CASE SCENARIO 1st CASE REPORT

1. Selamat pagi, pak. Silahkan masuk ke dalam

2. Silahkan duduk,pak
3. Patient comes walking independenty using unilateral crutches
4. Perkenalkan ini ada dokter Marina, SpKFR dan dokter Farida, SpKFR
5. Informed consent : Pak, pagi ini saya akan memeriksa bapak kembali yah. Bapak bersedia?
6. Before I do the examination, I wash my hand with alcohol rub with six step
7. The patient is compos mentis.
8. The receptive and expressive communication is good.
9. Now, i will check patient vital sign. cek tensi, pasang oxymetri. Sambil skrining singkat MMSE : tadi
pagi berangkat jam berapa? Sama siapa? Naik apa? Udah sarapan? Sarapan apa? The blood pressure
is 120/80 milimeter mercury, heart rate is 85 beat per minute, respiratory rate is 16 times per minute,
saturation is 98 percent.
10. Now, i will check head and neck region. There is no deformities, no inflammation sign.
There is no conjungtiva anemic, no sclera icteric, no lymph node enlargement
Cek pergerakan bola mata..lapangan pandang kasar...visus...
Pak coba ikuti gerakan tangan saya..pak coba tutup mata dan lihat gerakan jari saya...
Pak coba baca tulisan disana. Coba baca tulisan koran ini. Coba dengan menggunakan kacamata
Eye movement normal to all direction, visual field normal, visul normal with correction glasses +3
Pak nanti coba dengarkan suara dari belakang bapak y. Apakah kanan atau kiri ?
There is no impairment of hearing
11. Pak, coba ikuti gerakan leher saya. ROM of the neck is full.
12. Sekarang kita tahan tahanan pak. MMT of the neck is 5.
13. Now, i will check upper extremities. There is no deformities. No inflammation sign. There is no pain
14. I check ROM for upper extremities. Ikuti gerakan saya y pak. ROM is full except flexion, abdukction
and external rotation of right shoulder. I will confirm it with goniometer in supine position latter
according to physical examination of norkin.
15. I check MMT upper extremities. Kita kuat-kuatan y pak. All MMT is 5, except flexion, abduction,
external rotation of right shoulder due to limited ROM is 5 by impression with pain.
16. Due to resistence pain and limited motion on the right shoulder. I check several special test.
- For impingement...Neer Test & Hawkin kennedy.. positive..
- For rotator cuff muscle. ..Empty can test for supraspinatus tendinitis. positive..
- Drop arm test for supraspinatus tear..negative..
- Patte test for infraspinatus tear, negative
- Lift of test for subscapularis tear. Negative
Due to traumatic hystory of right shoulder. I check :
- Appley strecth test for AC dislocation. Negative
- Apprehension test for GH dislocation. Negative
17. I check the sensibility. Pak, saya akan menyentuhkan kapas lagi ke kedua tangan ibu, nanti bilang kalo
sama atau tidak rasanya antara kanan dan kiri.--> sensibility is normal at both side.
18. I will check physiology & pathological reflex  there is normal physiologi reflecx both side and no
pathological reflex
19. I check for coordination. Pak, sekarang tunjuk hidung bapak, kemudian ujung jari telunjuk saya yah. 
the coordination is good at both side.
20. I Check propioception. Pak, sekarang maen tebak”an yah. klo ini ke atas, ini ke bawah sekarang tutup
mata. The propioception is good both side.
21. Pak, sekarang berdiri y dan bajunya dibuka y pak. We can see patient can mobilize from sitting to
standing independently and patient can open the clothes independtly but has some difficulties
22. Now, i will check trunk. Alignment straight...no khyposis..wall occiput distance 5 cm.
23. I check standing balance...mendorong badan pasien...pak coba ambil pena ini...static and dynamic
balance is good
24. Sekarang bapak berbaring yah...
25. I will check the internal status, the JPV of the patient 5 ± 0 cmH20..there is simmetryc movement
thorax..normal vesiculer sound and normal heart sound.
26. Now, i will confirm the limited ROM for upper extremity.  cek ROM bahu pake goniometer : flexi,
abduksi dan eksternal rotasi. Flexion ROM is 0-100 (pain), abduction 0-90 (pain) and external rotation
0-40 (pain)
27. Now i will check the lower extremity. There is deformities and swelling at left lower leg. The left lwer
leg more warmth than right side. Pain positive.
28. I check for circumferentia on thigh and calf, 3 inc above and below MTP. The thigh same both side.
The right calf 36 cm..the left calf 36,5 cm...
29. I check the LLD of the patient. True LLD from SIAS to medialis malleolus..there is discrepancy 1 cm
30. Apparent LLD form umbilicus to medial malleolus. Same both side..
31. I will confirm the true LLD wth Galaezzi sign..from anterior and lateral..same right and left
32. I check the ROM lower extremity...Pak sekarang gerakan kakinya ke atas, tekuk lututnya, luruskan,
gerakan pergelangan kaki ke atas dan bawah, tekuk jari” kakinya. The ROM for both side full
33. I check MMT. Kita kuat-kuatan lagi y pak. The MMT for hip flexion is 5 both of side. I check the hip
extention in prone postion later...abbduction and adduction on sidelying position later...MMT knee
ekstension 5 both side but on the left knee whit resictancy on the third proximal cruris..i wil check the
knee flexion on the prone position later..ankle dorsi and plantar lexion is 5...toe flexion and extension
is 5...finger flexion and extention is 5..
34. I check the sensibility. Pak, saya akan menyentuhkan kapas lagi pada kaki y, dirasakan lagi yah sama
atau tidaknya antara kanan dan kiri. Tutup mata bapak...sama tidak kanan kiri... The sensibility for is
normal
35. Due to immobilization after operation of fracture. I check the thomast test for flexion contracture and
popliteal angle for hamstring thighness. There is no thignesss
36. Physiological reflex is normal both side. Pathological reflex is negative both side
37. I check the propioception. Sekarang kita main tebak-tebakan lagi y pak seperti ditangan tadi. Klo ini ke
atas, ini ke bawah. Sekarang tutup mata bapak yah... ini ke atas ato ke bawah? The propioception is
good both side.
38. Sekarang bapak lakukan gerakan angkat tumitnya, letakkan di atas lutut sebelahnya dan susurin tulang
keringnya sampai bawah yah. The coordination is good both side.
39. Sekarang bapak coba tidur ke arah samping y..
40. I will check MMT of abduction and addcution. MMT is 5 both side
41. I check the ober test for contracture abductor muscle. There is no thignesss
42. Sekarang bapak tengkurap yah...
43. I will check for MMT hip extension and knee flexion. MMT 5 both side
44. I check Elly Test for quadriceps thihgness. There is no thignesss
45. Pemeriksaan sudah selesai pak. Sekarang boleh duduk kembali pak dan pakai bajunya.