IDENTITY (May 16th, 2023) NIS/CIA/ dr. NS, Sp.K.F.R., Ger.

(K)
Name : Mrs. N
Age : 51 years old
Sex : Female
Religion : Moslem
Marital Status : Married
Address : Mojokerto
Occupation : Housewife, Catering Owner
Phone Number : 0811599066 (Husband, Mr. Haryono)
Medical record : 13002495
Referred from Neurosurgery OPC with Meningioma konveksitas FP D, Post Craniotomy eksisi tumor meningioma
konveksitas FP D + Dekompresi
AUTOANAMNESIS
II.1. Chief Complaint: Kesulitan untuk berjalan
II.2. History of Present Illness:
The patient complained of general weakness after the craniotomy tumor excision and decompression
surgery on April 25th 2023. Before the surgery, she complained of weakness from 5 years ago, but worsen since 1
year ago. She complained of headache, difficult in communication (not congruent), couldn’t control her emotion 1
year ago, and 3 days before the surgery there was decrease of consciousness, and before she wasn’t conscious, she
vomit, nausea, and headache, but there was no visual disturbance or dizziness. She didn’t completely remember the
memory what happen in 1 year, she only remember she easily got fatigue those year. When she wasn’t conscious
her family brought her to ER (April 15 th 2023) at RS Gatoel Mojokerto, at HCU Room. Her family just knew that she
had tumor from CT-Scan. After her consciousness back, she referred to neurosurgery RSDS for surgery. She
hospitalized at Bedah Gladiol ward from April 19 th 2023 until May 1st 2023.
Currently she still complained of difficult to walk, she used walker to ambulate around the house, she still
felt pain on surgery wound area right head with WBS 5, felt intermittent, with characteristic aching pain, not
radiating, no pain when move, the pain decrease when she lying on bed until the pain relieve with WBS 0. She able
to move from lying to sitting independently, but to stand she need to hold something like walker or holder. Then she
can ambulate by herself with walker. She needs walker because felt heavy on both anterior thigh (Right > Left).
Toiletting needs help to stand after use sitting toilet type. Bathing with sitting position able to do by herself. Able to
eat and drink, no choking. Still haven’t tried to use stair. Able to transfer from bed to chair, or chair to bed with hold
on something. Defecation and urination have no complaints.
II.3. History of Functional Ability: The patient is able to sit for 3 hours, if more than that she felt swelling on both leg,
transfers from lying to sitting able, sitting to standing with assistance or hold on something, basic ADL such as eating,
grooming, dressing, bathing, able independently. Unable using stairs, and transfer needs help. There were no
complaints of defecation and urinate. The patient able to pray with sitting position at this time.
II.4. History of Medication and Rehabilitation:
- RS Gatoel Mojokerto since April 15th 2023 until April 19th 2023
- RSUD Dr. Soetomo since April 19th 2023 until May 1st 2023, got medication from neurosurgery: paracetamol
and dexa 3x1, from internist: insulin novorapid 3x8 unit ac, omeprazole 2x20mg prn
- During hospitalized in Bedah Gladiol, she already got rehabilitation program only 1 time.
II.5. History of Past Illness: Hypertension (+) since 2 years ago taking amlodipin regularly, heart disease (-),
cholesterol (-), uric acid (-), DM (+) just diagnosed after the surgery, injection KB for 22 years, routine every 3 months
until before diagnosed with tumor
II.6. History of Hobby and Work: She is a housewife. Own catering, since 27 years ago, actively manage the catering.
Currently for the house chores help by her daughter.
II.7. History of Psycho-Social-Economic: The patient lives with her husband (Mr. Haryono, 57th, retired DPR) and 2
daughter (27 yo and 22 yo). She had sitting toilet with 2-storey house.
II.8. Family History: No history of same disease in her family.
II.9. Patient’s Expectation: She hopes she able to walk again as before.

PHYSICAL EXAMINATION
III.1. General Status
GCS E4 V5 M6 BP: 130/80 mmHg, HR: 85x/min, RR: 20x/min, Temp: 36.7oC, SpO2: 99%
Height: 171 cm, Weight: 60 kg, BMI: 20.5 (normal)
Posture: Forward head and rounded shoulder
Dominant extremity: Right handed.
Ambulation: independent with walker

Head and neck :

Conjunctiva anemia (-|-), icterus (-|-), cyanosis (-), enlargement lymph node (-)
Cor : S1-S2 normal, regular, murmur (-), gallop (-)
Pulmo : Vesicular (+|+), wheezing (-|-), ronchi (-|-)
Abdomen : Soefl, peristaltic (+), tenderness (-)
Extremities : Warm acral (-|-), cyanosis (-)

III.2. Head/Neck/Trunk,
Look : deformity (-|-), swelling (-|-), surgery scar post cranitiomy already healed & dry +15cm
Feel : tender point (-|-), warmth (-|-), edema (-|-),
Move : pain when move (-)

Movement Range of Motion Muscles MMT

Neck Flexion (0-450) F/F Flexor 5
Extension (0-450) F/F Extensor 5
Lateral flexion (0-450) F/F Lateral flexor 5/5
Rotation (0-600) F/F Rotator 5/5
Trunk Flexion(0-850) F/F Flexor 5
Extension (0-300) F/F Extensor 5
Lateral flexion(0-350) F/F Lateral flexor 5/5
Rotation(0-450) F/F Rotator 5/5
Cranial nerve : -
Sensory :-

III.3. Upper Extremities Region

Look : redness (-|-), swelling (-|-),
Feel : warmth (-|-), tender point (-|-), crepitation (-|-),
Move : pain when move (-|-)
Neuromuscular :
- Spasticity : elbow flexor (-|-), elbow extensor (-|-), wrist flexor (-|-), wrist extensor (-|-)
- Deep Tendon Reflex : BPR (+2|+2), TPR (+2|+2)
- Pathological reflex : Hoffmann (-|-), Tromner (-|-)
- Sensorics : exteroceptive and proprioceptive are normal
Region Movement ROM Movement MMT
Shoulder Flexion(0-1800) F/F Flexor 5/5
Extension (0-600) F/F Extensor 5/5
0
Abduction(0-180 ) F/F Abductor 5/5
Adduction(0-450) F/F Adductor 5/5
Internal Rotation (0-900) F/F Internal Rotator 5/5
0
External Rotation (0-70 ) F/F External Rotator 5/5
Elbow Flexion(0-1350) F/F Flexor 5/5
Extension (135º-0) F/F Extensor 5/5
Pronation (0-900) F/F Pronator 5/5
Supination(0-900) F/F Supinator 5/5
0
Wrist Flexion (0-80 ) F/F Flexor 5/5
Extension (0-700) F/F Extensor 5/5
0
Radial deviation (0-20 ) F/F Radial Deviator 5/5
Ulnar deviation (0-350) F/F Ulnar Deviator 5/5
Fingers Flexion F/F Flexor 5/5
Extension F/F Extensor 5/5
Abduction F/F Abductor 5/5
Adduction F/F Adductor 5/5
III.4. Lower Extremities Region.
Look : redness (-|-), edema (-|-), atrophy (-|-), deformity (-|-),
Feel : warmth (-|-), pitting edema (-|-)
Move : pain when move (-|-)
Neuromuscular :
- Spasticity : ankle dorsiflexion (-|-), ankle plantarflexion (-|-)
- Deep Tendon Reflex : KPR +2|+2; APR +2|+2
- Pathological reflex : Babinski (-|-) Chaddock (-|-)
- Sensorics : exteroceptive and proprioceptive are normal
- Clonus : (-|-)
Region Movement ROM Movement MMT
Hip Flexion(0-1250) F/F Flexor 5/5
0
Extension (0-30 ) F/F Extensor 5/5
Abduction (0-450) F/F Abductor 5/5
0
Adduction (0-20 ) F/F Adductor 5/5
Internal Rotation (0-450) F/F Internal Rotator 5/5
External Rotation (0-450) F/F External Rotator 5/5
0
Knee Flexion (0-135 ) F/F Flexor 5/5
Extension (135º-0) F/F Extensor 5/5
0
Ankle Dorsiflexion (0-20 ) F/F Dorsiflexor 5/5
Plantarflexion (0-500) F/F Plantarflexor 5/5
Eversion (0-150) F/F Evertor 5/5
0
Inversion (0-35 ) F/F Invertor 5/5
Big Toes Flexion F/F Flexor 5/5
Extension F/F Extensor 5/5
Toes Flexion F/F Flexor 5/5
Extension F/F Extensor 5/5

III.5. Functional Status

Balance : sitting static and dynamic good, standing static good and dynamic poor
Mobilization : turning: able, bridging: able
Transfer : lying to sitting able, sitting to standing unable
Coordination : Finger to nose (able/unable), dysdiadokokinesia (-/+)
5STS : 29.75 secs
Count test : 20
Chest expansion: 2.5 cm /2.5 cm/ 2.5 cm
FES : 34/64 (Severe fear of fall)
BI : 75 (minimally dependent)
Feeding 10/10 Bladder 10/10
Grooming 5/5 Toilet use 5/10
Bathing 5/5 Mobility 10/15
Dressing 10/10 Transfer 10/15
Bowel 10/10 Stairs 0/10

SUPPORTING EXAMINATION
CT Scan kepala dengan kontras (18.04.2023)
-Tampak lesi homogenous contrast enhance pada FP D berukuran 4,5x6,7x7,7 cm yg disertai dengan hiperostosis
dan peritumoral yang mendesak ventrikel lateral kanan kearah kontralateral, kesan suatu massa extraaksial FP D
- Tampak lesi homogenous kontras enhance dengan ukuran 1.2x 1.5x 2cm pada regio tubercullum selae
mengesankan suatu massa ekstraaksial susp. meningioma tubercullum selae
- Tampak lesi homogenous kontras enhance dengan ukuran 1.2x 1.3x 1,9cm pada regio F S mengesankan suatu
massa ekstraaksial susp. meningioma konveksitas F S
 - Tampak pelebaran temporal horn ventrikel lateral kiri sebesar > 2 mm, dengan FH/ID > 0,5, Evans Ratio > 0,3,
balloning frontal horn ventrikel lateral kiri serta adanya periventrikuler ejection mengesankan suatu hidrosefalus
non komunikan
- MLS (+) kearah kiri sejauh 20mm
- Edema cerebri (+)
CT Scan kepala tanpa dan dengan kontras (25-4-2023):
- Defek calvaria os frontotemporoparietooccipital kanan disertai ICH dan pneumocephaly (dapat merupakan defek
post op) dengan perifocal edema yang menyebabkan midline shift sejauh +/- 0,9 cm ke sisi kiri dan hydrocephalus
non communicans - Masih tampak meningiomatosis di tuberkulum sella, konveksitas frontalis kiri dan olfactory
groove dengan detail tersebut diatas - Mastoiditis kiri
PA (26-04-2023): Tumor jaringan otak, extraaxial, operasi: MENINGIOMA, MENINGOTHELIAL TYPE, CNS WHO GRADE
I
CXR (28-04-2023): - Keradangan paru (mohon korelasi klinis dan laboratoris) - Cor tak tampak kelainan

PROBLEM LIST
o Ambulation disturbance
o Balance disturbance
o Severe fear of fall
o Decrease of endurance
o Bad posture (forward head and rounded shoulder)
o Hypertension
o Diabetes mellitus

ICF
Body Function:
b789 Movement functions, other specified and unspecified (Ambulation disturbance)
b715 Stability of joint functions (Balance disturbance)
b440 Respiration functions (Decrease of CT&CE)
b122 Global psychosocial functions (severe fear of fall)
b420 Blood pressure functions (hypertension)
b555 Endocrine gland functions (diabetes mellitus)
Body Structure:
s110 Structure of brain (meningioma post craniotomy excision tumor + decompression)
s810 Structure of areas of skin (surgery scar post craniotomy)
Activities & Participation:
d410 Changing body position (sit to stand needs help)
d420 Transferring oneself (bed to chair, chair to bed needs help)
d450 Walking (still using ambulation aid)
d530 Toileting (need help sit to stand after using toilet)
d640 Doing housework
d910 Community life
d920 Recreation and leisure
d930 Religion and spirituality
d859 Work and employment, other specified and unspecified
Environmental Factors:
e310 Immediate family (support from family)
e580 Health Services, System and Policy (patient covered by BPJS)

ASSESSMENT
Ambulation Disturbance ec Multiple Mass Extraaxial Right Frontoparietal et Left Frontal et Tuberculum Sellae ec
Meningioma Post Craniotomy Tumor Excision et Decompression (20 Days) + Severe Fear of Fall

PROGNOSIS
Ad vitam : Dubia
Ad sanactionam : Dubia
Ad functionam :
- Transfer : Independent
- Ambulation : Independent with/without assistive device
- Other ADL : Independent

Goals:
Short Term Goals:
1. Safety transfer and ambulation
2. Increased cardiorespiratory endurance (CT, CE, sit to stand)
3. Increased muscle endurance (sit to stand)
4. Maintain muscle power (MMT)
5. Posture correction
Long Term Goals:
1. Independent ADL
2. Quality of life improves
3. Prevent worsening condition
4. Controlled comorbid (DM & HT)

Planning
PDx: -
PTx:
Therapeutic Exercise:
1. Posture correction
2. AROM both upper and lower extremities
3. Active breathing exercise with diaphragmatic breathing
4. Chest expansion exercise
5. Core strengthening exercise with abdominal drawing in
6. Strengthening lower extremity with sit to stand exercise using walker
7. Standing balance exercise with weight shifting
8. Gait training with walker
9. Endurance exercise (F:3-5x/week, I: HR Rest +20, T:10 minutes, increase 5 minutes every 1-2 days with target
>30 minutes, T: recumbent static cycle)
Ambulation aid: Walker
PMx: Vital sign, clinical signs and symptoms, MMT, ROM, 5STS, FES, BI, CT, CE
PEx:
1. Explain patient condition and rehabilitation program she will get
2. Continue exercise at home
3. Home exercise: endurance exercise (F : 3-5 times/week, I : Borg scale 11-13, T:10 minutes, increase 5
minutes every 1-2 days with target >30 minutes, T : water bottle lift and F : 3-5 times/week, I : Borg scale 11-
13, T:3 set, 1 set = 5-10 repetitions, T : sit to stand)
4. Home modification to decrease risk of fall