I.

IDENTITY
Name : Mrs. A GES/HAN/WIR/ dr. DW, Sp.K.F.R.
Gender : Female
Age : 61 yo 21/09/2022
Religion : Christian
Marital Status : Married
Address : Surabaya
Occupation : Pharmacy admin
Referred from Radioteraphy OPC ca mamae sinistra dengan limfaedema. Mohon Penilaian dan saran tindakan
medik saat ini.

II. AUTOANAMNESIS
Chief Complaint: Nyeri bahu kanan
History of Present Illness:
The patient complained of pain on her right arm since 2 months ago. Pain was felt intermittently, as sharp,
tingling and radiating from her fingers, wrist, lateral forearm, to upper arm. WBS 5. Pain aggravated when the
hand got swollen, writing 10 lines and holding heavy things. Decreased by resting her hand or when the swelling
decreased. Her right arm started swelling since 5 months ago, after 2 nd cycle of chemotherapy on April 2022. At
first her swelling reduce to normal arm’s size every morning, but now it gradually get bigger, it can be reduced
but not to normal size. Swelling increased during day while activities, reduce when patient resting her hand or
after lying or slepping. She also feels stiffness in the movement of his right upper arm and fingers due to swelling
so she can't bend maximally. She complains of difficulty when she has to put on and take off her clothes (need
assistance), bathing, and eating.

History of Past Illness:

-Ca mamae was found out one year ago (May 2021) initially complaining of a lump in the right breast, the patient
went for treatment to the Soetomo Hospital, some examination was carried out leading to ca mamae, then a
Modified Radical Mastectomy operation on the right breast was performed in May 2022. The tumor tissue was
examined by hystopatologist and was said to be invasive carcinoma. Then the patient from Oncology OPC
referred for chemotherapy and radiotherapy. She had 25 times radioteraphy and had 12 chemoteraphy. Because
complaints of swelling an the patient was referred to the PMR OPC.0
-No history of trauma (-) Stroke (-) DM (-).

History of Functional Ability:

She is unable to do ADL (dressing, toileting) independently. She has some difficulty in put on, take off. She
has difficulty doing her daily homework, unable to lift heavy things unable to write more than 10 lines with, help
to cutting vegetables. If she needs to raise her arm/hand to do something, she will ask her husband or her
daughter to help her.

History of Medication and Rehabilitation:

She got medication from radioterapy OPC, Vitamin B complex 1x1
She got chemotherapy program with Trastuzumab 560 mg, Docetaxel 110 mg, Carboplatin 450 mg 8 times
She never got rehabilitation before.

History of hobby and work:

She has no specific hobby. She likes hearing music. She works as pharmacy admin, while working the patient
typed and wrote a lot. Currently she is on leave because of the chemotherapy program.

History of Psycho-Social Economy:

She live with her husband 60 yo, bachelor, pharmacist work from Monday to friday at Jember city. She has
one daughter, 25 yo, bachelor work as public relation.

History of Family: Mother had Ca Cervix, already passed away 3 years ago.

Patien Hope/wish: She hope that she feels free from pain when doing activities

III. PHYSICAL EXAMINATION

A. General status
Consciousness: compos mentis
Vital sign: BP 120/80, HR: 100x/m, RR: 20x/m Tax 36,7, SpO2 99%
Weight 72,5 kg, Height 160 cm, BMI: 28 (Obese Grade I)
Posture : shoulder asymmetric L>R
Ambulation : gait shoulder asymmetric L>R, decrease right arm swing
right-handed dominance.

B. Head /Neck / trunk

Look : redness -, edema + pitting on right upper arm, fore arm, wrist, finger
Feel : uppertrap muscle spasm +, sulcus sign -
Move :
ROM MMT
Region Joint Movement Muscles Strength
Movement Range of Motion Muscles MMT
(active and passive)
Neck Flexion (0-450) F Flexor 5
0
Extension (0-45 ) Extensor
Lateral flexion (0-450) Lateral flexor
Rotation (0-600) Rotator
Special test :-
Cranial Nerve : PBI 3mm/3mm, Light Reflex +/+
Sensory : within normal limit

Trunk Flexion(0-850) F Flexor 5

Extension (0-300) Extensor
Lateral flexion(0-350) Lateral flexor
Rotation(0-450) Rotator

Special test : Spurling -/- Compression -/- Distraction -/- TOS I -/- TOS II -/- TOS III -/-
Sensory : within normal limit

D. Upper Extremities Region

Look : edema (-/+) pitting at right shoulder, upper arm, forearm, palm, fingers. redness (+/-),
deformity (-/-)
Feel : warmth (-), tenderness -/-
Move : pain when move (+/-)
Circumference :
Axilarry : 38 / 38
10cm above elbow : 38 / 29
Elbow : 31,5 / 25
10cm below elbow : 30 / 23,5
Wrist : 18 / 16,5
Palm : 22,5 / 18

ROM MMT
Shoulder Flexion(0-1800) A:0-100 P:0-120 Flexor 5/4p
Extension (0-600) A:0-45 P:0-50 Extensor 5/4p
Abduction(0-1800) A:0-110 P:0-120 Abductor 5/4p
Adduction(0-450) A:0-20 P:0-30 Adductor 5/4p
Internal Rotation (0-900) A:0-70 P: 0-80 Internal Rotator 5/4p
External Rotation (0- A:0-50 P:0-60 External Rotator 5/4p
700)
 Elbow Flexion (0-1350) 0-120 A P : 0-120/F Flexor 5/4p
Extension (135º-0) F/F Extensor 5/4p
Pronation (0-900) F/F Pronator 5/5
Supination (0-900) F/F Supinator 5/5
Wrist Flexion (0-800) F/F Flexor 5/3p
Extension (0-700) F/F Extensor 5/3p
Radial deviation (0-200) F/F Radial Deviator 5/4p
Ulnar deviation (0-350) F/F UlnarDeviator 5/4p
Fingers Flexion 0-45 P /F Flexor 5/4
Extension F/F Extensor 5/4
Abduction F/F Abductor 5/4
Adduction F/F Adductor 5/4

Special test : Painful arch -/ + 100 Empty can -/-, Neer -/-, Hawkin -/-, Yergason -/-, speed test -/- Apley
scratch test as high as gluteal, lift off -/unable, belly press -/- Phalen -/- kontra phalen -/-
tinnel test -/-
Reflex : BPR +2/+2, TPR +3/+3, Hoffman -/-, Tromner -/-
Spasticity :-
Sensoric : deficit sensoric 20% of right arm
Proprioceptive : within normal limit
Hand function : cylindrical WF/F, spherical WF/F,grasp WF/F, hook WF/F, grip WF/F, palmar tip WF/F,
lateral tip WF/F

E. Lower Extremities region

Look : edema (-/-), redness (-/-), deformity (-/-), within normal limit
Feel : warmth (-), within normal limit,
Move : crepitation (-/-)
ROM MMT
Hip Flexion (0-1250) F/F Flexor 4/4
Extension (0-300) Extensor
0
Abduction (0-45 ) Abductor
Adduction (0-200) Adductor
Internal Rotation (0-450) Internal Rotator
0
External Rotation (0-45 ) External Rotator
Knee Flexion (0-1350) F/F Flexor 5/5
Extension (135º-0) Extensor
Ankle Dorsoflexion (0-200) F/F Dorsoflexor 5/5
Plantarflexion (0-500) Plantarflexor
0
Eversion (0-15 ) Evertor
Inversion (0-350) Invertor
Big Toes Flexion F /F Flexor 5/5
Extension Extensor
Toes Flexion F /F Flexor 5/5
Extension Extensor

Special test : -/-

Reflex : KPR +2/+2, APR +2/+2, Babinski -/-, Chaddock -/-
Sensoric : within normal limit
Spasticity :-

Functional Status
Count Tes : 25 Chest Expansion: 3/3/3
Balance :
Sitting balance static : good
Sitting balance dynamic : good
Standing balance static : good
 Standing balance dynamic : good
Mobilization (Transfer, ambulation)
Lying to sitting : able independently
Sitting to standing : able independently
Ambulasi : able independently
Coordination : dymetria : -, dysdiadokokinesia –, Romberg -, sharpen Romberg -
Hand dominance : right
History of Functional Ability:
Feeding 5/10 Bladder 10/10
Grooming 5/5 Toilet use 5/10
Bathing 0/5 Mobility 10/15
Dressing 5/10 Transfer 10/15
Bowel 10/10 Stairs 0/10
Total = 85
HDRS: 8

IV. SUPPORTING EXAMINATION

-Mamma Dextra, Immunohsitokimia: (17/05/2021)
Estrogen : Positif
Progesteron: Negatif
Her2/NEU: Positif (Socre 3+)
Ki67: Index Proliferasi 50%
-Mamma Dextra, Operasi MRM (07/05/2021)
- Invasive Breast Carcinoma no Special Type (infiltrating Ductal Carcinoma NOS) Grade I dengan
extensive ductal carcinoma in situ comedo necrosis type dari criboform type High Nuclear Grade
- Ukuran Tumor 5,5 x 3 x 4,5 cm
- Tampak Lymphangioinvasi, Tidak Tampak Perineural Invasi
- TIdak didapatkan metastasis pada 24 Nodul KGB yang Ditemukan
pT3N0Mx Stage II B
-Mamma Dextra kuadran cenrolateral, FNAB: (01/04/2021)
Ductal Carcinoma
-CT Scan Thorax (08/04/2022)
- Fibrokonsolidasi di lapang paru kanan dominan sisi lateral dapat merupakan proses metastase
- Subcentimeter ly7mphnode di axilla kiri
- Spondylosis lumbalis
- Fuisi Corpus VTh 11-12

V. FUNCTIONAL ASSESSMENT (include ICF)

Problem List (ICF):
Body Functions:
B198 Mental functions, other specified (mild depression)
B280 Sensation of pain (Right shoulder pain)
B435 Immunological system function (Lymphedema)
B440 Respiratory Functions (decrease of count test and chest expansion)
B530 Weight maintenance function (Obese grade I)
B710 Mobility of joint function (ROM limitation right shoulder)
B730 Muscle power functions (decrease MMT upper extremity)
B735 Muscle tone function (decrease upper extremity muscle tone)

Body Structures:
S420 Structure of immune system (Lymphedema)
S760 Structure of trunk region (Right Ca mammae, upper trap muscle spasm)
S720 Structure of shoulder region (ROM limitation of shoulder)
S730 Structure of upper extremity (Right lymphedema upper extrimity)
S810 skin and related structures, other specified (Lymphedema upper extrimity)
Activity Limitation:
D430 Lifting and carrying objects (unable to lift heavy things)
D510 Washing one self (difficult to wash hair)
D540 Dressing (unable to wear and take off clothes)
D640 Doing housework (difficult to doing housework)

Environmental factors:
E310 Immediate family (supported by her husband and her children)
E580 Health services, systems and policies (BPJS)

Personal factors:
Female, 51 yo, Ca Mamae

PROBLEM LIST
 Right shoulder pain
 ROM Limitation of Left shoulder
 Sensoric deficit 20% of right arm
 Decrease of muscle strength on righte upper limbs
 Left lymphedema upper extremity
 Ca Mammae
 Bad Posture
 Decrease of chest expansion and count test
 Decrease of cardiopulmonary endurance

VI. ASSESSMENT
Clinical Diagnosis : Right Upper Extremity Pain ec Lymphedema Upper Extremity Grade II + Ca Mammae T0N1M1
Lung Metastase Post Radical Mastectomy (1 Year) + Post Radioteraphy (25 Times) on
Chemoteraphy 2nd Cycle + Decrease of Cardiopulmonary Endurance ec Cancer Related Fatigue
+ Mild Depression + Obese Grade I
Goal:
Short Term :
1. Tolerable pain (WBS <2)
2. Decrease swelling ( Decrease arm circumference differences)
3. Functional ROM
4. Functional MMT (MMT>4)
5. Improved Cardiopulmonary endurance

Long Term :
1. ADL independently without pain (dressing, bathing, eating)
2. Better quality of life
3. Die in Dignity

Planning:
PDx : consult to pain paliatif care for her neuropathic pain caused by lymphedema
Consult to physiatrist
Bone survey xray

PTx :
Modalitas: High TENS 100Hz flexor retinoculum and antebrachia dorsal side (20 minutes) as patient tolerance
Thera exc: Precautuon fatique
1. Manual massage start form upper arm to distal, direction from distal to proximal right arm
2. Gentle active ROM AGA D
3. Wrist pumping
4. Breathing exercise : diaphragma breathing, chest expansion excercisee
5. Aerobic exercise :
F:3-5x
 I: borg scale 11-12
T: 20 minutes, gradually increase as patient tolerance
T:static cycle
OP: compression sleve

Monitoring: Clinical, VS, MMT, ROM, Circumference (swelling), sensoric, hand function, count test, chest expansion,

Edx:
1. Explain about patient’s condition, prognosis and rehab program
2. Continue to practice at home (wrist pumping with tennis ball, positioning, elevation)
3. Communicate to the family about the patient's expectations, if possible come with her to the hospital
4. Avoid activities that aggravate pain and edema, heavy lifting, long writing
5. Energy conservation technique
1. Plan and share activities
2. Pace breathing
3. Modification tools
4. Adjust activity: replace with left hand, activity by sitting, exercise while lying down
6. Skin care with oiling, followed by massage to the proximal