Post Amputation Transtibia e.

c Right Diabetic Foot

Examination Date: May 14, 2019

Identity:
Name: Mrs. S
Status: Married
Sex: Female
Age: 64 years old
Language: Indonesia
Ethnic Group: Javanese
Address: Lawang
Resident: AIK
Case: Post Amputation Transtibia e.c Right Diabetic Foot

Anamnesa
Chief complaint: Abnormal right leg posture (“her leg is out”)

Patient was referred from Orthopedic Outpatient Clinic with Right diabetic foot post amputation
transtibia pro prothesa.
History of present illness: patient felt her right leg is out after she did amputation 2 months ago
because of her diabetic foot. There was some pain & itchy in her stump, VAS 1-2. but there was no
numbness and no tingling sensation. She also felt her leg that the amputated leg is still there and pain
(VAS 2). For the ADL before the amputate, patients can carry out all activities independently, but now,
she has some difficulty in doing some activity like standing, walking, moving around & doing housework.
She do all activity at home in wheelchair

Past medical history:

Diabetes melitus (+) 2 years ago and uncontrolled
Post R transtibial amputation 2 months ago
no history of Hypertension
no history of Cardiac disease

Hystory of Medication :
-Wound care routinely at orthopedic 1 times in two weeks (1 times in two days at home).
-Using insulin : inject twice a day (before meal in the morning and night) (patient forget the name) -->
from internal department

History of Activity:
Patient was an housewive, and Before the illness, patient often selling “jamu” with riding bicycle. but,
now patient don't have any particular activity, only at home.

Psychological: no problem in psychological

Physical Examination:
Compos mentis.
Vital signs within normal limit.
Ambulation: independent in wheel chair
Standing Balance one leg : Independent sit to stand ,but not stable (hold the wheelchair)
ROM of cervical, trunk, upper and lower extremity: 0-full
MMT of cervical, trunk, upper extremity: 5/5
MMT of lower extremity:
HIP MMT
Flexion Minimal 4/5
Extension Minimal 4/5
Abduction Minimal 4/5
Adduction Minimal 4/5
Internal rotation Minimal 4/5
External rotation Minimal 4/5

KNEE MMT
Flexion Minimal 3/5
Extension Minimal 3/5

ANKLE MMT
Dorsoflexion - /5
Plantarflexion - /5
Inversion - /5
 Eversion - /5

Localis Status :
-Inspection
Level amputation: Below knee (Transtibial)
Stump shape : cylindrical
Wound : wet
Oedem : (+)
-Palpation
Warm : (-)
Deficit/hipersensitif : (-)
stump pain: (+) (VAS 1-2)
phantom sensation : (+)
phantom pain : (+) (VAS 2)
Barthel Index: 75

Diagnosis

• Post Amputation Transtibial e.c Right Diabetic Foot

• Diabetes Mellitus Type II

Problem List
R1 (Mobilisation): difficult to standing,walking & moving (independent using wheel chair)
R2 (ADL): Limitation to toileting, do housework
R3 (Communication): -
R4 (Psychological): patient worried about her disease
R5 (Socioeconomics): Limitation to social activities
R6 (Vocational) : can’t do household
R7 (others) :

- doesn't have right lower extremity until bellow knee

- stump pain(+), phantom pain(+) & sensation (+)
- cylindrical shape stump
- reduce the standing balance
- reduce the endurance
Functional Diagnoses:
- Impairment: stump pain & phantom sensation, cylindrical shape stump
- Disablity: independent with wheelchair, Limitation to do ADL (BI=75),
social activity, & vocational
- Handicap: no longer participating in social activity and do housework

Planning
Plan Therapy:
Exercise: strength of all the body(Trunk, UE & LE), Isometric & isotonic quadriceps exercise, ROM
exercise, Balance & coordination exercise, (Standing with one leg & walking exercise using walker),
Breathing exercise
Modality: ES at Quadriceps D intensity as patient tolerance, duration 15 minutes twice a week. (to
prevent atrophy)
Speech Therapy: n/a
Occupational Therapy: n/a
OP: (measuring prothesa) Right bellow knee prothesa (postpone) , bandaging
Other: reffer to internal medicine and nutrition department
Plan Mo: stump pain, stump condition, wound healing, ADL (BI), other chief complaint & PE
Education:
Patient condition, planning therapy, preparation before using prosthesis, consume health food, .
Continue exercise at home, support familly
 Examination Date: May 23, 2019
FOLLOW UP

Positive Findings
Anamnesa: pain & itchy in her stump at genu S decrease. VAS 1. She still feels that the amputated leg is still
there but no feel pain at amputated leg.

Physical Examination:
Compos mentis.
Vital signs within normal limit.
Ambulation: independent in wheel chair
Standing Balance one leg : Independent sit to stand ,but not stable (hold the wheelchair)
ROM of cervical, trunk, upper and lower extremity: 0-full
MMT of cervical, trunk, upper extremity: 5/5
MMT of lower extremity:
HIP MMT
Flexion Minimal 4/5
Extension Minimal 4/5
Abduction Minimal 4/5
Adduction Minimal 4/5
Internal rotation Minimal 4/5
External rotation Minimal 4/5

KNEE MMT
Flexion Minimal 3/5
Extension Minimal 3/5

ANKLE MMT
Dorsoflexion - /5
Plantarflexion - /5
Inversion - /5
Eversion - /5
Localis Status :
-Inspection
Level amputation: Below knee (Transtibial)
Stump shape : cylindrical
Wound :wound begin dry
Oedem : (+)
-Palpation
Warm : (-)
Deficit/hipersensitif : (-)
stump pain: (+) (VAS 1)
phantom sensation : (+)
phantom pain : (-)
Barthel Index: 75

Diagnosis

• Post Amputation Transtibial e.c Right Diabetic Foot

• Diabetes Mellitus Type II

Problem List
R1 (Mobilisation): difficult to standing,walking & moving (using wheel chair)
R2 (ADL): Limitation to toileting, do housework
R3 (Communication): -
R4 (Psychological): patient worried about her disease
R5 (Socioeconomics): Limitation to social activities
R6 (Vocational) : can’t do household
R7 (others) :

- doesn't have right lower extremity until bellow knee

- stump pain & phantom sensation (+)
- cylindrical shape stump
- reduce the standing balance
- reduce the endurance
Functional Diagnoses:

- Impairment: stump pain & phantom sensation, cylindrical shape stump

- Disablity: Independent with wheelchair, Limitation to do ADL (BI=75),
social activity, & vocational
- Handicap: no longer participating in social activity and do housework
Planning
Plan Therapy:
Exercise: strength of all the body(Trunk, UE & LE),Especially hip and knee Isometric & isotonic
quadriceps exercise, ROM exercise, Balance & coordination exercise, (Standing with one leg &
walking exercise using walker), Breathing exercise
Modality: ES at Quadriceps D & hamstring D intensity as patient tolerance, duration 15 minutes twice a
week. (to prevent atrophy)
Speech Therapy: n/a
Occupational Therapy: n/a
OP: prothesis is still being made (still not ready), & bandaging
Plan Mo: stump pain, stump condition, wound healing, ADL (BI), other chief complaint & PE
Education:
Patient condition, planning therapy, preparation before using prosthesis, consume health food, .
Continue exercise at home, support familly
 Examination Date: May 28, 2019
FOLLOW UP

Positive Findings
Anamnesa: pain & itchy in her stump at genu S decrease. VAS 1. She still feels that the amputated leg is still
there but no feel pain at amputated leg. Standing without grip (-)

Physical Examination:
Compos mentis.
Vital signs within normal limit.
Ambulation: independent in wheel chair
Standing Balance one leg : Independent sit to stand ,but not stable (hold the wheelchair)
ROM of cervical, trunk, upper and lower extremity: 0-full
MMT of cervical, trunk, upper extremity: 5/5
MMT of lower extremity:
HIP MMT
Flexion Minimal 4/5
Extension Minimal 4/5
Abduction Minimal 4/5
Adduction Minimal 4/5
Internal rotation Minimal 4/5
External rotation Minimal 4/5

KNEE MMT
Flexion Minimal 3/5
Extension Minimal 3/5

ANKLE MMT
Dorsoflexion - /5
Plantarflexion - /5
Inversion - /5
Eversion - /5
Localis Status :
-Inspection
Level amputation: Below knee (Transtibial)
Stump shape : cylindrical
Wound :wound dry
Oedem : (+)
-Palpation
Warm : (-)
Deficit/hipersensitif : (-)
stump pain: (+) (VAS 1)
phantom sensation : (+)
phantom pain : (-)
Barthel Index: 75

Diagnosis

• Post Amputation Transtibial e.c Right Diabetic Foot

• Diabetes Mellitus Type II

Problem List
R1 (Mobilisation): difficult to standing,walking & moving (using wheel chair)
R2 (ADL): Limitation to toileting, do housework
R3 (Communication): -
R4 (Psychological): patient worried about her disease
R5 (Socioeconomics): Limitation to social activities
R6 (Vocational) : can’t do household
R7 (others) :

- doesn't have right lower extremity until bellow knee

- stump pain & phantom sensation (+)
- cylindrical shape stump
- reduce the standing balance
- reduce the endurance
Functional Diagnoses:

- Impairment: stump pain & phantom sensation, cylindrical shape stump

- Disablity: Independent with wheelchair, Limitation to do ADL (BI=75),
social activity, & vocational
- Handicap: no longer participating in social activity and do housework
Planning
Plan Therapy:
Exercise: strength of all the body(Trunk, UE & LE),Especially hip and knee Isometric & isotonic
quadriceps exercise, ROM exercise, Balance & coordination exercise, (Standing with one leg &
walking exercise using walker), Breathing exercise
Modality: ES at Quadriceps D & hamstring D intensity as patient tolerance, duration 15 minutes twice a
week. (to prevent atrophy)
Speech Therapy: n/a
Occupational Therapy: n/a
OP: make and mold prothesa, & bandaging
Plan Mo: stump pain, stump condition, wound healing, ADL (BI), other chief complaint & PE
Education:
Patient condition, planning therapy, preparation before using prosthesis, consume health food, .
Continue exercise at home, support familly
 Examination Date: June 13, 2019
FOLLOW UP

Positive Findings
Anamnesa: pain & itchy in her stump at genu S decrease. VAS 1. She still feels that the amputated leg is still
there but no feel pain at amputated leg. Standing without grip (+)

Physical Examination:
Compos mentis.
Vital signs within normal limit.
Ambulation: independent in wheel chair
Standing Balance one leg : Independent sit to stand , stable
ROM of cervical, trunk, upper and lower extremity: 0-full
MMT of cervical, trunk, upper extremity: 5/5
MMT of lower extremity:
HIP MMT
Flexion 5-/5
Extension 5-/5
Abduction 5-/5
Adduction 5-/5
Internal rotation 5-/5
External rotation 5-/5

KNEE MMT
Flexion Minimal 3/5
Extension Minimal 3/5

ANKLE MMT
Dorsoflexion - /5
Plantarflexion - /5
Inversion - /5
Eversion - /5
Localis Status :
-Inspection
Level amputation: Below knee (Transtibial)
Stump shape : conical
Wound : dry wound + little new wound at stump
Oedem : (-)
-Palpation
Warm : (-)
Deficit/hipersensitif : (-)
stump pain: (+) (VAS 1)
phantom sensation : (+)
phantom pain : (-)
Barthel Index: 75

Diagnosis

• Post Amputation Transtibial e.c Right Diabetic Foot

• Diabetes Mellitus Type II

Problem List
R1 (Mobilisation): difficult to standing,walking & moving (using wheel chair)
R2 (ADL): Limitation to toileting, do housework
R3 (Communication): -
R4 (Psychological): patient worried about her disease
R5 (Socioeconomics): Limitation to social activities
R6 (Vocational) : can’t do household
R7 (others) :

- doesn't have right lower extremity until bellow knee

- stump pain & phantom sensation (+)
- conical shape stump
- reduce the standing balance
- reduce the endurance
Functional Diagnoses:

- Impairment: stump pain & phantom pain, conical shape stump

- Disablity: Independent with wheelchair, Limitation to do ADL (BI=75),
social activity, & vocational
- Handicap: no longer participating in social activity and do housework
Planning
Plan Therapy:
Exercise: strength of all the body(Trunk, UE & LE),Especially hip and knee Isometric & isotonic
quadriceps exercise, ROM exercise, Balance & coordination exercise, (Standing with one leg &
walking exercise using prothesa and walker), Breathing exercise
Modality:
Laser at stump
ES at Quadriceps D & hamstring D intensity as patient tolerance, duration 15 minutes twice a week. (to
prevent atrophy)
Speech Therapy: n/a
Occupational Therapy: n/a
OP: (fit and try to walk with prothesis) Right bellow knee prothesa
Plan Mo: stump pain, stump condition, wound healing, ADL (BI), other chief complaint & PE
Education:
Patient condition, planning therapy, preparation before using prosthesis, consume health food, .
Continue exercise at home, support familly