CVA hemorrhagic Subacute Phase (4 weeks)+

Trigger Finger Digiti IIi-IV manus S+ DM Type II

on Tx+HT on TX+ Underweight

Nisa Ulfah

Preceptor : Dr. Dwi Indriani L. Sp. KFR (K)

Dr. Gutama Arya Pringga, sp.KFR, M.Ked.Klin
Identity
Name : Mrs. S
Medical record number : 11536075
Gender : Male
Age : 56 y.o
Address : Probolinggo
Occupation : Teacher
Religion : Moslem
Ethnic : Javanese
Education : bachelor
Marital Status : Married
Health Insurance : BPJS
Referred from :-
Chief • Weakness at left upper and lower
limb since 1 months ago (On March
Complaint 2022)
History of Present Illness
3rd week of March 2022
• Patient suddenly felt weakness when she was just finished praying at home. The weakness was on the left side of the body.

•The patient was brought to puskesmas and then referred to emergency room RSUD Probolinggo :
• She still able to walk with physical help
• Asymmetrical face was denied
• The patient was able to communicate and no slurred spech
• There’s no numbness and tingling sensation
• The patient can swallow well and didn’t chokes
• The patient is conscious and there’s headache but no seizure and vomited
• Patient is able to sensation of urinate and defecate, and able to hold urinate and defecate
History of Present Illness
• She was only observed for a few hours, the doctors just gave her medication, and and ordered the patient to come to
the neurologic outpatient clinic at the next day.
• When she came home from the hospital the weakness on the left side felt a little better than before
•The patient walked still with physical help
•Asymmetrical face was denied
•The patient was able to communicate and no slurred spech
•There’s no numbness and tingling sensation
•The patient can swallow well and didn’t chokes
•The patient is conscious and there’s headache but no seizure and vomited
• Patient is able to sensation of urinate and defecate, and able to hold urinate and defecate
History of Present Illness
The next day after the onset
• patient controlled to the neurologist
• The weakness is still same with before
• She was given medications and routine controlled for every week.

4th week of march 2022

• When she controlled at the next week, she complained that she often falls while walking.
• The patient feels that his body is not balanced and sometimes felt dizziness while walking
• The weakness is still same with before
History of Present Illness

1st week of April 2022

• she still complained that she often falls while walking and causing blisters on her feet
• There was no difference about the weakness compare than before
• She did ct scan examination
• The doctor suggest her to use quadripod as walking aid
CT Scan
April 4th 2022

Kesimpulan :
ICH di genu capsula Interna
Sampai corona radiata
dekstra volume 2ml
History of Present Illness
2nd week of Aril 2022
• She controlled again to the neurologiost
• Using a quadripod made the patient did not fall when walking
• the weakness felt by the patient was still the same, there was no improvement

April 18th 2022

• The patient took the initiative to go to the neurologist at RSSA at her own expense because she felt there was no change in
her weakness and balance.
• She got a prescription and she is advised to go to the PM&R outpatient clinic for further therapy
• She also complained she has stiffness at her left fingers since 1 month ago
• The finger can’t extend. She heard clicking when the fingers is force to extend
• There is no pain
• There was no numbness, but there was tingling sensation.
History of Past Illness

• There is history of hypertension since 1 month

• History of DM type II since 2015 but she didn’t routine control
• History of trauma and malignancy were denied
Family History

• Her family denied any history of hypertension, DM, heart disease or

malignancy
History of Medication

• The patient and her family didn’t remember the name of the drugs
History of Functional Activity

The patient is a teacher of 1st grade elementary school

When teaching she needs in standing position for long period of time. Curently she can not do that
due to her condition

Previously, she was able to do ADL independently.

After she got sick, she was unable to do ADL independently such toileting and bathing

She doesn’t have any particular hobby

History of Psycho-Socio-Economic
• The patient is married. she has 2 children

• She lives with her husband, her 1st child, daughter in law and 1 grandchild

• Her house is 1 floor. Fences and main door 3 m. Distance between door and bedroom 4 m. The
bathroom is inside home with squatting toilet.

• Her source of income is from herself

• Economic status: middle

• Health Insurance: BPJS

 Barthel Index

2
3

2
3
17/20
1
mild dependency 2

1
1

2
0
!7
General Examination
GCS E4V5M6 (Compos Mentis)
Ambulation: Independent with quadripod
Vital sign:
BP: 152/98 mmHg , MAP : 116 mmHg, HR: 94x/m, RR: 20 x/m , T 36,5°C, SpO2: 98%
BW : 38 kg BH : 152 cm BMI : 16.45 (underweight)
Head and neck : Anemic -, jaundice -, cyanosis -

Thorax : Cor : S1S2 single, murmur -, gallop -

Pulmo : Rh-/-, Wh-/-
Chest expansion: 2 -2 -2
Breath Count : 18 – 19 - 17
Abdomen : Soefl, hepar & lien unpalpable
Extremity : Acral (warm) , CRT <2 s
 Neuromuscular Examination
Upper Extremity Lower extremity

D S D S

ROM Full

MMT 5 As a table 5 As a table

Muscle tone normal Normal normal Normal

Clonus - - - -

Spasticity - - - -

Brunnstrom stage Level 7

Physiological Reflexes BPR +2 / TPR +2 BPR +2 / TPR +2 KPR +2/ APR +2 KPR +2 / APR +2

Pathological Reflex Hoffman (-) Hoffman (-) Babinski (-) Babinski (-)
Tromner (-) Tromner (-) Oppenheim (-) Oppenheim (-)
Sensory Exteroceptive (touch, pressure, temperature, pain): normal
Proprioceptive (joint position sense, vibration): normal
ELBOW ROM MMT
Flexion F/F (0-1500) 5/4
Extension F/F (1500-0) 5/4
Supination F/F (0-900) 5/4
Pronation F/F (0-900) 5/4

WRIST ROM MMT

Flexion F/F (0-800) 5/4

Extension F/F (0-700) 5/4

Ulnar deviation F/F (0-300) 5/4

Radial deviation F/F (0-200) 5/4

27
THUMB ROM MMT

Flexion
MCP F/F (0-900) 5/4
IP F/F (0-800) 5/4
Extension F/F (0-300) 5/4
Abduction F/F (0-700) 5/4
Adduction F/F (700-0) 5/4
Opposition F/F 5/4

28
 FINGERS ROM MMT
Flexion
MCP F/F (0-900) 5/4
PIP F/F (0-1000) 5/4
DIP F/F (0-900) 5/4
Extension F/F (0-300) 5/4
Abduction F/F (0-200) 5/4
Adduction F/F (200-0) 5/4
Opposition F/F 5/4

FINGERS III-IV PROM END FEEL

Extension
MCP F/F (0-300) firm
PIP F/F 00 firm
DIP F/F 00 firm
29
MUSCULOSKELETAL STATUS

HIP ROM MMT

Flexion F (0-1200) 5/4

Extension F/F (0-300) 5/4
Abduction F/F (0-450) 5/4
Adduction F/F (0-300) 5/4
Internal rotation F/F (0-350) 5/4
External rotation F/F (0-450) 5/4
 KNEE ROM MMT
Flexion F/F (0-1350) 5/4
Extension F/F (1350-0) 5/4

ANKLE PROM MMT

Dorsoflexion F/F (0-200) 5/4

Plantarflexion F/F (0-500) 5/3
Inversion F / F (0-350) 5/4
Eversion F / F(0-150) 5/4
I (Olfactory)
Cranial
Smell function (+)
Nerve Examination
II (Opticus) Visus (NT) visual field (same with the examiner) Pupillary reflex (+)
III (Occulomotor) Eye movement Superior (+), Inferior (+), Medial (+),

IV (Trochlear) Eye movement inferonasal (+)

V (Trigeminal) Mastification muscle (+), mid face sensory (N), kornea reflex (not tested)
VI (Abducens) Eye movement lateral (+)
VII (Facialis) Face expression (+), 2/3 anterior tongue (+), schimmer test (not tested)

VIII (Vestibulotrochlear) Hearing (+), hallpike manuvre (not tested)

IX (Hypoglosus), X (Vagus) 1/3 posterior tongue sensory (not tested), voice quality normal, uvula, pharnx arcus (normal), gag
reflex ( not tested), swallowing test (+)
XI (Asesorius) Trapezius, sternocloidomastoideus muscle (normal)
XII (Glossopharingeal) Tongue movement (normal)
 Functional Examination
Hand Function Balance
Spherical : F/F
Cylindrical : F/F Sitting Balance
Hook : F/F Static : good
pinch : F/F Dynamic : good
Lateral tip : F/F
Grasp : F/F Sitting Tolerance : good
Standing Balance
Hand grip: 10,4/5,8 kg Static : good
Dynamic : poor

Transfer Communication function

Lying to sitting : able
Sitting to standing : able Speech : good
Transfer to chair : able with walking aid
Language : comprehension (good) fluency (good) repetition
(good) naming (good) reading (able), writing (able)
 FUNCTIONAL EXAMINATION

Cerebellar function Special Sensory Test

Coordination Stereognosis : able
Dysdiadokokinesia : able Graphesthesia : able
Finger to nose (dysmetria) : able Sensory extinction: able
Heel to shin : able Barognosia : able
Two point tactile : able
Balance :
Romberg test : able
Tandem walking test : unable
 4
3
4
4
4
3
3
4
4
3
2
0
0
1
39
 x x ✓ ✓ 2 MoCa-Ina : 21/30

✓ ✓ ✓3

✓
✓ 2
✓ 1
✓ x ✓ ✓ x 3
✓
✓ 2
✓ 1
✓ x 1

✓ ✓ ✓
0
✓ ✓ ✓ ✓ ✓ ✓ 6
21
Medical problem CVA hemorrhagic Subacute Phase (4 weeks)
Trigger Finger Digiti II-III manus S
DM Type II on Treatment
Hypertension on Treatment
Underweight

Rehabilitation problems Hemiparese S

PROBLEM LIST
Stiffness at digiti II-III manus S
Poor dynamic standing balance
Difficulty to walk
Difficulty to do ADL independently
cognitive impairment
Unable to work
 Diagnosis
Clinical Diagnosis CVA hemorrhagic Subacute Phase (4 weeks)

Topical Diagnosis genu capsula Interna until corona radiata dekstra

Etiological Intracerecbral hemorrhagic

Secondary Diagnosis Trigger Finger Digiti II-III manus S

DM Type II on Treatment
Hypertension on Treatment
Underweight
 ICF Code
CVA hemorrhagic Subacute Phase (4 weeks)
Trigger Finger Digiti II-III manus S
DM Type II on Treatment
Hypertension on Treatment
Underweight

Body Function Activity

D580 Walking
Participation
B163 Basic cognitive function
D510 Washing oneself D859 Work and employment
B415 Blood Vessel Functions
B440 Respiration Functions D530 Toileting
B730 Muscle power functions
B710 Mobility of joint function
Body Structure
S110 Structure of Brain
S580Structure of endocrine glands

Personal Factor
Environmental Female, 56 yo
E310 Immediate family Teacher,
E580 Health services system and policies Javanese,
Moeslem
 • Ad vitam : dubia ad bonam
• Ad sanationam : dubia ad malam
• Ad functionam :
• Patient able to do ADL ( toileting, bathing)
Prognosis independently
• Patient able to ambulate independently without
walking aid
• Patient able to back to work
 Goals

SHORT TERM MID TERM LONG TERM

1. Prevent further complication
1. Improve standing balance 1. Patient able to ambulate
(contracture, muscle atrophy) independently without
2. Improve cognitive function walking aid
2. Educate family to help patient do
3. Patient able to do ADL (toileting, 2. Patient able to back to work
ADL
bathing) independently
3. Improve breathing count and
chest expansion test
4. Increase MMT UE, LE S
5. Reduce stiffnes at III-IV fingers
manus S
 Medical Continue medication from Neurology

Surgical -
Planning Rehabilitation P. Dx LOTCA
Therapy P. Tx Modality:
USD at digiti III-IV manus S frequency 3 MHz, intensity 1 W/cm2, duration 5-8
minutes, mode intermittent, 2x/week
Exercise:
• AROM exercise UE, LE S
• Isotonic Strengthening exercise at UE, LE S
o F: 2 day/week
o I: 60-70% of 1-RM
o T: No specific duration of training
o T: use equipment (arm pulley, Quadricep bench)
• Standing balance exercise
• Breathing and chest expansion exercise
• Endurance Exercise with ergocycle
o F: >5 day/week
o I: 64-76% of HRmax
o T: 30-60
o T: with ergocycle
 OT:
• Stretching exercise at digiti III-IV manus S
• Tendon gliding
• ADL exercise (toileting, bathing)
• Cognitive therapy
P. Mo Subjective, MAP, MMT, ROM, ADL, balance, cognitive function, breathing
function,

P. Ed Explain the patient condition

Purpose and benefit of PMR therapy
Routine control
Continue medications
Continue exercise at home
Family support
Caregiver education
 Summary
Patient is Mrs. S/56 y.o./Teacher/Probolinggo, came to PM&R clinic with chief complaint is weakness of
left upper and lower limb since 1 months ago. From physical examination we found reduced MMT at UE & LE S,
stiffness at digiti III-IV manus S, Poor standing balance, cognitive impairement. We diagnose patient with CVA
hemorrhagic Subacute Phase (4 weeks)+Trigger Finger Digiti III-IV manus S+DM Type II on
Treatment+Hypertension on Treatment+Underweight .
We plan to give therapy with continue medication from neurology. Modality : USD at digiti III-IV manus S.
Exercise: AROM exercise UE, LE s, Isotonic strengthening exercise at elbow extensor S, fingers manus S, knee
extensor S, plantar flexor S , Standing balance exercise, Breathing and chest expansion exercise, Endurance
exercise with ergocycle. OT: ADL exercise, Cognitive therapy. We educate the family about patient’s condition,
PMR therapy, Routine control, Continue medications, Continue exercise at home, Family support, Caregiver
education
Thank You