Physical theraphy form

Physical therapist : virgorika, S.Ft

Doctor

: Beno putra, Sp.KFR

Register number

: 1335247

Specification

: Neuromuscular physical therapy

Room

: hydrotherapy room

Date of assesment : February 20th 2015

A. Patient Identity data collection

Name

: Mrs. ARS

Date of birth

: jayapura, april 10th 1976 (39 years old)

Address

: Komp. Lereng Indah, Jl. Arjono B 33, pondok cabe udik,

pamulang, south tangerang, banten

Education

: Diploma

Occupation

: nurse at RSUD DOK 2 Jayapura

Hobby

: Singing

Medical Diagnosis

: CVD Stroke Ischemic recurrent

B. history of illness data collection

chief complaint

: left arm and leg weakness , tingling and numbness

history of present illness

: she reports that she had her first stroke in june
2013. It made her left arm and leg become tingling and
numbness, then she went to the doctor clinic in Jayapura.
the diagnosis was a stroke. Then she referred to Dok 2
Jayapura hospital in Papua for 1 month, it was until the
end of July. While she was inpatient, she admitted that she
already had therapy. She had outpatient care for 2
months from August to September 2013 and then she was
able to walk using a walker to perform everyday activity
like working, and riding motorcycle while having
condition with numb and tingling left arm and leg. she
suffered a second stroke in August 2014 in the morning at
work. she could not move her both arms and legs . so,
she used a wheelchair to go to Emergency Unit in Dok 2
Jayapura hospital and back as inpatient for 1 month. She
was suspected that her arteries narrowing due to her

stroke was less than 5 years. because of limitations of the

tool, she was referred to Fatmawati hospital in Jakarta.
She arrived in Jakarta on November 27th with having
difficulty to walk. She arrived at Fatmawati Hospital on
November 28th and got schedule for catheterization on
December 12th, 2014. She had her first catheterization
from 10-10.30 am. It showed the narrowing of blood
vessels. Then she had her second catheterization to set a
balloon on desember 19th. She hospitalized for 6 days and
had therapy. She already able to use tripod cane. She
already had theraphy for 7 times and 4 times
hydrotherapy treatment.
RPD : Hypertensi, Hypoglikemi
RPK :Hypertensi (mom)
RPsikososial : she work as nurse in RS Dok 2 Jayapura, she live with her husband
and 3 sons, she live with her family while shes having treatment in Jakarta.

Inspection
General Inspection
Arrived
Awareness

: With Canadian
: Compos Mentis

Cooperative
Blood Pressure

: 120/70 mmHg

Heat Rate

: 79x/minute

Respiratory Rate

: 26x/minute

Temperature

: Afebris

Height

: 165 cm

Weight

: 82 kg

Nutritional Status

: 82/(1,65)2 = 30, 12 (1st Obbes)

Specific Inspection
Inspection
1

Static
Able to have normal conversation
Not face pale
Breathing pattern : deep and slow

Theres no deformity in both legs

No muscle atrophy in upper extremity and lower extremity
Dynamic
Posture
Anterior
- Depression of sinistra shoulder
- elbow flexion sinistra
- Pronation wrist
- Finger Flexion
Lateral
-

Retraction Shoulder
Lumbal Lordosis
Posterior
Normal Spine
Walking
Hemiplegic Gait sinistra with Canadian
Palpation
Muscle spasm in biceps brachii, deltoid, upper trapezius, hamstring and
gastrocnemius sinistra

Move

joints

move

mmt

should
er

flexion

dxt
5

sin
3

dxt
0

5
5
5
5

5
3
4
3

5
5
5
5
5
5
5
5
5
5

elbow
wrist
hip

Extension
Abduction
Adduction
Internal
rotation
External
rotation
Flexion
Extension
Flexion
extension
Flexion
Extension
Abduction
Adduction
Internal
rotation

vas

Rom dextra

Rom
sinistra

Norm
al
rom

sin
0

dxt
N

sin
N

dxt
70

sin
N

90

0
0
0
0

0
0
0
0

N
N
N
N

N
N
N
N

30
40
30
-

N
N
N
N

50
90
50
90

90

3
4
4
4
3
5
3
4
3

0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0

N
N
N
N
N
N
N
N
N

N
N
N
N
N
N
N
N
N

120
0
60
55
90
15
45
25
-

N
N
N
N
N
N
N
N
N

140
0
80-90
70-90
120
15
45
30
35

knee
ankle

External
rotation
Flexion
Extension
Dorsoflexi
on
palmarflex
ion

45

5
5
5

4
5
4

0
0
0

0
0
0

N
N
N

N
N
N

50
0
20

N
N
N

135
0-15
20

15

50

description:
left sided weakness
no complaints of pain.
limited AROM in left arm and leg

D. reflex examination
Babinski reflex: sinistra (+), dextra (+)
patellar tendon reflex: (-)
biceps reflex: (-)
achiless tendon reflex : (-)

E. Spasticity
spasticity asworth scale is 1 on the left arm and leg
F. examination of gait
cadence: 49 x/minute
description: she leans her weight on the right leg while shes walking, so her gait
pattern is hemiplegi gait.
g. endurance examination
six minutes walking test: 140 meter
patients finished the test without any rest, and she felt tired and a little bit out of
breath.
H. functional examination (barthel index)
activity
Eating

indicator
0: Unable to do it by
herself/himself
5: require assistance in a few

score
5

things
10: able to do it by herself/himself
bathing
0: Unable to do it by
herself/himself
5: able to do it by herself/himself
Self sanitation
0: Unable to do it by
herself/himself
5: able to do it by herself/himself
Dressing
0: Unable to do it by
herself/himself
5: require minimal assistance
10: able to do it by herself/himself
Defecation
0: incontinensia alvi
5: sometimes there is
incontinensia
10: there is no incontinensia
micturition
0: urine incontinensia or
sometimes by using
catheterization
5: sometimes there is
incontinensia
10: there is no incontinensia
toileting
0: unable to do it
5: require some assistance
10: able to do it by herself/himself
Transfer (bed to
0: unable to do it, imbalance
chair and return
5: require help from a few people,
to bed)
able to sit
10; require minimum assistance
15: able to do it
mobilization
0: immobile
5: need wheel chair
10: walking with assistance
15: independent/ using cane
Using stairs
0; unable to do it
5; require some assistance
10: independent
Description: independent, but she worries about falling
I.

10

10

10

15

15

while walking

Sensory examination
She has good respond about smooth, rough touch, perceptual and
pressure.
Description: No sensory deficits.
J. anthropometric
No atrophy in both legs and arms
K. time up and go test examination

35 seconds
D. Written data collection from supporting examination
1. catheterization 1 ( desember 12th 2014)
Result: stenosis 70%
2. . catheterization 2 (desember 19th 2014)
Result: checking procedure with DSA cerebral, RICA angioplasty, blood vessels looks
normal
E. list of physical therapy problems based on priority
1. left arm and leg weakness
2. limited move of right shoulder flexion,elbow,and hip
3. left biceps brachii, deltoid, upper trapezius, hamstring and gastrocnemius muscle
spasm
4. spasticity
5. imbalance
6. low endurance
7. abnormal gait