Patient : Mrs.
B /80 th/11571961/Retiree/Malang
Referred From : Orthopedic Department (CF intercondylar Left Femur post PFNA)
Resident : IFA/AIK/RIN
Anamnesis
Anamnesis : (Heteroanamnesis)
Chief Complaint: Pain at left hip since 7
weeks ago
History of Present Illness :
o "The patient's sister said that the
patient has been complaining about
pain in her left thigh for the past 2
months.
o Patient couldn’t describe the nature
of pain
o The pain was provoked by moving
her left leg , and reduce by resting or
took medication.
o "The patient's sister also said that
The patient refused to do active
sitting since she underwent surgery
due to her left hip fracture.
o "The patient refuses to get out of
bed, turn to the right or left, and sit
down."
o All of her ADL was help by her sister
and nephew
o Patient was fully bedridden and
using diapers for urinate and
defecate
Problem List
Medical:
CF Collum Femur S post THA S (2
months) + geriatric problem
(immobility, instability, visual and
hearing impairment)
Surgical : post Proximal Femoral
Nail Antirotation (9 days)
R1 (M) : Unable to walk, unable to
transfer lying to sit, sit to stand
independently
R2 (A) : Difficulty to do ADL
(dressing, bathing, toileting, eating,
grooming).
R3 (C) : -
R4 (P) : -
R5 (S) : Unable to go to the church
R6 (V) : Unable to do household
task
R7 (O) :
• Left hip pain (VAS 5)
• Limited ROM hip S
• Reduced MMT at LE S d.t pain
Diagnosis
Clinical diagnosis:
CF Intertrochanter Femur S post
PFNA (9 days) + geriatric problem
(immobility, instability, visual and
hearing impairment)
Functional diagnosis :
Impairment:
• Left hip pain (VAS 5)
• Limited ROM hip S
• Reduced MMT at LE S d.t
pain
Disability :
• Unable to transfer (lying to
sit, sit to stand, bed to chair)
• Unable to walk
• Difficulty to do ADL (dressing,
bathing, toileting, eating,
grooming).
Handicap :
• Unable to do household task
• Unable to go to the church
Planning
PDx : Comprehensive geriatric assessment
PTx :
• Continue medication from orthopedic
Modality :
• Cryotherapy at surgical site (left hip) start
from the low level, intensity as patient
tolerance, duration 5 minutes, 2x/week
• TENS at tender point (left thigh) high
intensity 50-100 Hz, intensity as patient
tolerance, duration 15 minutes, 2x/week
Exercise : (avoid PROM)
• AAROM hip, knee, ankle S in all planes
• Isometric strengthening gluteus,
quadriceps
F: 2-3days/week
I: 60-80% max isometric contraction
T: 10 seconds
T: isometric strengthening
• Heel slide & ankle pumping
• Transfer exercise (lying to sit  sit to
stand with walker (weight bearing as
patient tolerance))
• Balance exercise (sitting balance)
• Deep Breathing exercise & chest
expansion exercise
Patient : Mrs. B /80 th/11571961/Retiree/Malang
Referred From : Orthopedic Department (CF intercondylar Left Femur post PFNA)
Resident : IFA/AIK/RIN
Anamnesis Problem List Diagnosis Planning

o On March 9th 2023 OT: ADL training (dressing, bathing, toileting, eating, grooming)
• Patient got slip in her house while OP: walker
cooking in the kitchen. PMo: Subjective, VAS, ROM, muscle strength, mobilization (transfer and
• she felt pain in her left thigh (VAS 9) ambulation), ADL, breathing and chest expansion
• Since she falls, she unable to PEd:
ambulate and mobilized - Explain about patient’s condition
independently - Extended family support
• She visited RKZ Hospital, according to - Purpose and benefit of PMR therapy
xray result, she was hospitalized - Routine control to PMR clinic
within 2 days. - Continue exercise at home
• She was planned to had 6kg traction - Icing when pain
at home for a month.
• She was on bedridden at home.
• She only had traction for 2 weeks due
to pain.
o On March 24th 2023
• Patient visited RKZ Hospital due to
persisted pain.
• She was referred to RSSA and got
planned for surgery.
Patient : Mrs. B /80 th/11571961/Retiree/Malang
Referred From : Orthopedic Department (CF intercondylar Left Femur post PFNA)
Resident : IFA/AIK/RIN
Anamnesis Problem List Diagnosis Planning

On April 14th 2023

• Patient was hospitalized under orthopedic department RSSA.
• She was prepared to had surgery.
• She refused to had traction again before surgery,
• She underwent surgery on April 18th 2023.
• She wasn’t consulted to PMR during hospitalization, but she has learnt to stand during
hospitalization.
• She was discharged from hospital 2 days after surgery.
• she felt afraid to try to stand and sit at home and only bedridden.
On April 27th 2023
• She controlled to orthopedic department RSSA and consulted to PMR outpatient clinic for
early transfer and ambulation.

History of Past Illness :

DM/HT/HF/stroke/tumpors/previous trauma (-)
The patient had history of presbyopia and hearing impairment at left ear.

History of Family Illness :

No related family has same condition with the patient

History of Medication & Rehabilitation:

Na diclofenac 2x50mg
During hospitalization patient didn’t consulted to PM&R department
Patient : Mrs. B /80 th/11571961/Retiree/Malang
Referred From : Orthopedic Department (CF intercondylar Left Femur post PFNA)
Resident : IFA/AIK/RIN
Anamnesis Problem List Diagnosis Planning

Functional activity :
• Patient was a retiree of supervisor in Transportation company (Vespa)
• After retiree, she only live at home, doing household task.
• Due to the current condition, the patient is unable to walk and do ADL independently (toileting,
eating, dressing, bathing, grooming).
• Patient unable to do household task
Psycho-Socio-Economic :
• The patient hasn’t married yet.
• She only lived by herself.
• She was a law diploma graduated.
• After being sick, she lives in her relative house (her cousin’s house)
• Patient lives in a house with 1 storey. There were no stairs in entrance of the house. From the
door to patient’s bedroom was approx. 3 m. The bathroom is inside the house with sitting closet.
• Current expenses for daily living are covered by herself, sometime she got donation from church.
• Currently patient unable go to the church
• Economic status: Low-Middle Class
• Health payment : BPJS
Barthel
2
Index 1

2
6/20 1
severe
dependent 0
0

0
0

1
0
7
 GERIATRIC PROBLEM
Immobility V Infection -
Instability V Inanition -
Intelectual Impairment - Impaction -
Incontinence - Insomnia -
Isolation - Iatrogenic disorder -
Impotence - Impairment of hearing, V
-
Immunodeficiency vision, and smell
Impecunity -
GERIATRIC ASSESMENT TOOLS

1. Mini Nutritional Assesment : 11 (malnutrition)

2. Frailty Index (FI-40) : 23/40=0,5 (severe frailty)
3. Skala Norton : 13/20 (risk of decubitus)
4. Moca-Ina : 25/30
5. Berg Balance Scale : 0/56 (wheelchair bound)
6. EQ5D : - (haven’t been assessed)
7. Geriatric Depression Scale: - (haven’t been assessed)
 MOCA-INA
Score : 25/30 (normal)
Patient : Mrs. B /80 th/11571961/Retiree/Malang
Referred From : Orthopedic Department (CF intercondylar Left Femur post PFNA)
Resident : IFA/AIK/RIN
Positive Finding
Physical Exam :
GCS : 456 (Compos Mentis)
BP : 118/68 mmHg
HR: 96x/m RR: 20x/m SpO2: 98%
BW : 42 kg BH: 145 cm BMI: 19.2 (normoweight)
Ambulation : Dependent bedridden
Gait : NT
Cranial Nerve : N. I-XII : Normal
Head and Neck : Anemic (-), Jaundice (-), Cyanosis (-)
Thorax :
• Cor : S1-S2 single, murmur (-), gallop (-)
• Pulmo : Ves +/+ RH -/- WH -/-
• Chest expansion : 2-2-2
• Breath count test :12/14/14
Abdomen : soefl, hepar & lien unpalpable, pain (-)
Extremities : warm +/+ oedema -/-
Musculoskeletal Status
NECK ROM MMT
Flexion F (0-450) 5
Extension F (0-450) 5
Lateral bending F/F (0-450) 5
Rotation F/F (0-600) 5

TRUNK ROM MMT

Flexion F (0-800) Impression < 3
Extension F (0-300) Impression < 3
Lateral bending F/F (0-350) Impression < 3
Rotation F/F (0-450) Impression < 3
 SHOULDER ROM MMT

Flexion F/F (0-1800) 5/5

Extension F/F (0-600) 5/5

Abduction F/F (0-1800) 5/5

Adduction F/F (0-450) 5/5

Internal rotation F/F (0-700) 5/5

External rotation /FF (0-900) 5/5

 ELBOW ROM MMT

Flexion F/F (0-1500) 5/5

Extension F/F (1500-0) 5/5

Supination F/F (0-900) 5/5

Pronation F/F (0-900) 5/5

23
 WRIST ROM MMT
Flexion F/F (0-800) 5/5

Extension F/F (0-700) 5/5

Ulnar deviation F/F (0-300) 5/5

Radial deviation F/F (0-200) 5/5

 THUMB ROM MMT

Flexion
MCP F/F (0-900) 5/5
IP F/F (0-800) 5/5
Extension F/F (0-300) 5/5
Abduction F/F (0-700) 5/5
Adduction F/F (700-0) 5/5
Opposition F/F 5/5

25
 FINGERS ROM MMT

Flexion
MCP F/F (0-900) 5/5
PIP F/F (0-1000) 5/5
DIP F/F (0-900) 5/5
Extension F/F (0-300) 5/5
Abduction F/F (0-200) 5/5
Adduction F/F (200-0) 5/5
Opposition F/F 5/5

26
 HIP AROM End Feel MMT

Flexion F/limited (0-600) firm 5/3 (pain)

Extension F /lim (600-0) firm 5/3 (pain)

Abduction F/limited (0-300) firm 5/3 (pain)

Adduction F/F (0-300) 5/3 (pain)

Internal rotation F/F (0-350) 5/3 (pain)

External rotation F/F (0-450) 5/3 (pain)

 KNEE AROM PROM End Feel MMT
Flexion F/lim (0-300) F/lim (0-450) Firm 5 / 3 (pain)

Extension F/lim (300-0) F/lim (450-0) Firm 5 / 3 (pain)

ANKLE PROM MMT

Dorsoflexion F/F (0-200) 5/5

Plantarflexion F/F (0-500) 5/5
Inversion F / F (0-350) 5/5
Eversion F / F(0-150) 5/5
BIG TOE ROM MMT

Flexion
MTP F/F (0-300) 5/5
IP F/F (0-500) 5/5
Extension F/F (0-800) 5/5
TOES ROM MMT

Flexion

MTP F/F (0-250) 5/5

IP F/F (0-250) 5/5

Extension F/F (0-800) 5/5

Patient : Mrs. B /80 th/11571961/Retiree/Malang
Referred From : Orthopedic Department (CF intercondylar Left Femur post PFNA)
Resident : IFA/AIK/RIN
Positive Finding
A/R Hip S:
Inspection :
• Scar (+) dry scar at lateral
thigh S
• Erytema (-)
• Atrophy (-)
• Edema (+)
Palpation :
• Tenderness (+) at surgery
site
• Warmth (-)
Move :
• ROM : limited
• Pain during movement (+)
TLL: 77/77
ALL: 83/83

• Thigh ∅ : 28/33
• Knee ∅ : 31/31
• Calf ∅ : 24/24
• Ankle ∅ : 21/21
FUNCTIONAL EXAMINATION
Transfer Balance
Rolling : unable Sitting Balance
Lying to sitting : unable Static: NT
Sitting to standing : unable Dynamic : NT
Transfer to chair : unable Sitting Tolerance: NT
Standing Balance
Static: NT
Dynamic : NT
Xray Femur AP/Lat (RS RKZ)
March 10th 2023
Xray Femur AP/Lat (RSSA)
April 6th 2023

Kesimpulan: 
•Fraktur oblique komplit pada collum femur kiri dengan
displacement dan shortening 
•Osteoporosis
•OA hip joint kiri
•Soft tissue swelling regio hip kiri
Xray Pelvic AP (RSSA)
April 6th 2023

Kesimpulan: 
•Fraktur oblique komplit pada collum femur
kiri dengan displacement dan shortening 
•Osteoporosis dengan OA hip joint kiri
•Soft tissue swelling regio hip kiri
Xray Femur AP/Lat(RSSA)
April 18th 2023

Kesimpulan (dibandingkan foto

Pelvis tanggal 06-04-2023), saat
ini:
•Masih tampak fraktur oblique
komplit pada collum femur
kiri terpasang internal fiksasi baik
•Osteoporosis
•Soft tissue swelling regio hip
hingga femur kiri ⇒ berkurang
•Emfisema subkutis regio hip
hingga femur kiri ⇒ lesi baru
Xray Pelvic AP (RSSA)
April 18th 2023

Kesimpulan (dibandingkan foto Pelvis tanggal

06-04-2023), saat ini:
•Masih tampak fraktur oblique komplit pada collum
femur kiri dengan terpasang internal fiskasi baik
•Osteoporosis dengan OA hip joint kiri
•Soft tissue swelling regio hip hingga femur kiri ⇒
berkurang
•Emfisema subkutis regio hip hingga
femur kiri ⇒ lesi baru
ICF DIAGNOSIS PATIENT CONDITION
Body Function
B280 Sensation of pain Left hip pain
B710 Mobility of joint function Limited ROM hip S
B730 Muscle power functions Reduced MMT

Body Structure
S750 Structure of lower extremity CF Intertrochanter femur S post PFNA

Activity and Participation

D450 Walking Unable to walk
D510 Washing oneself Unable to bath independently
D530 Toileting Unable to do toileting
D540 Dressing Unable to dress independently
D550 Eating Unable to eat independently
D649 Household tasks Unable to do household tasks
D910 Community life Unable go to the church
D930 Religion and spirituality Difficulty to pray
Environment
E315 Extended family Her relatives support her
E580 Health services, systems, and policies BPJS

Personal Factor Female 80 y.o, retiree, Chinese, Catholic

Prognosis

Ad Vitam • Bonam

Ad Sanationam • Bonam

Ad Functional • Dubia ad Bonam

 Goal

Short Term Mid Term Long term

• Prevent complications • Able to walk with walker • Able to walk without

(contracture, stiffness, • Able to transfer walking aids
independently (lying to sit,
muscle atrophy) sit to stand, bed to chair) • Able to do all ADL
• Reduce pain • Able to active sitting independently
• Improve ROM • Able to do household
• Improve muscle task
strength • Able to pray and go to
church