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GENERAL STATUS
CM, independent ambulation, normal gait, right handed
Body Weight : 85 Kg. Body Height : 169 cm. BMI :29,8
(Overweight)
BP : 150/80 mmHg, HR : 84 x/minute , RR : 20 x/minute
Head & Neck : no anemia, icterus, cyanosis & dyspneu
Thorax : Cor : S1S2 sound, murmur -, gallops -
Pulmo : vesiculer, wheezing -/-, ronchi -/-
Abdomen : Meteorismus -,
Hepar / Lien : unpalpable
Extremities : warm acral +/+ , edema -/-
Physiatric examination
Musculoskeletal examination
Cervical ROM MMT
Flexion F (0-450) 5
Extension F (0-450) 5
Lateral Flexion F/F (0-450) 5/5
Rotation F/F (0-600) 5/5
l
Elbow ROM MMT
Extension-Flexion F/F (0-1500) 5/5
Forearm supination F/F (0-800) 5/5
Forearm pronation F/F (0-800) 5/5
Special Test
Empty can (-/-)
Drop arm (-/-)
Neer Impingement (+/-)
Yergason (-/-)
Hawkins (+/+)
Apley scratch test
abd ext.rot paracervical
add int.rot paralumbal
Painful arc 120
Diagnosis :
Supraspinatus Impingement Syndrome Dextra/Sinistra
+ DM + HT + Post Prostatectomy ec Prostat
Carcinoma (2 years) + Overweight
Functional diagnosis :
Impairment : Shoulder Impingement syndrome
D/S
Disability : Difficulty to take off a t-shirt by
himself
Handicapped :-
Problem list :
Surgical :-
Medical : Supraspinatus Impingement
Syndrome Dextra/Sinistra + DM +
HT + Post Prostatectomy ec Prostat
Carcinoma (2 years) + Overweight
Rehabilitation Medicine:
R1 (Ambulation) :-
R2 (ADL) : difficulty in take off a shirt by
himself
R3 (Communication): -
R4 (Sociological) :-
R5 (Psychological) :-
R6 (Vocational) :-
R7 (Others) : - Pain on both shoulder (VAS 5)
- Upper Trapezius Muscle Spasm,
- DM, HT, Overweight
Planning :
1. Surgical : -
2. Medical : continue the medication from Internal Medicine and Cardiology
Outpatient Clinic
3. Rehabilitation Medicine :
P. Dx : consult to Nutrition Outpatient Clinic
P.Tx :
Modality : - High TENS 100Hz on Shoulder Region D/S duration : 30
minutes
- Icing
Therapeutic Exercise :
Static Cycle with moderate intensity according to Target
Heart Rate 130,9
P.Mx : Clinical sign, VAS, ROM
P.Ed : Health Education & Home Exercise Program
- Icing at shoulder D/S
- Gentle active ROM exercise at shoulder D/S
Towel Exercise
Summary
Reported a 69 y.o male, referred from Cardiology outpatient
clinic with Frozen Shoulder + DM + HT
Chief complaint was pain at both shoulders
Pain at both shoulders, localized, appears when he moved his
shoulder in rotated position especially when he want to take off
his t-shirt.
Physical examination reveals empty can, neer impingement, and
hawkins were (+)
Diagnosis is Supraspinatous Impingement Syndrome D/S + DM
+ HT + Post Prostatectomy ec Ca Prostat (2 years) + Overweight
Therapy consist of modalities (High TENS), icing and ROM exc.
Health education/ home exercise programs are explaining about
her disease, Icing at both shoulder, Active ROM exercise, and
routinely control to DM and cardiology outpatient clinic
THANK YOU
PEMERIKSAAN LUAS GERAK SENDI
Luas Gerak Sendi (LGS) atau Range of Motion (ROM) :
luasnya pergerakan yang dapat terjadi pada suatu sendi
3
SHOULDER
Donny
ANATOMI
1. Sendi Glenohumeralis
2. Sendi Suprahumeralis
3. Sendi Akromio- klavikularis
4. Sendi Skapulokostalis
5. Sendi Sterno- klavikularis
6. Sendi Kostosternalis
7. Sendi Kostovertebralis
AROM
Posisi pasien berdiri
ABDUCTION - ADDUCTION
ABDUCTION ADDUCTION
ENDOROTATION - EXOROTATION
SCAPULAR ELEVATION
SCAPULAR RETRACTION
SCAPULAR PROTRACTION
YERGASON TEST
APPREHENSION TEST
Towel Exercise
Wall Climbing Exercise