POLICLINIC CASE REPORT

7 Oktober 2019

I. IDENTITY
Name : Mr. MR
Age : 41 years old
Occupation : Seller
Religion : Moslem
Date : September 30th, 2019

II. ANAMNESA
 Chief complaint : Pain and stiffness in the right foot
 Present history of illness :
On October 16, 2018 the patient had a traffic accident. The
patient was hit by a truck and entered under the truck. There
are open sores on right foot. After the accident the patient
is still conscious. After that the patient was taken to the
Demak District Hospital and was referred to the Kariadi
Hospital. The patient underwent STSG surgery 7 times
since being treated at the Kariadi Hospital. The last
operation was in May 2019. There were no bones fracture.
The patient was admitted to the medical rehabilitation
department due to pain and stiffness in the right ankle.
Previously the patient mobilized in a wheelchair and was
practicing using crutches at home. The patient is no longer
working.
 Past history of illness : HT (-), DM (-)
 Social economics :
The patient work as a seller. The patient lives with his wife
and two children. Financing with BPJS PBI. Poor
socioeconomic impression.

III. PHYSICAL EXAMINATION

General condition : CM, contact good
BP 120/80 mmHg
VAS static : 2
VAS dynamic : 5
Head : conjuctiva anemic (-), icteric sclera (-)
Thorax : cor pulmo within normal limit
Abdomen : flat, supel
Extremity : oedema (+), deformity (+) in the right foot

Localized status regio cruris and pedis dekstra

Inspection : dry operation wound, deformity (+), edema (+),
dark brownish colour of grafted skin
Palpation : pressure pain (+), warm (+)
Move : ROM Ankle joint S : 5 - 0 - 20, F : 0 - 0 – 0
MMT : Genue extension: 5
Dorsoflexion : 3
Plantarflexion : 3
Finger flexion & extension : 5

IV. DIAGNOSIS
 Clinical diagnosis : Post STSG ec skin degloving
regio pedis dekstra and cruris dekstra
 Functional diagnosis :
- Body structure function : Ankle stiffnes, ankle pain,
limited ROM of the ankle
- Activity : Walking and mobilization difficulty
- Perticipation : Unable to work yet
- Environment : Patient have family support
- Personal : Patient can accept her condition and
have positive thought
V. GOAL
 Short term goals : - Reduce pain and edema
-Increase ankle ROM
 Longterm goals : Patient able to walk, undergo daily
activities, and working

VI. REHABILITATION PROGRAM

 Physical Exercise : - AROM exercise on the right ankle
- Ambulation exercises with axillary
crutches
 Physical Modalities : Cryotherapy pedis dekstra, TENS
pedis dekstra

VII. PROGNOSIS
Ad vitam : Bonam
Ad functionam : Dubia ad Bonam
Ad sanationam : Bonam