I. IDENTITY December 21st 2023 SUR/AYA/ dr.AL, Sp.K.F.R., M.S.

(K)
Name : Mrs. Samsia
Gender : Female
Age : 48 yo
Religion : Moslem
Marital Status : Married
Address : Matekan Probolinggo
Education : Elementary School
Occupation : Cigarette factory worker
MR :13054070
Phone : 083843121046
Referred from Neurology OPC with Spondylosis Cervical

II. AUTOANAMNESIS
Chief Complaint: Nyeri leher dan punggung atas kanan
History of Present Illness:
Patient complains of pain on right neck area and upper back since 1 year ago with WBS 7-8.
Pain was felt after patient work extra time making cigarettes with manual device (3000 cigarettes
in a day). Pain was intermittent and was described like dull pain, burning, sometimes
accompanied with tingling sensation around right upper back area. There’s no radiating pain to
upper extremities, no numbness or tingling sensation. Pain getting worse when patient work
more than 8 hours in her factory and disturbing her sleep. Pain getting better when patient rest,
stop doing her activities with right hand and lying down. Her symptoms getting worst in last 6
months, she usually felt pain about 3-5 times a week until she must absent from her work. She
then checked to general practitioner at factory, given painkiller but not reducing pain much, then
she was referred to Neurology OPC RS Waluyo Jati Probolinggo and afterwards underwent
rehabilitation at PMR OPC, got Physiotherapy for 5 months but still felt pain. She asked to be
referred to Neurology OPC RSDS because her relatives recommended her. Patient already
checked for Xray cervical and thoracolumbal. Currently, she still felt pain, localized on right
neck and upper back, no radiating, sometimes felt like hot. There’s no limitation of movements
and she still can do her ADL independently despite of her pain. There’s no complains of
urination and defecation.

History of Past Illness:

There’s history of trauma she slipped when walking on wet floor about 1,5 years ago, fell in side
lying position, hit her right upper back, got traditional massage, but after that no complains.
History of Hypertension known since 6 months ago when she controlled her condition to
Neurology OPC RS Waluyo Jati, her systolic BP around 200 then given medication amlodipine
10 mg, not consume routinely. No history of DM, malignancy and other chronic disease. Her
menstruation is regular, no history of hormonal contraceptive use, she delivered babies twice per
vaginam.

History of Functional Ability: The patient was able to do all the activities of daily living
independently. (Feeding, Bathing, Grooming, Dressing, Toilet Use, Transfer, Walking and
Stairs). She felt pain after working in factory more than 8 hours, and now she avoid fatigue and
her house chores helped by her husband.

History of Medication and Rehabilitation:

Neurology OPC RSDS :Paracetamol 500 mg, Diazepam 2.5 mg, Amitriptilin 6.25 mg 3 x 1 caps
PO - Natrium Diclofenac 2 x 50 mg PO - Vitamin B1 2 x 10 mg - Vitamin B12 2 x 50 mcg

Rehabilitation history in PMR OPC RS Waluyo Jati Probolinggo, given USD and HITENS,
attend routinely twice a week, her condition getting better with reduced pain to WBS 6.
 History of Hobby and Work: She works as cigarette manufacturer at Sampoerna, repetitive
movement pull and push the manual device, usually work 8-10 hours a day, making around 3000
cigarettes a day, 6 days a week. Now she’s stil on sick leave and still got salary eventhough not
full amount. She has no specific hobby only watching TV and Tiktok in her spare time.

History of Psycho-Social Economy: In Probolinggo she lives with husband (49 yo, welding
worker) and second daughter (20 years old, elementary school) in one story house, squatting
toilet. During her medical control in RSDS she lives temporarily in Sidoarjo with her first son
(23 yo, freelance), her daughter in law and her grand daughters. They have BPJS for health
insurance

History of Family: No family history of DM, HT or other chronic disease

Patient’s Hope/wish: She hopes she can do ADL pain free, and not dependant with analgesics

III. PHYSICAL EXAMINATION

A. General status
Consciousness: compos mentis
Vital sign: TD : 139/94, HR: 79x/m, RR: 18x/m Tax 36,5, SpO2 98%
Weight 55 kg, Height 152 cm, BMI: 23.8 (Overweight)
Posture : forward head and neck, left shoulder slight higher than left, rounded shoulder, lumbar
lordosis, symmetrical pelvic, knee, ankle, and no flat foot.
Gait: normal gait
Ambulation : independent ambulation, right-handed.

B. General Status:
Head/Neck : Anemia -, Icterus -, Cyanosis -, Dyspnea -
Thorax :
Cor : S1-S2 single, murmur -, gallop –
Pulmo : Vesicular / vesicular, Wheezing -/-, Rhonci -/-
Abdomen : Soefl, peristaltic (+), tenderness (-)
Extremities : Warm acral +/+, edema -/-, CRT < 2 sec

C. Musculoskeletal & Neuromuscular Status

Head /Neck :
Look : forward neck (+)
Feel : paracervical muscle spasm (+)
Move : wnl
ROM MMT
Region Joint Movement Muscles Strength
Movement Range of Motion Muscles MMT
(active and passive)
Neck Flexion (0-450) F Flexor 5
Extension (0-450) F Extensor 5
0
Lateral flexion (0-45 ) F Lateral flexor 5
Rotation (0-600) F Rotator 5

Special test : compression (-), spurling -/-, distraction -, TOS I -/-, TOS II -/-, TOS III -/- ,
ROOS (-/-)
Cranial Nerve : wnl

Trunk
Look : Deformity (-)
Feel : Upper trapezius muscle spasm (+/-), parathoracal muscle spasm (+/-)
 Move : wnl
ROM MMT :

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

Special test : Knock pain -, doorbell sign -, step off –, kemp Test (+/-)
Sensory : wnl

D. Upper Extremities Region

Look : left shoulder slight higher than left, no atrophy
Feel : warmth -/-, tender point -/-
Move : pain when move (-)
ROM MMT
Shoulder Flexion(0-1800) F/F Flexor 5/5
Extension (0-600) Extensor 5/5
0
Abduction(0-180 ) Abductor 5/5
Adduction(0-450) Adductor 5/5
0
Internal Rotation (0-90 ) Internal Rotator 5/5
External Rotation (0-700) External 5/5
Rotator
Elbow Flexion (0-1350) F/F Flexor 5/5
Extension (135º-0) Extensor 5/5
Pronation (0-900) Pronator 5/5
0
Supination(0-90 ) Supinator 5/5
Wrist Flexion (0-800) F/F Flexor 5/5
0
Extension (0-70 ) Extensor 5/5
Radial deviation (0-200) Radial Deviator 5/5
Ulnardeviation (0-350) UlnarDeviator 5/5
Fingers Flexion F/F Flexor 5/5
Extension Extensor 5/5
Abduction Abductor 5/5
Adduction Adductor 5/5
Special test: Hawkin -/-, Neer test -/-, Empty can -/-, Yergason test -/-, Painful arc -/-, Drop
arm test -/-, Belly press -/-, Lift off test -/-, Phalen -/-, Prayer -/-, Tinnel of n.
medianus -/-, Tinnel of cubital tunnel -/-

DTR : BPR ++/++, TPR ++/++,

Pathological Reflex: Hoffman -/-, Tromner -/-
Spasticity : -/-

Dermatome and myotome :

Dermatome D Myotome D Area Dermatome S Myotome S

100% 5 C5 100% 5
100% 5 C6 100% 5
100% 5 C7 100% 5
100% 5 C8 100% 5
100% 5 T1 100% 5

E. Lower Extremities region

 Look : wnl
Feel : wnl
Move : no pain when move
ROM MMT
Hip Flexion (0-1250) F/F Flexor 5/5
Extension (0-300) Extensor
Abduction (0-450) Abductor
Adduction (0-200) Adductor
Internal Rotation (0-450) Internal Rotator
External Rotation (0-450) 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
Eversion (0-150) 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 : SLR -/- Bragard -/-, Sicard -/-, Patrick -/-, Contra-Patrick -/-, Pelvic rock -/-
Reflex : KPR +2/+2, APR +2/+2, Babinski -/-, Chaddock -/-, Clonus: -
Sensoric :-

Functional Status
Count Test : 12 Chest Expansion: 2.5/2.5/2.5
Balance :
Sitting balance static : good
Sitting balance Dynamic : good
Standing balance static : good
Standing balance dynamic : good
Coordination :
Dysdiadokinesia: -, finger to nose: -
Romberg test: able, Sharpened romberg test: able, Tandem walking test: able
Mobilization (Transfer, ambulation)
Lying to sitting : able independently
Sitting to standing : able independently
Ambulation : independent walking, No. ambulation aid
Hand Function : Functional/Functional
HDRS : 16 (No depression)
6MWT : 240 m, METs: 4, 3. VO2 Max 15,16
ADL (Bartel Index) : 100

Activity Score Normal Score

Feeding 10 10
Bathing 5 5
Grooming 5 5
Dressing 10 10
Bowels 10 10
Bladder 10 10
Toilet use 10 10
Transfers 15 15
 Mobility 15 15
Stairs 10 10
TOTAL 100 100

IV. SUPPORTING EXAMINATION (X-ray):

Xray Thoracal AP/Lat 19/12/23: Spondylosis Thoracolumbalis
Xray Cervical AP/Lateral 19/12/23: Spondylosis Cervicalis

V. ASSESSMENT
Neck Pain ec Paracervical et Upper Trapezius Muscle Spasm + Spondylosis Cervicalis et
Thoracolumbalis + Hypertension Grade II (Uncontrolled) + Overweight

V. FUNCTIONAL ASSESSMENT (include ICF)

Body Function:
b280 Sensation of pain (pain on right neck and upper back)
b440 Respiratory functions (decrease CT and CE)
b735 Muscle tone functions (muscle spasms)
b420 Blood Pressure function (Hypertension Grade II)
b530 Weight Maintenance Function (Overweight)
Body Structure
s710 Structure of head and neck region (paracervical muscle spasm, spondylosis cervicalis)
s760 Structure of trunk (upper trapezius muscle spasm, quadratus lumborum muscle spasm, spondylosis
Thoracolumbalis)
Activity Limitation Participation Restriction
d859 Work and employment (unable to work due to pain when working)
d649 Household task (need assistant to help her doing household chores)
Environmental factors
e310 Immediate Family (married and full support from her family)
e580 Health service (covered by BPJS Kesehatan)
Personal Factors:
Female, 48 yo, High motivation, supported by family

GOAL:
Short term:
1. Pain decrease to tolerable with target WBS < 3
2. Maintain independent ADL
3. Increase Count test and chest expansion
4. Controlled Comorbid
5. Proper posture

Long Term:
1. Pain free activities
2. Prevent worsening condition (increase pain, spasm, etc)
3. Good Cardiopulmonary endurance
4. Return to work
5. Normal BMI

Prognosis
Ad Vitam : bonam
Ad Sanasionam : bonam
Ad Fungsionam : Transfer: independent
Ambulation: independent without ambulation aid
 Other ADL: independent with Barthel index 100
PROBLEM LIST
1. Right neck pain
2. Right paracervical, quadratus lumborum and upper trapezius muscle spasm
3. Poor Posture
4. Spondylosis Cervicalis and Thoracolumbalis
5. Decrease count test and chest expansion
6. Hypertension Grade II (Uncontrolled)
7. Overweight

Planning
PDx : Suggest consult to Cardiology OPC for Hypertension Grade II
PTx :
Modality:
 USD 1 mHz 2 watt/cm2 for 10 minutes at right paracervical to upper trapezius and Quadratus
Lumborum area following by gentle stretching
 Low TENS 10 Hz at tender area right paracervical to upper back

Therapeutic exercise (Precaution avoid Valsava)

 Posture correction
 Kinesthetic awareness
 AROM Exercise neck and shoulder to all motions
 Stretching neck, upper trapezius and quadratus lumborum muscle to all motions
 Neck rhythmic stabilization with neck cailliet exercise
 Active breathing exercise with deep diaphragmatic breathing exercise
 Chest Expansion Exercise
 Endurance exercise (when pain is tolerable <WBS 4)
F: 3-5x/week
I: HR Rest + 20
I: 30 minutes
T: Static Cycle

OP: Soft Cervical Collar

PMx: WBS, Muscle Spasm, Clinical sign, Vital Sign

PEx:
1. Explain to patient about her condition, goals and planning of rehabilitation program that she will
get
2. Icing if pain around neck and upper back area for 15-20 minutes can be repated every 4 hours
when pain remained
3. Continue exercise at home: Active breathing exercise with deep diaphragmatic breathing exercise,
neck cailliet exercise, stretching neck and upper back, endurance exercise with brisk walking
4. Regularly control and continue medication from neurology OPC
5. Balance diet, intake low calorie, low fat, low salt