RAI/WIR/ dr. HY, Sp.

KFR

CASE REPORT
Identity
Mr. K / 61 yo/ 12936807/Moslem/Unemployee
Patient was referred from Oncology Surgery OPC with : Nonmelanoma Skin Cancer (SCC)
regio Dig III, IV, V manus D akan dilakukan Tindakan Below elbow amputation Dextra +
diseksi axilla dextra, mohon evaluasi dan tatalaksana terkait pemasangan prostesis dan
rehabilitasi fisik pasca operasi.

I. ANAMNESIS
1. Chief Complain
Nyeri lengan bawah dan tangan kanan
2. History of Present Illness :
Eight months ago, he complaint pain on his hand until forearm and the wound does not
healing. Then he went to the same Clinic and was advised to refer to Muhammadiyah
Hospital in Lamongan. At the hospital, he got PA examination and diagnosed with skin
cancer and was recommended to amputate the fourth finger. After the amputation was
performed, the wound did not heal, a lump appeared at the site of the amputation wound and
black spots appeared around the 3rd and 5th fingers. The lump was getting bigger and he
complained of pain in the right hand. He returned to Muhammadiyah Hospital for treatment
and was referred to the Soetomo Hospital. Reduce pain with he take painkiller without
doctor’s prescription (Ibuprofen, Paracetamol and Caffein)
Three weeks ago, he went to Soetomo Hospital and underwent chest X-ray, ultrasound and
tissue examination. Then he was advised to perform an amputation below the elbow.
Initially he and his wife refused. Then he is accepted to be amputated due to hand’s pain.
Currently, he complains of pain on right hands until forearm, continuous pain with WBS 9-
10 and reduced by taking medication for 2-3 hours to WBS 5-6. He had to bend his hand and
complained pain if he had to straighten his hand The pain interferes with sleep and he's
appetite has decreased since 2 weeks. There in no numbness, tingling sensation, cough or
shortness of breath.
History of Cancer :
At the age of 8 years, the patient complained the fourth finger on the right hand has wound
then appeared a lump with size tip of a pin. These lumps do not have complaints of pain,
easy to bleed or itch. He’s hands are still used for hoeing and weaning due to he's work as a
farmer. The lump is getting bigger but it takes a long time.
4 years ago the patient complained of a lump on his fourth finger that was as big as his big
toe and became sore. He went to Clinic, the wound was cleaned and sutured. He routinely
visits the clinic to clean the wound, but the wound does not heal until he decides to clean it
himself at home. The wound did not heal and the patient began to complain of pain in the
right hand. pain is increasing and got worsen. The lump getting bigger.
3. History of Functional Ability
He able to do ADL independently (bathing, toilet use, mobility, transfer and going up
and down stairs). Bowel and bladder was normal. He complaint about difficult to eating
with left hand and button pants and shirt, so need help.
 4. History of Past Illness
No history of HT, DM (-), trauma (-), or stroke (-)
5. History of work / hobby
Before sick (4 years ago), she was farmer and he unemployee.
6. History of Psycho-Social-Economy
The patient currently lives with his wife, 66 yo background education : elemtary school.
Housewife. He has 3 children, married and lived in a different place.
7. History of Family
There was no history of HT, DM, Stroke, or cancer in her family.

II. PHYSICAL EXAMINATION

1. General Status
 GCS 456, independent, right handed domination
 Vital sign : BP : 130/80 mmHg; HR : 90bpm; RR : 20x/min; Temp : 36.8
 Height : 172 cm
 Weight : 65 kg
 BMI : 21,97 (normoweight)
 Posture : forward head-neck, rounded shoulder, kyphotic thoracic
 Ambulation : Independent

2. Head/Neck/Trunk (WNL)
 Look : swelling -, deformity -, gibbus -,
 Feel : warmth -, tenderness -, lymph node enlargement (-/-)
 Move : pain when move (-/-)
 Special test : -
Region Movement ROM Muscles MMT
Neck Flexion (0-450) F Flexor 5
Extension (0-450) F Extensor 5
Lateral flexion (0-450) F Lateral flexor 5
Rotation (0-600) F Rotator 5
Trunk Flexion(0-850) F Flexor 5
Extension (0-300) F Extensor 5
Lateral flexion(0-350) F Lateral flexor 5
Rotation(0-450) F Rotator 5

3. Upper Extremities Region

 Look : on right hand there is a tumor that is shaped like cauliflower, redness +,
blood -. Dig IV was amputated
 Feel : warmth -, muscle Spasm (-/-), tenderness (-/-), lump on posterior axilla
(+/-).
Move : pain when move (-)
Neuromuscular :
 Deep Tendon Reflex : BPR : +2/+2 TPR +2/+2
 Pathological reflex : Hofmann -/-, Tromner -/-
 Sensory : Sensory deficit on right digiti II, III and V 30%
  Special Test: (-/-)
Region Movement ROM Movement MMT
0
Shoulder Flexion(0-180 ) 0-100/F Flexor 5/5
0
Extension (0-60 ) F/F Extensor 5/5
Abduction(0-1800) 0-100/F Abductor 5/5
0
Adduction(0-45 ) 0-25/F Adductor 5/5
0
Internal Rotation (0-90 ) 0-70/F Internal Rotator 5/5
External Rotation (0-700) 0-40/F External Rotator 5/5
0
Elbow Flexion(0-135 ) F/F Flexor 5/5
Extension (135º-0) F/F Extensor 5/5
Pronation (0-900) F/F Pronator 5/5
0
Supination(0-90 ) F/F Supinator 5/5
0
Wrist Flexion (0-80 ) F/F Flexor 5/5
0
Extension (0-70 ) F/F Extensor 5/5
Radial deviation (0-200) F/F Radial Deviator 5/5
0
Ulnar deviation (0-35 ) F/F Ulnar Deviator 5/5
Fingers Flexion NE Flexor NE
Extension Extensor
Abduction Abductor
Adduction Adductor
 Hand Function : grasp, cylindrical, cpherical, hook, pinch, lateral tip and palmar tip
: NE/F
 Circumference :
 Above Elbow : 22/23 cm
 Below Elbow : 22/23 cm

4. Lower Extremities Region

 Local Status
o Look : redness -/-, swelling -/-, edema -/-
o Feel : warmth -/-, tenderness -/-, pain when move, crepitation (-/-).
o Move : rigidity -/-, limitation of ROM (-/-)
Region Movement ROM MMT
Hip Flexion(0-1250) F/F 5
Extension (0-30 ) 0
F/F 5
Abduction (0-450) F/F 5
Adduction (0-20 ) 0
F/F 5
Internal Rotation (0-450) F/F 5
External Rotation (0-450) F/F 5
Knee Flexion (0-135 )0
F/F 5
Extension (135º-0) F/F 5
Ankle Dorsiflexion (0-20 ) 0
F/F 5
Plantarflexion (0-500) F/F 5
Eversion (0-15 )0
F/F 5
Inversion (0-350) F/F 5
 Big Toes Flexion F/F 5
Extension F/F 5
Toes Flexion F/F 5
Extension F/F 5
 Neuromuscular :
o Deep Tendon Reflex : KPR : +2/+2 APR +2/+2
o Pathological reflex : Babinski -/-, chaddock -/-
o Sensory : wnl
o Exteroceptive : wnl
o Proprioceptive : wnl

5. Functional Status
 Sitting balance : static & dynamic good
 Standing balance : static & dynamic good
 Romberg : Able
 Sharpen Romberg : Able
 Tandem Walking : Able
 Coordination : Disdiadokokinesia dte, finger to nose (dte/able)
 Chest expansion : T2/T4/T6 : 3/3/3
 Count test : 25
 6MWT : 306 m, METs : 5,21; VO2 max : 18,236
 GDS : 11 (Depression)

6. SUPPORTING EXAMINATION: -
 PA (2/10/2021) :

 PA (30/06/2022) :
  THORAX PA (30/06/2022) :

 USG Axilla (01/07/2022) :

III. FUNCTIONAL ASSESSMENT

1. ICF :
 Body Function
o B280 Sensation of Pain (Pain on right hand)
o B735 Muscle tone function (atrophy on right upper extremity)
o B455 Exercise tolerance function
o B435 Immunological system functions (Non Melanoma skin cancer dig III, IV and V
Right manus)
o B530 Weight maintainance function (loss of appetite)
o B198 Mental function, other specified (depression)
o B849 Function of the skin, other specified and unspecified (Non Melanoma skin
cancer dig III, IV and V Right manus)
 Body Structure
o S810 Structure of areas of skin (Non Melanoma skin cancer dig III, IV and V Right
manus)
o S730 Structure of upper extremity (Non Melanoma skin cancer dig III, IV and V Right
manus)
o S420 Structure of immune System (Non Melanoma skin cancer dig III, IV and V Right
manus)
 Activities and Participation
o D550 Eating
 o D598 Self care, other specified (grooming)
o D859 Work and employment, other specified and unspecified (Unable to work again)
o D930 Religion and sprituality (unable to came recitation/pengajian)
 Environmental Factors
o e3104 Immediate family
o e5804 Health Service (BPJS)

2. Problem List :
 Right hand pain
 Digiti III right manus
 Atrophy right upper extremity
 Non Melanoma skin cancer
 Loss of appetite
 Depression
 Decrease of cardiopulmonary endurance
 Bad Posture

IV. ASSESSMENT
Right Hand Pain ec Non Melanoma Skin cancer (Squamous Cell Carsinoma) Stage
T4N1M0 Region Digiti III, IV and V Right Manus + Pro Below Elbow Amputation +
Geriatric Syndrome

V. PROGNOSIS
Ad vitam : malam
Ad sanactionam : malam
Ad functionam :
- Transfer : independent
- Ambulation : Independent
- Other ADL : partial dependent/independent with or without prosthesis
V. GOALS
 Short term:
1. Reduce Pain
2. Maintain ROM
3. Maintain muscle strength
4. Patient understand the treatment plan
5. Pre prothesis preparation
6. Improve nutritional intake
7. Maintain cardiopulmonary endurance
 Long term:
1. Prevent worsen condition
2. Improve ADL (independently with left hand)
3. Improve QoL

VI. PLANNING
1. Planning Diagnostic:
 Consult to psychiatrist (has been done from Oncology Surgeon OPC)
 Consult to Palliative OPC
 Consult to bone survey examination
 CGA examination
2. Planning therapy:
A. Pharmacotherapy : continue medication from oncologi surgery and consult to
Palliative OPC for pain management
B. Non Pharmacotherapy :
 Modality : HI TENS 100 Hz on right paracervical area C5-T1 with intensity as
patient tolerance.
 Therapeutic exercises: PRECAUTION : : isotonic strengthening and endurance
exercise was conducted when WBS < 5, Vital sign, fatigue
1. Posture correction
2. BEA with deep breathing dan chest expansion exercise
3. Isometric Strengthening exercise on right shoulder to abduction, flexion, internal
and external rotation direction
4. AROM exercise on right upper extremity with patient tolerance, on upper
extremity and lower extremity for both side and scapular mobilization exercise
5. Isometric/isotonic strengthening exercise on right upper extremity
6. Endurance exercise : (F : 3-5x/weeks, I : HR + 20, I : 5’ warm up, 20’ core
exercise, 5’ cool down, T : static cycle)
 OT : hand function exercise substituted with left hand (eating and grooming)
 OP : arm sling

3. Planning monitoring: Clinical Condition, VS, WBS, ROM, MMT, EBS, endurance,
sign of metastasis (bone: pain in other bone area, lung: cough, shortness of breath,
lymphnode: lump/pain in lymphnode area (neck, contralateral axilla)

4. Planning education:
 Explain the patient’s condition, rehabilitation program and the goals to the
patient and caregiver
 Continue Exercise at home (isometric strengthening exercise on proximal of
upper extremity and endurance exercise with brisk walking) as patient tolerance
 Encourage patient to doing ADL with left hand (eating, grooming)
 Motivated patient that after amputation, ADL can be done independently with
the left hand or assisted with prothesis.
 Encourage mental preparation for patient and his wife (caregiver)