MORNING REPORT

19 T H MARCH 2021
DPJP : DR. Dr. Joudy Gessal, Sp.KFR-K
PATIENT IDENTITY
Name : Mr. KA
Age : 55 years old
Sex : Male
Address : Gorontalo
Religion : Islam
Education : SMP
Occupation : Farmer
Medical Record Number : 737029
Referred from : Neurologist
Date of examination : 18th March 2021
 ANAMNESIS
Chief complaint : Weakness on all extremities
History of present illness :
Weakness occured on 5 years ago since he had been treated for Spondylitis
Tuberculosa for 6 months (complete resolved). Weakness was found on upper and
lower extremities symmetrically starting from both arms and hips then progress
slowly to the end of respectively extremities in 3 months period. He was treated in
local neurologist for this complaint. The weakness then relieved after 2 months
therapy, so he stopped seeing the doctor and start taking herbal medicine.
While taking herbal medicine for 1 month, he experienced excessive appetite,
weight gain and round facial shape, also the weakness occurred again. He continued
to take the herbal until 3 months later.
These last 2 years the weakness getting worse until this last 2 weeks he seek
neurologist and referred to RSUP Kandou for further examination and treatment.
Now, he felt weakness on shoulder and hip, unable to move and transfer without
assistance, easily exhausted also difficulty in fine hands skills. Tingling and numbness
(-), Chest pain (-), Shortness of breath (-), night sweat (-), Cough (-), History of
trauma (-), Sudden weight loss (-). Micturition and defecation are regularly normal.
Patient’s ADL is dependent, assisted by his wife and daughter. He was anxious about
his condition (due to occupation and expenses).
ANAMNESIS
History of past illness :
- Spondylitis Tuberculosa (5 years ago)

History of diabetes mellitus : –

History of chest pain, shortness of breath while activity : -

Habitual activity :
Smoking -
Using drugs and alcohol -

History of family disease :

History of hypertension, diabetes mellitus, heart disease in family were
denied
ANAMNESIS
Sosio-economic status :
Patient is a farmer. The house is permanent cemented and painted,
cemented floor at living room to the bathroom which is inside the
house. His wife is housewife. They have 3 children. Currently, patient
is economically dependent on his sons. Insurance by BPJS.
Wish :
He wish he can be functionally normal again so he can work properly
PHYSICAL EXAMINATION
STATUS PRESENCE
General condition : good, cooperative, looking clean and neat
Conciousness : compos mentis (E4M6V5)
Vital sign :
Blood pressure : 100/70 mmHg
Heart rate : 92x/ minute
Respiratory rate : 20x/minute
Temperature : 36,7 C
Saturation : 99%
Weight/height : not evaluated/ 165 cm
Posture (standing using walker) :
Anterior:
- The head is in the midline
- Both shoulders in symmetry
- Upper extremity : no deformities
- Lower extremity: no deformities
- No pelvic obliquity
PHYSICAL EXAMINATION
Posterior:
Lateral :
- The head is in the midline
- No neck deformities - No forward head
- Both shoulders in symmetry
- Thoracal hyper kyphosis (-)
- Scoliosis (-)
- pelvic obliquity (-) - genu recurvatum (-)
PHYSICAL EXAMINATION
Internal status
Head : mesocephale
Eyes : conjungtiva anemis -/-, sclera icteric -/-, pupil isochoric,
diameter 3mm/3mm, strabismus -/-
Nose : septum deviation -, shape is normal, conchae hypertrophy -/-
Mouth : cyanosis -, drooling -
Tongue : atrophy -, tremor -, fasciculation -, no deviation
Neck : trachea in the midline, lymph node enlargement -
PHYSICAL EXAMINATION
THORAX : No abnormalities found
ABDOMEN : No abnormalities found
 MOTORIC EXAMINATION (UPPER
EXTREMITIES)
Right Left
Movement Normal Normal
Muscle strength 3/4/4/4/4 3/4/4/4/4
Muscle tone Hipotone Hipotone
Muscle trophy Hipotrophy Hipotrophy
Physiological reflex (+) (+)
Pathologic reflex Absent Absent
Sensibility Normal Normal
ROM EXAMINATION
SHOULDER Dextra Sinistra
Extension-Flexion 40-0-170 40-0-170
(passive)
Abduksi-Adduksi (passive) 170-0-40 170-0-40
Ext. Rotation-Int. rotation 70-0-90 70-0-90

ELBOW and FORE Dextra Sinistra

ARM ROM
Extension-Flexion 10-0-150 10-0-150
Supination-Pronation 80-0-70 80-0-70

WRIST Dextra Sinistra

Extension-Flexion 70-0-80 70-0-80
Radial Deviation- 20-0-30 20-0-30
Ulnar Deviation
WRIST and DIGITS Dextra Sinistra
MCP Finger Flexion 0-90 0-90
PIP Finger Flexion 0-100 0-100

DIP Finger Flexion 0-80 0-80

Thumb Flexion- 50-0-60 50-0-60

Thumb Extension
Thumb Abduction- 70-0-40 70-0-40
Thumb Adduction
HIP Dextra Sinistra
Extension-Flexion 20-0-170 20-0-170
(passive)
Abduksi-Adduksi (passive) 40-0-20 40-0-20
Ext. Rotation-Int. rotation 40-0-40 40-0-40

KNEE Dextra Sinistra

Extension-Flexion 0-0-140 0-0-140

ANKLE Dextra Sinistra

Plantarflexion – 40-0-20 40-0-20
Dorsiflexion
Sensoric Examination

• All dermatomes within normal limit

 Cognitive function : MMSE 30/30
 Coordination and proprioception :
• finger-to-nose test (opened eyes) : positive (bilateral)
• finger-to-nose test (closed eyes) : positive (bilateral)
• Heel-to-shin test : positive
 Balance :
• Standing balance : not evaluated
• Sitting balance : inadequate
 Cardiorespiration :
• Chest Expansion : 2cm-3cm-3cm
• Count test : 21
 ADL :
• Modified Barthel Index : 43 (partially dependent)
Additional Examination
 Electromyography : conducted on 17/03/2021, results coming
out on 22/03/2021
 Spine MRI : planned on 24/03/2021
 Cervical X-ray : Spondylosis cervical
 Diagnosis
Tetraparesis LMN ec. Susp. Myopathy + Cervical
Spondylosis

Body Structure
s7202 Muscles of shoulder region Activity
s75002 Muscles of thigh • d540 Dressing
s7102 Bones of neck region • d410 Changing basic body Participation
Body Function position d8452 Terminating a job
•b7308 Muscle power functions, other • d420 Transferring oneself
specified • d499 Mobility, unspecified
•b7354 Tone of muscles of all limbs • d760 Family relationships
•b260 Proprioceptive function
•b152 Emotional functions

Environment Personal
• e1101 Drugs Male, 55 years, dependent on family
• e1108 Products or substances for personal consumption, other specified members
• e310 Immediate family
• e5801 Health systems
DIAGNOSIS
Clinical Diagnosis : Tetraparesis LMN ec. Susp. Myopathy
Topical Diagnosis : Muscles of upper and lower extremities
Etiology Diagnosis : Probable inflammation/autoimmune
GOAL
Short term goal Long term goal
-Maintain ROM of upper and lower - Maintain muscle strength and ROM on
extremities upper and lower extremities
- Maintain muscles strength of upper and - ADL as normal as possible
lower extremities
- Acceptance of the disease condition
- Improve balance and coordination
- Improve cardiorespiration
- Reduce anxiety
PROGRAM
- AROM exercise upper & lower extremities bilateral
- Isometric exercise upper & lower extremities bilateral
- Gradual mobilization : lying to sitting, sitting without support 5-10 minutes
three times daily, sitting to standing with aid 5-10 minutes three time daily
- Occupational therapy : ADL training, balance training
- Mental support
- Education
EDUCATION
- About the disease

- Motivation to do therapy regularly

- Home program exercise

- AROM exercise upper & lower extremities bilateral

- Isometric exercise upper & lower extremities bilateral

PROGNOSIS
Prognosa ad vitam : ad bonam
Prognosa ad sanationam : dubia ad malam
Prognosa ad functionam :
• Mobility and transfer : dubia ad malam
• ADL : dubia ad malam
THANK YOU