BP: 116/72 mmHg

HR: 78x/minute

RR: 18x/minute

Temperature: afebris

Oxygen Saturation: 99%

Borg Scale: 7-0-0

Nutritional status:

Body Weight: 95 kg

Height: 175 cm

(BMI: 31,02 Obese grade I)

Ideal body weight : (Height-100) + 10% (Height-100) = 82,5 kg

Waist circumference : 108 cm

Neck circumference : 41 cm

Gait examination:

Patient walked independently, without any walking aid


Head : in midline, no deviation
Arms : swing symmetrically
Trunk : shoulders are symmetrical, no lateral movement
Hip : no anteflexion or retroflexion
Knees : normal knee flexion and locking
Ankle and feet : adequate heel strike and push off
Stability : normal base

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

- clavicles are symmetrical

- shoulders are symmetrical on both side

- body-arm distance are symmetrical


Lateral:
- slight forward head

- slight hyperkiphotic thoracal

- no hyperlordotic lumbal

- no knee recurvatum
Posterior:
- head in midline
- shoulders are symmetrical

- body-arm distance are symmetrical

- vertebral alignment is normal

- no pelvic obliquity

- no deformity of ankle

General Physical Findings


Head : no deformity, head in the midline
Hair : grey hair, wavy, hard to be pulled out
Eyes : no anemic conjunctiva, no icteric sclera, isochoric pupils, pupil diameter

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 :

- Inspection: thoracoabdominal breathing pattern, symmetrical in


static and dynamic chest movement, no accessory muscle activity
- Palpation: no mass, vocal fremitus of both sides were equal

- Chest expansion: 3-5-6 cm

- Percussion: sonor in both side

- Auscultation: vesicular in both side. No ronchi or wheezing.


-Heart : normal heart sound I-II, no murmur, no gallop

Abdomen : distented, no defense muscular, no enlargement of liver and spleen,


tympanic sound on percussion, normal peristaltic sound

Functional Examination
Fine Coordination : in normal limit

Mobility activities : independent

Neurologic Examination
Higher Function and Mental state :

Cognitive state : Mini Mental State Examination score: 30 (no cognitive impairment)

Mental State

- Appearance and behavior: no sign of self-neglect, no appearance of anxiety and


depression, mood was stabil, behavior was appropriate
- Mood: normothym

- Affect: normal

- There was no vegetative symptoms and symptoms of anxiety

Communication : in normal limit

Language : in normal limit

Memory : in normal limit

Sensory agnosia : in normal limit

Cranial Nerve Examination : in normal limit


Motoric:
- Muscle tone : normotonus
- Physiologic reflexes

Biceps : +2/+2
Triceps : +2/+2
Brachioradialis : +2/+2
Patella : +2/+2
Achilles : +2/+2

- Pathologic reflex : negative

Sensoric: normal sensibility

Musculoskeletal Examination
CERVICAL

Look : No deformity

No sign of inflammation

Feel : No muscle spasme, no tenderness

Move : No pain on movement


ROM MMT

Movement Right Left Movement Right Left

CERVICAL
Flexion 0-400 Flexion 5

Extension 0-450 Extension 5

Lateral Bending 0-450 0-450 Lateral Bending 5 5


Rotation 0-800 0-800 Rotation 5 5

Special test:

Spurling/compression test : negative/negative


Distraction test : negative

Lhermitte sign : negative

TRUNK

Look : Shoulders are symmetrical

Slight hyperkiphotic thoracal

Body-arm distances are symmetrical

Accumulation of fat on upper back, belly and waist

Feel : No Tenderness

No pelvic obliquity

No Spasm of paralumbal bilateral

Move : No pain on movement

ROM MMT

Movement Right Left Movement Right Left

Thorakolumbal
Flexion 0-600 Flexion 5

Extension 0-250 Extention 5

Lateral Bending 0-300 0-300 Lateral Bending 5 5

Special test:

SLR test: >700/>700

Patrick : negative/negative

Contra-patrick : negative/negative
Braggard : negative/negative

Thomas test : negative/negative

UPPER EXTREMITIES

Look : Both arm in neutral position, no sign of inflammation

Accumulation of fat in the upper arms

Feel : No Tenderness , No signs of inflammation, no muscle spasm


Normotone

Normal sensibility

Normal proprioception (identifying direction & position)

Move : Pain on left shoulder when flexion and abduction movement

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

Special test for the shoulder

Neer test : negative/positif


Hawkins Kennedy test : negative/positif
Emptycan test : negative/negative
Droparm test : negative/negative
Speed test : negative/negative
Yergason test : negative/negative
Lift off test : negative/negative

LOWER EXTREMITIES

Look : No sign of inflammation

No deformity

Accumulation of fat in the gluteus and thighs

Feel : Femorotibia angle 70/50 valgus

No effusion
Tenderness on Medial Right Knee and Pes Anserinus region???

Normotonus

Normal sensibility

Normal proprioception (identifying direction & position)

Move : No pain on movement

Crepitation positive in both knees

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

Hematology (17th May 2017)

Fasting blood glucose 98 mg/dl


Asam Urat 6,7 mg/dl
Triglyceride 92 mg/dl
Total cholesterol 195 mg/dl
HDL cholesterol 55 mg/dl
LDL cholesterol 133 mg/dl*

Radiology
Radiography of genu AP and lateral (29122016)

Kedudukan tulang masih baik. Tak tampak subluksasi / dislokasi

Struktur tulang intak, tidak tampak fraktur / destruksi


Tampak formasi spur di eminetia interkondilaris bilateral, condyles medial dan lateral
femur tibia, dan apeks serta basis patella.
Celah sendi femorotibial sisi medial tampak menyempit.

Jaringan lunak tidak tampak kelainan.


Kesimpulan:
Sesuai Gambaran Osteoarthritis genu bilateral ( KL grade II )

Ultrasonography (14th June, 2017) : Genu Bilateral


Tidak tampak akumulasi cairan bilateral
Tendon Patella intak bilateral, cartilage menyempit kanan > kiri
Medial Meniscus dan Lateral Meniscus intak
Medial Collateral Ligament Dextra protusi, menebal, hipervaskularisasi tidak ada.
Lateral Collateral Ligament intak bilateral
PCL Menebal Bilateral, hipervaskularisasi tidak ada
Pes Anserinus Tendon Dextra menebal, kiri dalam batas normal
ITB Intak Bilateral
Kesimpulan:

Sprain Medial Collateral Ligament Dextra

Tendinophaty Pes Anserinus Dextra

Ultrasonography (23th August 2017) : Shoulder Sinistra

Tampak akumulasi cairan di tendon sheath bicipitalis

Kalsifikasi pada tendon subscapular

Hipoechoic pada substansi tendon supraspinatus short axis suspek partial tear

Cortical irregularity

Infraspinatus tendon menebal

Labrum intak

AC joint menyempit
Kesan :

Kronik partial tear tendon Supraspinatus Sinistra

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

Bilateral knee osteoarthritis

Shoulder pain Sinistra ec. Chronic partial tear tendon supraspinatus and
tenosynovitis bicipitalis

Hypertension

Hyperuricemia

Rehabilitation Diagnosis :

Obesity grade I

Knee pain due to bilateral knee osteoarthritis

Shoulder Pain and Limited Range of Motion Shoulder Flexion and Abduction due
to chronic partial tear tendon supraspinatus and tenosynovitis bicipitalis.

International Classification of Functioning Disability and Health:

Body Functions :

B2101 visual field function


b2801 Pain in body part
b4200 Increased blood pressure function
b530 Weight maintenance functions
b660 Procreation function
b7101 Mobility of several joints
Body Structures :
s220 Structure of eye ball
s410 Structure of cardiovascular system
s6306 Prostate
s7201 Joint of shoulder region
s7501 Structure of lower leg
Activities and Participation :

d410 Changing basic body position


d430 Lifting and carrying objects
d449 Carrying, moving and handling objects, other specified and
unspecified

GOALS
Short term goal :

Achieving weight loss

Reduced pain in both knees

Reduced pain in left shoulder

Increased ROM of left shoulder

Maintaining normal blood pressure

Maintaining normal blood uric acid

Long term goal :

Improve the Quality of life

Preventing the recurrence of musculoskeletal problems :

left shoulder pain

knee osteoarthritis progression (joint structure damage)


Improve the risk factors (hypertension )

Maintance muscle mass

Rehabilitation Program
PROBLEMS TARGET PROGRAMS

Obesity grade Achieving weight Education:


- About obesity and complications.
II loss
- Encourage patient to have an active life style: routine
Target: home exercise, less watching television.
Reduce 10 % body
weight in 6 month (= Diet Modification:
- Control diet program by consulting to nutritionist.
9,5 kg or around 1,58
- Motivation to eat healthy food: eating fruit or
kg per month) vegetables as snack
Reduce waist - Suggestion to eat breakfast, lunch and dinner in
circumference smaller portion.
- Low calorie diet

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.

Management of hypertension and hyperuricemia


- Telmisartan 40 mg, 1 time/day
- Amlodipine 5 mg, 1 time/day
- Allopurinol 100 mg, 1 time/day
- Routinely consult to the internist.
Improving balance Physical exercise:
Balance exercise using balance board for 30 minutes, 3
times a week.
Reduced pain on Education:
Pain on the - Joint protection (avoid squatting, standing or
the knee
knee due to walking for a long time, climbing up and down
knee stair).
osteoarthritis - Encourage patient to do home exercise routinely
Preventing
progression of knee Physical exercise:
- Quadriceps isotonic exercise with NK-table (using
osteoarthritis
last stress test results) 7- 10,5 - 14 kg, hold 6s,
3x10 repetition with 1 minute rest in between sets.
Strenghtening
- Hamstring isotonic exercise with NK-table (using
last stress test results) 4-6-8 kg, hold 6s, 3x10
quadriceps and repetition with 1 minute rest between sets.
hamstring muscles
Left shoulder Reduced pain of left Education:
pain due to shoulder Proper posture and body mechanic when doing household
chronic partial activities
tear tendon Improve Range of
supraspinatus Motion of left Modality:
and shoulder Laser therapy at tendon bicipitalis and supraspinatus, 3
times/week
tenosynovitis
bicipitalis Physical exercise : Home program
- Finger ladder and pendulum exercise, 3 times/day

- Stretching for improving ROM left shoulder

Prognosis

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CASE ANALYSIS
REFERENCES

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