MORNING REPORT (Wednesday, July 21st 2021)

DATE IDENTITY DIAGNOSE Residents

1 19/07/2021 Mrs. D/35 y.o. LBP e.c. susp. HNP VL3-L4, L4-L5 D + Overweight MIF
2 19/07/2021 Ch. S/18 m.o. Cerebral Palsy spastic quadriplegic type + Epilepsi on Tx + LEL
Underweight + Microcephalic
3 19/07/2021 Mrs. T/33 y.o. SCI AIS D NLI C5 e.c. susp. Transverse Myelitis SAN

PM&R Outpatient Report (Monday, 19th July 2021)

Total Patient : 13 New Patient : 3 Follow-up patient : 10

DATE IDENTITY DIAGNOSE Residents

1 19/07/2021 Mrs. D/35 y.o. LBP e.c. susp. HNP VL3-L4, L4-L5 D + Overweight MIF
2 19/07/2021 Ch. S/18 m.o. Cerebral Palsy spastic quadriplegic type + Epilepsi on Tx + LEL
Underweight + Microcephalic
3 19/07/2021 Mrs. T/33 y.o. SCI AIS D NLI C5 e.c. susp. Transverse Myelitis SAN
Patient: Mrs. T/33 y.o./11511385/Housewife/Blitar
Referred from: Neurology outpatient clinic (Tetraparese UMN type due to post myelitis)
Resident: SAN
Positive Findings Problem List Diagnose Planning
Anamnesis: Medical: SCI AIS D NLI C5 Clinical diagnoses: SCI PDx:
Chief Complaint : Weakness of all e.c. suspect transverse AIS D NLI C5 e.c. suspect MRI from Neurology Dept.
four limbs since 6 months ago myelitis transverse myelitis PTx: -
Surgical: - Modality:
History of Present Illness : R1 (M): - Functional diagnoses: NMES on finger D/S frequency
• The weakness initially felt on the R2 (A): Difficulty in doing 70-85pps,on-time 5-10s,off-
both of upper limbs then ADL (feeding) Impairment: time 50s- 2M, duration
progressively followed the R3 (C): - Tetraparese minimal 10 contraction,
weakness to the both of lower R4 (P): - Decreased MMT at UE 2X/week
limbs. R5 (S): - and LE D/S Exercise:
• There’s no numbness and R6 (V): Difficulty in doing • Strengthening exercise at
tingling sensation. household tasks Disability: UE D/S and plantar flexor
• She doesn’t feel pain. (cooking) Difficulty in doing ADL D
• She still able to hold urinate and R7 (O): (feeding) • AROM exercise UE and LE
defecate. And still has sensation • Tetraparese D/S
before urinate and defecate • Decreased MMT at Handicap: • AAROM exercise at finger
UE and LE D/S Difficulty in doing UE D/S and ankle plantar
• Reduced breathing household tasks (cooking) flexor
capacity
 Patient: Mrs. T/33 y.o./11511385/Housewife/Blitar
Referred from: Neurologic outpatient clinic (Tetraparese UMN type due to post myelitis)
Resident: SAN
Positive Findings Problem List Diagnose Planning
Anamnesis: Exercise:
History of Present Illness : • Endurance exercise with
• She’s still able to walk ergocycle
independently but has difficulty • Deep breathing exercise
at transfer lying to sitting and • Chest expansion exercise
sitting to standing because the
weakness of her hands. OT:
• In January 2021 patient had Hand Function
prolonged fever for about one
week with diarrhea and had no PMo:
appetite. Subjective, MMT, ADL, Hand
• In May 2021 Patient visited Function
neurologist at Mardi Waluyo
Hospital in Blitar because she felt Others:
weakness on both of her upper Psychotherapy (PSM)
limbs.
• In Mardi Waluyo she got
medication and PM&R therapy
(heat therapy).
 Patient: Mrs. T/33 y.o./11511385/Housewife/Blitar
Referred from: Neurologic outpatient clinic (Tetraparese UMN type due to post myelitis)
Resident: SAN
Positive Findings Problem List Diagnose Planning
Anamnesis: PEd:
History of Present Illness : • Explain the condition
• In June 2021 Patient referred • Purpose and benefit of
from Blitar to RSSA to get MRI PMR therapy
Whole Spine. • Routine control
• In July 19th the patient referred • Continue exercise at home
to PM&R because her condition • Family support
didn’t improved.
History of Past Illness : HT (-), DM (-),
Stroke (-), Trauma (-), Malignancy (-).
Hyperhidrosis (+)
History of Family Illness : HT (-),
DM (-), Stroke (-), Trauma (-)
Medication :
Mecobalamin 2x1
Neurodex 2x1
 Patient: Mrs. T/33 y.o./11511385/Housewife/Blitar
Referred from: Neurologic outpatient clinic (Tetraparese UMN type due to post myelitis)
Resident: SAN
Positive Findings Problem List Diagnose Planning
Functional activity :
- Patient is a housewife
- After she got sick, she is still able
to do ADL independently but
discomfort in walking.
- Patient can walk upstairs
independently if there’s railing
on the staircase.
- After she got sick, she had
difficulty in cooking.
 Patient: Mrs. T/33 y.o./11511385/Housewife/Blitar
Referred from: Neurologic outpatient clinic (Tetraparese UMN type due to post myelitis)
Resident: SAN
Positive Findings Problem List Diagnose Planning
Psycho-Socio-Economic:
• Patient is married, she lives with
her parents and her children
• Current income was from the
patient’s husband who works as
a civil cervant in Sidoarjo
• Patient’s house is 1 floor, there’s
no stairs. From the door to he
bedroom approx. 3m. The
bathroom inside the house with
sitting closet.
• Economic status : middle class
• Health payment : private
BI: 20 /20 (independent).
 Barthel Index
2
3

2
20/20 3
Independent
1
2

2
2

2
1
20
Patient: Mrs. T/33 y.o./11511385/Housewife/Blitar
Referred from: Neurologic outpatient clinic (Tetraparese UMN type due to post myelitis)
Resident: SAN
Positive Findings
Physical exam: • Cerebellum :
• GCS 456 (Compos mentis) Disdiadokokinesia : able
• BP : 113/80 mmHg, HR : 90x/min, RR : 22x/min Heel to shin : able
• BW = 50kg, BH : 154 cm BMI : 21.1 (Normal) Finger to nose : able
• Ambulation : Independent
• Gait : Wide base Gait • Balance Examination:
• Chest : heart : S1S2 single, murmur -, gallop – Sitting balance : static (good) & dynamic (good)
lung : rh-/-, wh-/-, ves +/+ Sitting tolerance : good (>30 minutes)
Chest expansion: 2-2-2 cm Standing balance : static (good) & dynamic (poor)
Breath count test: 12-12-13
• Abdomen : soefl, hepar and lien unpalpable • Romberg test : (-)
• Extremities : warm+/+, oedema -/- • Sharpened Romberg test : (-)
• Cranial Nerve: N.I-XII normal
 Neuromuscular Examination
Upper extremity Lower extremity
D S D S
ROM Normal
MMT Decreased Decreased
(according to ASIA Chart) (according to ASIA Chart)
Tonus Normal Normal Normal Normal
Spasticity MAS 1 MAS 1 None none
Physiological BPR +3 / TPR +3 BPR +3 / TPR +3 KPR +4 / APR +4 KPR +4 / APR +4
reflex

Pathological Hoffman (+) Hoffman (+) Babinski (-) Babinski (-)

reflex Tromner (+) Tromner (+) Chaddock (-) Chaddock (-)
Sensoric Normal Normal Normal Normal
(Exteroceptive)
Proprioceptive Normal Normal Normal Normal
Patient: Mrs. T/33 y.o./11511385/Housewife/Blitar
Referred from: Neurologic outpatient clinic (Tetraparese UMN type due to post myelitis)
Resident: SAN
Positive Findings

Upper Extremities (D/S):

Inspection:
Deformity (-)
Edema (-)
Erythema (-)
Atrophy (-)
Deltoid circumference : 33 cm/ 33 cm
Muscle atrophy : (+)

Palpation:
Tenderness (-)
Warmth (-)

Move:
ROM- full
Patient: Mrs. R/28 y.o./10971697/Banker/Malang
Referred from: -
Resident: SAN
Positive Findings
Lower Extremities (D/S):
Inspection:
Deformity (-)
Edema (-)
Erythema (-)
Atrophy (-)
Thigh circumference : 43 cm/ 43 cm
Calf circumference : 37 cm / 37 cm
• ALL 84/84 cm
• TLL 82/80 cm
Palpation:
Tenderness (-)
Warmth (-)
Move:
ROM- full
May 28th 2021
Head MSCT Scan without Contrast
RSUD Mardi Waluyo Blitar
Kesimpulan :
Saat ini tak tampak infarct maupun
perdarahan pada intracranial, tidak
menyingkirkan adanya infarct
MRI WHOLE SPINE
July 5th 2021

Kesimpulan :
• Tak tampak abnormalitas pada
medulla spinalis

• Mild spinal canal stenosis pada C4-C5,

C5-C6 ec bulging disc, spondylosis
cervicallis
 HAND FUNCTION

Hand Function Examination Hand Grip : 4.2 / 4.3

Cylindrical : WF/WF
Spherical : WF/WF
Pinch : WF/WF
Hook : WF/WF
Lateral tip : WF/WF
 Functional Diagnosis
ICF Code Description Patient Condition
Environment
E310 Immediate Family Patient’s husband help to get
medication
E580 Health services, systems and policies Healthcare payment by BPJS
Personal Factors
Female, 33 yo, Housewife, Javanese, Moeslem
 Functional Diagnosis
ICF Code Description Patient Condition
Body Function
B449 Function of respiratory system Count test: 12-12-13
Chest expansion: 2 cm
B730 Muscle power function Decrease MMT on UE and LE D/S
B735 Muscle tone function Muscle atrophy on the UE
Body Structure
S760 Structure of trunk Mild spinal canal stenosis at C4-C5,
C5-C6 ec bulging disc, spondylosis
cervicallis
Activities and Participation
D469 Walking and moving Discomfort in walking
D540 Dressing Discomfort in dressing
D699 Domestic life Discomfort in doing housework
(cooking)
Patients’ Video
Patient’s Video