I. IDENTITY III.

PHYSICAL EXAMINATION
Name : Mrs. K PYU/WIC/ dr. DS, Sp.K.F.R., M.S. (K) A. General status
Gender : Female 26/1/2023 Consciousness: compos mentis
Age : 50 yo Vital sign: BP 120/90, HR: 98x/m, RR: 16x/m Tax 36.2, SpO2 99% room air,
Religion : Moslem Weight 53 kg, Height 155 cm, BMI: 22 (normoweight)
Marital Status : Married Posture: forward head, rounded shoulder, protruded abdomen
Address : Surabaya Ambulation : walking independent without assistive device
Occupation : Tailor Right Handed
Referred from Neurology OPC with shoulder pain post stroke trombotik
B. Head /Neck/Trunk:
II. AUTOANAMNESIS Look : edema -, redness -, deformity -
Chief Complaint: Nyeri kedua bahu Feel : warmth -, wound -, uppertrap muscle spasm +/+
History of Present Illness: Move : pain with move -
The patient complained of pain in both shoulders, more severe on the right. ROM MMT
Right shoulder pain appeared 6 months ago, left shoulder pain appeared 4 Special test : spurling test -/-, distraction test -/-, compression test -/-
months ago, felt intermittent, like "cekot-cekot", no radiated, no weakness. Pain Cranial nerve : dbn
worsens when she lift hands above head WBS 4-5 right shoulder, WBS 2 left
shoulder. Pain was decreasse when at rest WBS 0 Regio Joint Movement Muscles Strength
History of Functional Ability: n Movement Range of Muscles MMT
Able to do eating, grooming, bathing, dressing, toileting, transferring from bed Motion
to chair or chair to chair, or go up or downstairs independently, walking (active and
independently without assistive device. No urine or stool incontinence. But passive)
there was pain that appear while she take off the clothes. Neck Flexion (0-450) F Flexor 5
History of Past Illness: Extension (0-450) F Extensor 5
Patient has history of Stroke on November 2019. That time, patient was Lateral flexion (0- F Lateral 5
hospitalized at Seruni A RSDS, unconssioussness for 2 days and hospitalized 45 )
0
F flexor 5
for 1 week. After discharge from RSDS she can walk and do activity Rotation (0-600) Rotator
independently 2 months later until now. Patient had DM since 2019, history of Trunk Flexion(0-850) F Flexor 5
hypercholesterol since 6 months ago. Extension (0-300) F Extensor 5
History of Medication/rehabilitation: Lateral flexion(0- F Lateral 5
 Neuro OPC : gabapentin, b complex vit 350) F flexor 5
 IPD OPC glimepirid, omeprazole Rotation(0-45 )0
Rotator
History of Hobby and Work:
She is a tailor usualy work alone, sometimes assisted by her daughter. She C. Upper Extremities Region
said 6 months ago had a lot of order to sewing dress/clothes on Ied Day. Look : atrophy -/-, edema -/-, deformity -/- redness -/-
History of Psycho-Social-Economy: Feel : warmth -, tenderpoint on bicipital groove at right and left side, nodule -/-
She lives in one storey house with her family: husband (57 yo), work as Move : move with pain (+)
security, 1st son 30 yo, 2nd daughter 23 yo, and 3rd was son 13 yo. She covered ROM MMT
by BPJS.
Patient Hope/Wish: Pain free and able to do activity like she used to be
 Shoulder Flexion(0-1800) F (pain)/F 5p/5 Hip Flexion (0-1250) F/F 5/5
Extension (0-600) F/F 5/5 Extension (0-300) F/F 5/5
Abduction(0-180 ) 0
F (pain)/F 5p/5 Abduction (0-45 )0
F/F 5/5
Adduction(0-450) F/F 5/5 Adduction (0-200) F/F 5/5
IR (0-900) F/F 5/5 IR (0-450) F/F 5/5
ER (0-700) F/F 5/5 ER (0-450) F/F 5/5
Elbow Flexion (0-1350) F/F 5/5 Knee Flexion (0-1350) F/F 5/5
Extension (135º-0) F/F 5/5 Extension (135º-0) F/F 5/5
Pronation (0-90 ) 0
F/F 5/5 Ankle Dorsiflexion (0-20 )0
F/F 5/5
Supination(0-900) F/F 5/5 Plantarflexion (0-500) F/F 5/5
Wrist Flexion (0-800) F/F 5/5 Eversion (0-150) F/F 5/5
Extension (0-700) F/F 5/5 Inversion (0-350) F/F 5/5
Radial deviation (0-200) F/F 5/5 Toes Flexion F/F 5/5
Ulnar deviation (0-35 )0
F/F 5/5 Extension F/F 5/5
Fingers Flexion F/F 5/5 Special test : -
Extension F/F 5/5 Reflex : KPR +2/+2, APR +2/+2, Babinski -/-, Chaddock -/-, Clonus: -/-
Abduction F/F 5/5 Sensorics : no deficit sensoric. Proprioceptive good/good
Adduction F/F 5/5 Spasticity : no spasticity
Special test : Painful arch -/-, Drop arm -/-, Neer -/-, Hawkin -/-,
Empty Can -/-, Yergasson +/-, Lift Off -/-, Speed +/-, F. Functional Status
Cross arm -/- Count Test : 32
Reflex : BPR +2/+2, TPR +2/+2, Hoffmann -/-, Tromner -/-, Chest Expansion : 4/3.5/3.5 cm
Sensoric : deficit sensoric -/- Balance :
Spasticity : no spasticity Sitting : static good, dynamic good
Hand function : Functional/ Functional Standing : static good, dynamic good
Transfer : lying to sitting able, sitting to standing able
Dermatome D Myotome D Area Myotome S Dermatome S Coordination : dysdiadokokinesia -/-, dysmetria -/-
Romberg : good
100% 5 C5 5 100%
ADL (Bartel Index) : 95 (independent)
100% 5 C6 5 100% Feeding 10/10 Bladder 10/10
100% 5 C7 5 100% Grooming 5/5 Toilet use 10/10
100% 5 C8 5 100% Bathing 5/5 Mobility 15/15
100% 5 T1 5 100% Dressing 5/10 Transfer 15/15
Bowel 10/10 Stairs 10/10

E. Lower Extremities region

Look : edema -/-, deformity -/-, atrophy -/-, dry skin -/-, IV. SUPPORTING EXAMINATION:
Feel : warmth -/-, tenderness -/- Lab (12/01/23) : TG 100/ Chol Tot 216**/ HDL 76**/ LDL 127**/ GDP 113/
Move : move with pain (-) GD2PP 223**/ HbA1c 6.9**/ AU 3.2
ROM MMT
 1. Establish the diagnosis
2. Decrease pain
V. PROBLEM LIST 3. Reduced muscle spasm
- Bilateral shoulder pain 4. Maintain of shoulder range of motion
- Upper trapezius muscle spasm Long Term :
- Suspect tendinosis bilateral biceps 1. ADL function with pain free
- Bad posture 2. Improvement of quality of life
- DM type 2 3. Improve posture

VI. FUNCTIONAL ASSESSMENT (include ICF) IX. PLANNING

Body function PDx:
b280 Sensantion of pain (pain at bilateral shoulder)  USG Musculoskeletal of shoulder D
b735 Muscle tone function (spasme of upper trapezius muscle spasme)  X ray examination of shoulder D
b555 Endocrine glands function (DM type 2)
Body structures PTx:
s720 Structure of shoulder region (suspect shoulder tendinosis bilateral biceps) Modalitas : Laser 2j/cm2 pada tender poin area bicipitalis groove D/S
s580 Structure of endocrine gland function (DM type 2) USD 2w/cm2 1mhz selama 10 menit pada upper trapezius dilanjutkan gentle
Activities and participation stretching
d430 Lifting and carrying object (lift heavy things) Thera exc :
d930 Recreation and leisure - Posture corection
d859 Work and employment - BEA dgn deep breathing dan CE exc
Environmental factors - AROM exc AGA AGB D S
e310 Immediate family (support from her family) - Isometric Strengthening exc Shoulder D S
e580 Health services, systems, and policies (patient covered by BPJS) - Scapular mobilization exc
- Stretching upper trap
VI. ASSESSMENT PMx: Clinical sign, vital sign, WBS, MMT, ROM, posture, count test, chest
Bilateral Shoulder Pain (D>S) ec Suspect Tendinosis of Bilateral Biceps dd MTPS expansion.
+ Upper Trapezius Muscle Spasm + DM Type II (Controlled) + Dyslipidemia + PEx:
History of Stroke Infarct 1st Attack (3 Years) 1. Explain the patient's condition, goal, and rehabilitation program
2. Continue exercise at home
VII. PROGNOSIS 3. Icing if pain, for 15 minutes, every 3-4 hours
Ad vitam : Bonam 4. Avoid repetitive or overuse activities
Ad sanactionam : Bonam 5. Routinely control to Internist and Neurologist
Ad functionam :
- Transfer : Independent
- Ambulation : Independent
- Other ADL : Independent

VIII. GOAL
Short Term :