Otrhopedic Division

Departement of Surgery
University of Halu Oleo

“Frozen shoulder Dextra & Sinistra +

Myalgia”

Presentation by: Orthopedic Division

Guided by: “dr.”
Emergency Case Report
June 2023
 Patient’s Identity

Name : Mrs. IA
Age : 52 YO
Sex : Female
Religion : Moeslim
Marital status : Married
RM Number :
Hospitalized : dr. Tri Tuti Hendarwati, Sp.OT
 Patient’s History
Main Complaint:
Right and left chest pain
Full History:
The patient came to the IGD RSUB with complaints of right and left chest pain since 2
weeks ago, the pain was felt continuously, the pain felt like a feeling of attraction which
was exacerbated by changing positions, coughing, and during defecation. Pain relieved at
rest. Pain is felt radiating to the breast, shoulder, hand, and back. Fever (-), cough (-),
vomiting (-). The patient has a history of the habit of lifting heavy objects. History of
treatment with an orthopedic specialist was given medication then improved and
reappeared. History of trauma (-), History of pneumonia (+), history of 6 months of
treatment (+) history of fatty liver (+). The patient has been taking UDCA regularly since 3
months. Controlled history of HT (+). DM (-).
 Physical Examination
General Status:
General state : Moderate illness
Consciousness : Compos mentis (E4V5M6)

Vital Sign:
BP : 123/92 mmHg
HR : 77 x/minute
RR : 26 x/minute
Temp : 36.1 C
SpO2 : 99% on room air
VAS : 7/10
 Physical Examination
Localist Status :

Thoracic region
Inspection: edema (-), erythema (-), scar (-)
Palpation: tenderness (+), crepitus (-)

ROMS
Extremitas superior dextra: active and passive
movement with limited range of motion

Left superior extremity: active and passive

movement with limited range of motion
 Laboratorium test
Routine Blood Test:
(30/06/2023)

Item Result Unit Reference

WBC 6.3 10^3/µL 4.0-10.0
RBC 3.47 10^6/µL 4,00-6,00
PLT 310 10^3/µL 150 – 400
HB 11.5 g/dl 12.0-16.0
HCT 31.5 % 37,0-48,0
MCV 90.9 fL 80.0-97.0
MCH 33.10 pg 26.5-33.5
MCHC 36.4 g/dl 31.5-35.0
 Radiology (30/6/2023)

X-ray of the right and left shoulder shows no

abnormalities
 Resume
The patient came to the IGD RSUB with complaints of right and left chest pain since 2 weeks ago, the pain was felt
continuously, the pain felt like a feeling of attraction which was exacerbated by changing positions, coughing, and during
defecation. Pain relieved at rest. Pain is felt radiating to the breast, shoulder, hand, and back. Fever (-), cough (-),
vomiting (-). The patient has a history of the habit of lifting heavy objects. History of treatment with an orthopedic
specialist was given medication then improved and reappeared. History of trauma (-), History of pneumonia (+), history
of 6 months of treatment (+) history of fatty liver (+). The patient has been taking UDCA regularly since 3 months.
Controlled history of HT (+). DM (-).

General state : Moderate illness

Consciousness : Compos mentis (E4V5M6)

Vital Sign: BP: 123/92 mmHg ,HR: 77 x/minute, RR: 26 x/minute,Temp : 36.1 C SpO2: 99% on room air VAS : 7/10

Localist Status :
Thoracic region
Inspection: edema (-), erythema (-), scar (-)
Palpation: tenderness (+), crepitus (-)
 Diagnosis
Working Diagnosis: Frozen shoulder Dextra & Sinistra + Myalgia
 Planning
- IVFD RL 20 tpm
-Inj. Ketorolac 1 amp/8 jam/iv
-inj. Ranitidine 1 amp/12 jam/iv
-pain loss 1 amp/extra
-inj. methylprednisolone 1 amp in RL 500 cc running 8 hours
-inj. ciprofloxaxin 1gram/12 jam
-inj. dexamethasone 1 amp/8 jam/iv
-inj. Ondansetron 1 amp/8 jam/iv
-Inj.pct 1 gram/8jam/iv)
 Thank You
For Your Attention