CASE REPORT OF STROKE PTS

Mrs. A, 67 years old, right handed, lived in Muara Rajeun Baru,Bandung,

I.

ANAMNESA

(Autoanamnesa and alloanamnesa from her daughter)

Chief complain on Dec 15, 2009 :
Weakness of left extremities
History of present illness:
About 18 months ago, suddenly she felt weakness of left extremities when she was
cooking. Her left extremities was difficult to be moved and felt heavy , with deviation of the
mouth and her speech being slurred. She felt numbness and tingling at left extremities.
Sometimes,she choked when drinking. She felt headache but she didnt have
convulsion,double vision,black out,vertigo,tinnitus and vomitus. She was still conscious
when got stroke attack. And then she was brought to RSHS and hospitalized in 19 A Room
for 4 days. The doctor said that she had stroke. Her BP was 170/80 mmHg.
After discharged from hospital, she could walk dependently. She could eat by herself
but for bathing,dressing,defecation and urination,she needed help from her daughter. There
was still a slight asymmetrical of her left face and a slight slurred speech. She was reffered to
PM&R Departement and got AAROM exercise,Strengthening exercise and Balance exercise.
But she didnt control to PM&R Departement for 10 months because there was nobody to
accompany her to hospital.
On Dec 15, 2009, she still complained about her left extremities. She felt heavy when
walking and sometimes, tingling was felt at her left extremities. Now, when she was
walking,she used walking aid. Although she seldom went to hospital to control,she went to
Cikutra PHC once a month and got Amlodipin tab 1x1,vitamin Bplex 3x1,vitamin C 3x1.
She could speak clearly but sometimes slurred. For her all activities of daily living,she can do
them by herself except dressing and bathing. She still needs help for dressing and bathing.

History of past illness:

History of hypertension : she was diagnosed with hypertension since 3 years ago
(2007). She controls and takes medicine regularly (Amlodipin 5 mg 1x1).

History of hypercholesterolemia : she was diagnosed with hypercholesterolemia since

3 years ago but she didnt control regularly .

History of diabetes mellitus was denied.
History of heart disease was denied.
History of prior stroke or TIA was denied.
Family history of the same disease was denied.

Before the illness :

Communication
Mobilization
Self care

: she can speak fluently.

: independent.
: independent.

Habituation:

Habit of eating salty food is denied.

Habit of eating fatty food is denied.
Habit of smoking is denied.
Habit of drinking alcohol is denied.
Habit of eating or drinking sweet beverages are denied.

History of Education:
She was graduated from elementary school.
History of Occupational:
She was a part time housekeeper before she got ill with a Rp. 10.000 / day wage but now,she
doesnt work anymore.
History of Psychosocial:
She has a daughter and one grand child. She lives with them. She lives in a house
about 24 m2 without any yard with two floors. There is no living room,but only a small room
with a bed on the floor, its very messy. There is well and a bathroom beside this room. Her
daughter and her grandchild usually use a room at the second floor. Her house has bad
lighting and ventilation.
Before the illness,she worked as a part time house keeper and sometimes,helped her
neighbour if they needed some help from her. Now,she just stays at home alone.

After discharged from the hospital, she is helped by her daughter to do home program
given from PM&R department.
She fulfills her daily living cost from the money given by her daughter. For medical
cost, she uses jamkesmas. For transportation cost to the RSHS, she needs Rp 10000 until Rp
50.000,- .
. He has a good relationship with his family and neighbour.

II. PHYSICAL EXAMINATION

Examination at PM&R Department on Dec 15,2009
Consciouness

: compos mentis,adequate contact

Communication

: Receptive language : good

Expressive language : slight dysarthria

Ambulation

: using walking aid

Nutrition

: weight 43 kg,height 143 cm. BMI : 21.03

Body Position and Mobilization :

Lying

: alignment good

Side lying

: independent

Lying to sitting

: independent

Sitting to lying

: independent

Gait

: Hemiparetic gait

Vital Sign on Dec 15,2009 :

BP : 140/100 mmHg, HR : 80x/min, RR : 20x/min,Temp. : 36,80 C
MMSE

: 22 (see appendix)

Barthel Index

: 15 (see appendix)

Internal State :
Head

: deformity (-),conjunctiva: anemic (-/-), sclera : icteric (-/-)

Neck

: JVP isnt elevated,lymph node isnt palpable

Thorac

: symmetric shape and movement

Cor : left margin of heart LMCS,heart sound I-II normal,murmur(-),gallop(-)
Lung : sonor, ronchi (-/-),wheezing (-/-)
Chest expansion : 1 cm/1cm/1 cm

Abdomen

: flat,hepar and lien arent palpable,normal bowel sound.

Extremities

: edema (-/-),cyanosis (-/-)

Neurologic State :
Meningeal irritation sign : nuchal rigidity (-),laseque test (-),kernig sign (-),brudzinsky I-II (-)
Nervi Cranialis :
N. I

: normal

N.II

: visus : normal
visual field : normal

N.III

: ptosis (-/-)
pupil : round,isochor,diameter 3 mm
direct and indirect light reflex +/+
eye movement : good to all direction except inferior oblique and lateral movement.

N.IV : eye movement : good to inferior oblique movement

N.V

: sensibility of face : normal

Right and left masseter and temporalis muscle strength : good
Jaw reflex (+)

N.VI : eye movement : good to lateral direction

N.VII : slight asymmetrical of the face (+)
Raising eyebrow : symmetric
Left nasolabialis plica is more flat
Closing the eyes (+) symmetric,fully closed
Protruded lip : left side is delayed
When smiling deviated to the left slightly
Sensory of 2/3 anterior tounge is good
N.VIII : normal/normal
N.IX-X: right and left palatum movement : symmetric, uvula is in the middle
Sensory of 1/3 posterior tongue is good
N.XI : m. Sternocleidomastoideus : 5/5
M. Trapezius

: 5/4

N.XII : tongue fasciculation (-),tremor(-),atrophy (-)

Tongue deviated to the left slightly when protruded

Musculosceletal State :
a/r Head Neck
Look

: deformity (-),inflammation sign(-)

Feel

: spasm(-),pain on pressure (-),inflammation sign (-)

Move

:
ROM : Full
MMT : 5

a/r Upper Extremity :

Look

: deformity : shoulder asymmetrical, Flexor Synergic Pattern (-/+),

inflammation sign (-/-),muscle hipotrofi (-/+)

Feel

: subluxation shoulder joint (-/+ ) with indentation =1 cm, pain on pressure

(-/-),spasm(-/-), arm circumference (24 cm/22 cm)

Move

:
ROM : Full(active)/Full(passive)
Tonus : spasticity

: -/+2 AS

MMT : 5-5-5-5/2-3-2-2
Sensibility : Light touch N/N
Pin Prick : N/N
Proprioseptive : N/impaired
Physiologic Reflexes : Biceps ++/+++
Brachioradialis ++/+++
Triceps ++/+++
Patologic Reflexes : -/+ (Hoffmann Tromner)
Coordination : Finger to Nose : N/Cant be evaluated
Hand Prehension :
Pinch

Good /Poor

Palmar

Good/Poor

Lateral

Good/Poor

Cylindris

Good/Poor

Hook

Good/Poor

Grasp

Good/Poor

a/r Lower Extremity

Look

: Extensor Synergic Pattern (-/-),drop foot (-/+),muscle hipotrofi (-/+)

Feel

: pain on pressure (-/-),spasm (-/-),Thigh circumference (42 cm/40 cm), Leg

Length : True (74 cm/74 cm);Apparent (76 cm/76 cm)

Move

:
ROM

: Full (active)/Full(active & passive)

MMT

: 5-5-5-5/4-4-2-2

Sensibility

: Light Touch

N/N

Pin Prick

N/N

Proprioseptive

N/impaired

Physiologic Reflexes : KPR ++/+++

APR ++/+++
Patologic Reflexes

: -/+ (Babinski)

Clonus

: ankle (-/+)

Coordination

: Heel to Knee N/Fair

Balance Test
Static : Sitting Balance : Good
Standing Balance : Poor
Romberg Test : Good
Dynamic : Tandem Walking Test : Poor
Vegetative : Bladder & Bowel incontinence (-)

III.SUPPORT EXAMINATION
Hematologic (June 3,2008)
Kholesterol Total : 257 mg/dl
Kholesterol HDL : 39 mg/dl
Kholesterol LDL : 196 mg/dl
Trigliserida

: 108 mg/dl

Asam Urat

: 7,0 mg/dl

X-Rays Thorax (Jun 3,2008)

Kardiomegali tanpa bendungan paru, Atherosklerosis Aorta
Tidak tampak TB Paru Aktif
EKG (Jun 2,2008)
Irama sinus normal
IV. DIAGNOSIS
Clinical Diagnosis

: Completed Stroke

Location Diagnosis

: Right Carotis System

Etiological Diagnosis : Brain Infarction, risk factors hypertension,hyperlipidemia and age

Diagnosis based on Konsensus Nasional Rehabilitasi Stroke Perdosri 2004 :
Post Stroke Non Hemorragic ec emboli with Total Anterior Circulation Syndrom with Partial
Dependent.
Impairment : Musculosceletal (Left Hemiparesis,drop foot)
Sensory (Poor Proprioseptive of left extremities)
Balance (Poor standing balance)

Disability
Handicap

: Locomotor,ADL
: Mobilization,Economic,Vocational

PROGNOSIS
Quo ad vitam

: dubia ad bonam

Quo ad sanationam

: dubia

Quo ad functionam

: dubia

CASE REPORT OF FRACTURE CASE

Mr. ES, 47 years old, lives in Antapani Bandung, referred from Orthopaedic
Department on 12 May 2010 with diagnose : Post ORIF small NP a.i. Open
Fracture

midshaft

radius dextra comminutive displace; Post Paralel Wire a.i

Close Fracture Proc. Styloid Ulna dextra and anterior slab a.i. Open Fracture
midshaft metatarsal IV transverse displace.
I.

ANAMNESIS
Anamnesis was taken from auto anamnesis from patient and medical
record.

Chief Complaint (on 12 May 2010)

Couldnt hold anything with his right hand normally grasp
History of Present Illness :
Since 2 weeks ago, the patient complained that he could not hold anything
with his right hand normally grasp. He also complained about stiffness at his
right hand and pain when it was moved (VAS=4). There were also numbness
and tingling at the right dorsal thumb. Other complains were pain on his right
foot when walking (VAS=3) and his forearm and hand became swollen. For
Activity of Daily Living he could performe all the items in Barthel Index using
his left hand independently. Because of intermittent pain, he didnt do his job,
just takes a rest and sometimes, he does exercise of his right upper limb.
3 weeks ago (on 18 April 2010), the patient got traffic accident when he was
riding the motorcycle on Sindanglaya. He fell down to the right side with his
hand hold back his body. He was still conscious at that time.

After that

happened,he felt pain at his right forearm and foot. There were open wound
with bone exposure about 8x4x2 cm at his right forearm and 3x1x1 cm his
right foot. Also, there were bone protruded(+) and swelling (+) in his right
forearm and foot, so that he couldnt bend his elbow. Beside that, there were
multiple laceration at his right forearm and foot. After the accident, he was
taken to Santo Yusuf hospital and he got pain killer injection and anti tetanus
injection then he was referred to RSHS because his family wanted to use
health insurance (Gakinda).
At RSHS, the patient got debridement on wound site (his forearm and his foot)
and immobilization with boot slab on his foot and anterior slab on his forearm.
After 1 weeks hospitalized, he got surgery to fix with ORIF (Open Reduction
Internal Fixation) at his right forearm and got slab at his right foot . He was
hospitalized for 14 days. At hospital, he got pain killer drugs and Antibiotic.

One week later, he was controlled at Orthopaedics departement and referred

to PM&R departement.
History of Past Illness :
He had normal mobilization and activities previously.
There was no history of previous surgery or trauma
There was no history of diabetes, hypertension, cardiac and pulmonary
disease.
Psychosocial History :
He is married. He lives in his parents in law-house with his wife, 3 children
and parents in law. His children are 16 y.o girl and then 10 y.o boy and the
youngest 1 y.o. girl. The size of the house is about 60 m 2, with second floor, 2
bedroom, 1 living room, 1 kitchen and 1 bathroom with squatting toilet. He
usually sleeps with matras at the floor at living room.
Vocational and Avocational History :
He was graduated from elementary school. He was a construction worker. He
used

health

insurance

(Gakinda)

for

his

surgery,hospitalization

and

medication.He got the fee about Rp. 40.000/day for 8 am-4 pm when there
was a job for him. Unfortunally, he didnt have other skill. Because he dont
have job now, he feel ashamed with his condition. It makes his self confident
decrease. His wife is laundry worker and her fee is about Rp 10.000/day but
she do her job when there is someone need her.
II.

PHYSICAL EXAMINATION : (on 17 May 2010)

General appearance : compos mentis, adequate contact
Communication
: Good (reseptive and expressive)
Transfers
: Side lying : independent
Lying to sitting : independent
Sitting to standing : independent
Mobilization
: walking independently
Balance
: sitting balance : good
Nutritional Status
: BW : 49 kg, BH : 159 cm, BMI : 19,4
Barthel Index
: 20
MMSE
: 30
General examination
Vital Sign
BP : 120/80 mmHg
HR: 80 x/min

RR: 18 x/min

Internal Status :
Head
: deformity(-), hematoma (-), edema (-), tenderness (-)
Eyes
: conjunctiva: Anemic (-/-); Sclera: icteric (-/-), pupil equal in
diameter 3 mm
Ear
: discharge (-/-), tenderness (-/-)
Chest
: Symmetrical on static and dynamic, no trauma lesion
Heart sound : normal, murmur (-), gallop (-)
Lung
: VBS, wheezing (-/-), Ronchi (-/-)
Abdomen
: flexible in palpation, liver and spleen not palpable,
masses (-), tenderness (-), bowel sound (+)normal.
Neurological Examination
Cranial nerves I-XII
: within normal limit
Sensibility
: decreased sensibility (20%) a/r dorsum right
thumb
Proprioception : Good/Good
Coordination
: within normal limit
Physiologic Reflexes : ++/++
Pathologic Reflexes
: -/Vegetative
: normal bladder and bowel habit.
Musculosceletal Examination
a/r HEAD-NECK
Look
Feel
Mov
e

: Deformity (-); inflammation sign (-)

: Inflammation sign (-); tenderness (-); spasm (-)
: ROM full at all direction
MMT 5 at all direction

a/r UPPER EXTREMITIES

Shoulder
Look
Feel
Move

Deformity (-); inflammation sign (-)

Inflammation sign (-); tenderness (-)
ROM
Shoulder flexion-extension
Full/Full
Shoulder adduction-abduction
Full/Full
Shoulder
ext.rotation- Full/Full

MMT
5/5
5/5
5/5

int.rotation
Elbow
Left Elbow : within normal limit
Right Elbow
Look

Deformity (-); edema (+) at forearm; scar (+) at

lateral side of forearm 2x8x4 cm; surgical scar (+)
at medial side of forearm 12 cm; pus (-)

Feel

Pitting edema (+) at forearm ; tenderness at surgical

side (+); adhesion (-), muscle hipotrofi (-), forearm

Move

circumference (22 cm/20 cm)

ROM
Flexion
Extension
Supination
Pronation

MMT (by imp.)

5o130o
130o5o
0o10o
0o15o

4
3
3
3

End of the ROM : firm end-feel

Pain on movement (end of the ROM) : +
Wrist and Hand
Left Wrist and Hand: within normal limit
Right Wrist and Hand
Look

Deformity (-); edema (+) at wrist and hand; surgical

scar at anterior and posterior 5th digiti 3x2 cm and

Feel
Move

lateral palmar hand-2,5 cm distal wrist 2x0,5 cm

Pitting edema at wrist and hand (+); tenderness at
surgical scar (+),muscle hypotrophi (-)
ROM
MMT (by imp.)
Wrist Flexion
0o30o
4
Wrist Extension
0o5o
4
o
o
Ulnar Deviation
0 20
4
Radial Deviation
0o10o
4
Thumb

MCP

flexion-

extension
2st finger MCP flexionextension
3st finger MCP flexionextension
4st finger MCP flexionextension
5st finger MCP flexionextension
Thumb IP flexion
2st finger PIP flexion
3st finger PIP flexion
4st finger PIP flexion

0o45o/0o

10o
o

4
o

0 40 /0 5

0o35o/0o5o
0o25o/0o5o
o

0 15 /0
0o35o
0o50o
10o55o
15o45o
0o45o
0o55o

4
4
4

4
3
3
3
3
3

5st finger PIP flexion

2st
3st
4st
5st

finger
finger
finger
finger

DIP
DIP
DIP
DIP

flexion
flexion
flexion
flexion

Abduction thumb
Adduction thumb
Abduction fingers
Adduction fingers
Opponens thumb
Opponens 5st finger

0o40o
0o45o
0o

3
3
3

0o50o
50o0o
0o10o
10o0o
Not full
Not full

3
3
3
3
3
3

End of the ROM : firm end-feel

Pain on movement (end of the ROM) : +
Hand Prehension :
Pinch
: Fair/Good
Palmar
: Fair/Good
Lateral
: Fair/Good
Cylindris
: Fair/Good
Hook
: Fair/Good
Grasp
: Fair/Good

a/r LOWER EXTREMITIES

Hip and Thigh:
Right and Left Hip and Thigh : within normal limit
Look
Feel
Move

: Deformity (-); inflammation sign (-); atrophy (-)

: Inflammation (-); tenderness (-); adhesion (-)
:
ROM
MMT
Hip flexion
Full/Full
5/5
Hip extension
Full/Full
5/5
Hip abduction
Full/Full
5/5
Hip adduction
Full/Full
5/5
Hip external rotation
Full/Full
5/5
Hip internal rotation
Full/Full
5/5

Knee
Right and left knee : within normal limit
Look
Feel
Move

: Deformity (-); inflammation sign (-); atrophy (-)

: Inflammation (-); tenderness (-); adhesion (-)
:
ROM
MMT
Knee flexion
Full/Full
5/5
Knee extension
Full/Full
5/5

Ankle and Foot

Left ankle and foot : within normal limit

Right ankle and foot :
Look

Edema at dorsum pedis; atrophy (-); surgical scar (+)

at dorsum pedis below 4th finger 3 cm; boot slab

Feel

(+)
Pitting edema (+) at dorsum pedis; tenderness (+)at
operation scar; adhesion (-), foot circumference (24
cm/22 cm)

Move
Ankle plantar flexion
Ankle dorsi flexion
Forefoot eversion
Forefoot inversion
III.

SUPPORT EXAMINATION
X-Rays on 18th April 2010

X-Rays on 18th April 2010

X-Rays on 29th April 2010

ROM
Full
Full
Full
Full

MMT
5
5
5
5

Surgery Report 29th April 2010 :

Indication of operation
: early mobilization
Durante Operation
:
Found fracture of the right middle third radius oblique displace
Found disruption DRUJ antebrachii dextra
( Fixation with small NP 8 hole and 6 cortical screw; done parallel
wire at DRUJ)
IV.

ASSESSMENT
Clinical Diagnosis
Joint stiffness on the right elbow,wrist and hand
Post ORIF due to Open fracture of the right middle third radius
oblique displaced
Post ORIF due to Close fracture of the right proc. Styloideus ulna
Boot Slab due to Open fracture of the right middle third metatarsal
IV transverse displaced
Location diagnosis
Right elbow joint
Right wrist & hand joint
Right dorsal pedis
Etiologic diagnosis
Open fracture of the right middle third radius oblique displaced
Close fracture of the right proc. Styloideus ulna
Open fracture of the right middle third metatarsal IV transverse
displaced

Functional diagnosis
Impairment

Skeletal

(fracture,joint

weakness), decrease sensibility.

Disability

: ADL, vocational

Handicap

: Vocational, Psychosocial

stiffness,muscle

V.

PROGNOSIS
Quo at vitam
: ad bonam
Quo at sanationam
: ad bonam
Quo at functionam : ad bonam