POMR AMPUTATION

DATA BASE
I. IDENTITY
Name / Sex / Age
Married / Not Married
Occupation / Education
Religion
Address
Health Insurance

II. CHIEF COMPLAINT : (Bahasa)

Post amputation / want to wear prosthesis

III. HISTORY OF PRESENT ILLNESS

 Chief Complaint 4 W +1H :
 When the operation held? Cito orelective?
 Which part of the body? Upper or lower extremity?
 Why it should be amputed at that time?
 How's the mode of injury?
 How's the patient feeling now? Is there any feeling of the present of the
leg/arm or pain?
 How's the condition of the stump? Any swelling? tenderness? pain?
tingling sensation?
 Is there any other operation beside amputation?
 Other complaints
 ADL How's the patient's daily acitivity after the amputation? Any
disturbance ?
 How's the social life of the patient after amputation? Any poor self esteem?
 Review of systems (Quick 1) : Head to toe

IV. HISTORY OF PAST ILLNESS

 Trauma
 Diabetes Mellitus
 Hypertension
 Malignancy
 Other Surgery before
 Cardiac disease

V. FAMILY HISTORY

1
VI. PHYSICAL EXAMINATION
 GCS, ambulation status, gait, hand dominance
 Vital sign
BP:
HR:
RR
SaO2:

 Head/Neck: anemia, icteric,cyanosis,dyspneu

 Thorax: cor/pulmo
 Abdomen
 Extremities
 Musculosceletal examination :
 ROM / MMT
 Neurologic examination :
 Cranial nerves,
 muscle tone,
 DTRs,
 Pathological reflexes
 Sensation
 Local status:
 Inspection : Operation wound, inflammation, neuromas, shape of the
stump (conical, cylindrical, dog ear)
 Palpation : Stump Length, diameter, edema, neuroma, phantom sensation,
phantom pain, muscle atrophy
 Balance examination : standing with 1 feet, jump
 Barthel Index,
 Chest expansion
 6 minutes walking test

VII. PROBLEM LIST

I. Medical
II. Surgical : post amputation
III.Rehabilitation medicine: R1 – R7
R1= Ambulation independent with wheelchair/double axillary
crutches/other
R2= ADL, any limitation for doing daily activities; barthel index
R3= Communication
R4= Psychology of the patient, depressed, worried, acceptance
R5= Socioeconomy, any difficulty in economic condition due to the
amputation
R6= Difficuly doing his job/not

2
 R7= shape and size of the stump, other condition of the patient

VIII. DIAGNOSIS

I. FUNCTIONAL DIAGNOSIS
Impairment : Post amputation below/above.....
Disability: can't walk by him/herself, can't bathing/dressing/toilet
Handicap : Can't attend the social activity because of the condition, can't fulfill
the job's target

II. GOALS
Short : Reduce the pain/inflammation
Intermediate : Use prosthetic for aesthetic
Strengthen the muscles, improve balance
Long : increasing independently in daily activities
Fulfill the role in his/her environment

III. PLANNING
Diagnosis :-
Therapy:
Therapeutic exercise (ROM exercise, strengthening exercise,
endurance exercise, breathing exercise; Occupational Therapy ( hand
Prosthetics)
Monitoring: clinical, condition of the stump
Education : educate for family and environmental support; exercise at home

IX. PROGNOSIS
Ad vitam
Ad sanam
Ad functionam