Sit Dolor Amet

MORNING REPORT (Wednesday, 2nd September 2020)

DATE IDENTITY DIAGNOSE Residents
1 31/08/2020 Mr. MA/ 34 y.o Hip pain susp sacroilitiis s NAN
2 31/08/2020 Mr. M/ 34 y.o Radial nerve lesion s ec CF midshaft humerus s post ORIF NAN
3 01/09/2020 Mrs.S / 69 y.o LBP e.c fr. VL III ZEN
4 01/09/2020 Mr.A/ 49 y.o LBP e.c multipel canal stenosis + hip pain sinistra e.c suspek sacroiliitis ZEN
5 01/09/2020 Mrs. W/ 69 y.o Pathological Fracture Neck Femur Sinistra + Multiple Lytic Lession MAS
Cervicothoracolumbosacralis + Frozen Shoulder Sinistra ec Metastatic
Process of Ca Mammae Sinistra

PM&R Outpatient Report (Tuesday, 1st November 2020)

Total Patient : 20 New Patient : 5 Follow-up patient : 15

DATE IDENTITY DIAGNOSE Residents

1 01/09/2020 Mrs.S / 69 y.o LBP e.c fr. VL III ZEN
2 01/09/2020 Mr.A/ 49 y.o LBP e.c multipel canal stenosis + hip pain sinistra e.c suspek sacroiliitis ZEN
3 01/09/2020 Mrs. W/ 69 y.o Pathological Fracture Neck Femur Sinistra + Multiple Lytic Lession MAS
Cervicothoracolumbosacralis + Frozen Shoulder Sinistra ec Metastatic
Process of Ca Mammae Sinistra
4 01/09/2020 Mrs.R/ 72 y.o T7 Paraplegia AIS D ec Tumor IDEM VT1-T2 post hemilaminectomy D VAN
VT1-T2 + Osteoporosis + Rw/ TKR D
5 01/09/2020 Mrs. S/ 44 y.o Asma Bronkhiale + OA Genu Bilateral IEN
 Patient: Mr. MA/34 y.o/11490391/factory employee/pasuruan
Referred from: Neurology Outpatient clinic (LBP dt HNP)
Resident: NAN
Positive Findings Problem List Diagnose Planning
Anamnesis: Medical: left hip pain Clinical diagnoses: PDx:
• Left hip pain since 6 months, left hip pain d.t susp PTx:
sometimes the pain referred to the Surgical:- sacroiliitis Modality:
thighs. The pain was dull, comes & - SWD at hip joint (S)
goesIt increased by moving his left leg, R1 (M): discomfort in Functional diagnoses: contraplanar, frequency 27,12
and slightly relieved by lying. He had changing basic body (sitting, Impairment: MHz, intensity as patient
difficulty in walking. standing, walking) pain at the hip area tolerance, duration 15 minutes,
• Numbness (-) tingling sensation (-). R2 (A): discomfort in doing 2x/week
• No bladder/ bowel problem. ADL Disability: - TENS at hip joint s,
• History: trauma (+) fell from the R3 (C): - discomfort in changing basic frequencies 50-100 Hz,
motorcycle (2019) R4 (P): worried with his body (sitting, standing, intensity as patient tolerance,
• Patient is a factory employee, condition walking) duration 15 min, 2x/week.
sometimes had heavy weight activities R5 (S): discomfort in social discomfort in doing ADL Exercise
• VAS: 5-6, BI: 100 (independent). activities. - Ergocycle
• Medication: analgetic pills R6 (V): discomfort in doing Handicap: - ROM & flexibility exercise of
housework discomfort in social activities. the trunk
R7 (O): pain at the hip area discomfort in doing
housework PMo:
VAS, MMT, ROM, ADL, symptom

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 Patient: Mr. MA/34 y.o/11472084/factory employee/pasuruan
Referred from: Neurology Outpatient clinic (LBP dt HNP)
Resident: NAN
Positive Findings Planning

Physical Examination: • a/r spine: PEd :

• GCS 456, gait : antalgic SLR -/-, Bragard -/-, Sicard -/-, Thomas -/-, • Explain the condition.
• BP 130/99 mmHg, Pulse 90 x/mnt FABERE -/+, FAIR -/+, gaenslen -/+ • Purpose & benefit of PMR
• Cranial nerves: within normal limit therapy.
• Sensory : 100%/100% • Chest expansion 3 cm • Continue exercise & training at
• MMT: UE 5/5 • Breathing Count Test : 24 – 20 – 24 home.
LE 5/4 (pain) • Routine control.
• BPR: +2/+2, TPR/: +2/+2, KPR: +2/+2, APR: • Family support.
+2/+2, clonus -/-,
• Babinski: -/-, Chaddock -/-, Oppenheim -/-, Hoffman
-/-, Tromner -/-
• TLL : 85 cm/85 cm
• ALL : 80 cm/ 80 cm
• Thigh circumference : 32 / 29 cm
• Calf circumference : 29 / 28 cm
• Heel stand (-) & toe stand (-) HIP ROM MMT
Flexion F/F (0-1200) 5/4 (pain)
Extension F/F (0-300) 5/5
Abduction F/F (0-450) 5/4 (pain)
Adduction F/F (0-300) 5/5
Internal rotation F/F (0-450) 5/4 (pain)
4
External rotation F/F (0-350) 5/4 (pain)
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RO Lumbosacaral AP/lat (26/03/2020)
Kesimpulan: lumbosacral muscle spasm
MRI Lumbosacral (24/8/2020)
kesimpulan: MRI lumbosacral dalam batas normal
tidak tampak penyempitan pada canalis spinalis maupun
foramina neuralis vertebrae lumbalis
MRI Lumbosacral (24/8/2020)
kesimpulan: MRI lumbosacral dalam batas normal
tidak tampak penyempitan pada canalis spinalis maupun
foramina neuralis vertebrae lumbalis