BLANKO STUDI KASUS

KOMPETENSI : MUSKULOSKELETAL

NAMA MAHASISWA : SUKRI INDRA

N.I.M. : P272262022041

TEMPAT PRAKTIK : RSUD DR SOESILO SLAWI

PEMBIMBING : EKO PRIHATI, S.Fis FTR

Tanggal Pembuatan SK : 26 Oktober 2022

I. IDENTITAS PENDERITA
Nama : Ny. Gandes

Umur : 36 Tahun

Jenis Kelamin : Perempuan

Agama : Islam

Pekerjaan : Guru Olah Raga

Alamat : Tegal

No. CM : 0308
 II. SEGI FISIOTERAPI

1. Deskripsi Pasien dan Keluhan Utama

Seorang pasien bernama Ny. Gandes, umur 36 tahun datang ke poli fisioterapi
mengeluh nyeri pada siku kanan sejak 3 minggu yang lalu. Nyeri awalnya terasa ringan
dan makin lama terasa makin berat. Keluhan nyeri bertambah berat saat menggerakkan
sikunya seperti saat membuka handle pintu, mengangkat gayung ketika mandi dan saat
aktivitas masak. pasien mengatakan keluhan muncul setelah pasien tanding badminton
dan melakukan smash terlalu keras.

Sebelum ke fisioterapi pasien sudah 2 kali pijat dan minum obat nyeri namun
keluhan tidak kunjung hilang. Pasien mengatakan sudah beberapa kali mengalami
keluhan serupa setelah melakukan olahraga namun bisa sembuh dengan sendirinya.
Pasien tidak menderita penyakit lain seperti patah tulang lengan dan keluhan pasien
bukan termasuk keluhan yang di sebabkan oleh faktor keturunan.

2. Data Medis Pasien

Diagnosa medis: Tenis elbow dextra

Medika mentosa
 III. PEMERIKSAAN FISIOTERAPI

1. Pemeriksaan Tanda Vital ( Umum)

(Tekanan darah, denyut nadi, pernapasan, temperatur, tinggi badan, berat badan)
Tekanan darah: 120/90mmHg

Denyut nadi : 80x/menit

Pernapasan : 18x/ menit

Temperatur : 360 C

Tinggi badan : 160cm

Berat badan : 65kg

2. Inspeksi / Observasi
a. Inspeksi statik
- Tidak terlihat adanya bengkak
b. Inspeksi dinamis
- Pasien terlihat menahan nyeri saat menggerakkan siku kanannya.
3. Palpasi
- Terdapat nyeri tekan pada elbow kanan bagian lateral
- Adanya spasme pada otot pronator
- Tidak da perbedaan suhu lokal di banding anggota tubuh lain
4. Joint Test
Pemeriksaan Gerak Dasar (Gerak aktif/pasif/isometrik fisiologis)

Gerak aktif Mampu melakukan gerakan secara full ROM pada gerakan flexi,
ekstensi, pronasi dan supinasi tetapi ada nyeri.
Gerak pasif Mampu digerakkan secara full ROM pada gerakan flexi, ekstensi,
pronasi dan supinasi tetapi ada nyeri dengan soft endfeel
Isometrik Mampu mampu melawan tahanan maksimal, full ROM pada gerakan
flexi, ekstensi, pronasi dan supinasi tetapi ada nyeri.

5. Muscle Test dan Antopometri

a. Muscle test : kekuatan otot dalam batas normal, mampu melawan tahanan
maksimal
b. Antopometri test : tidak dilakukan karena tidak terlihat adanya bengkak
c. Pemeriksaan spesifik
Test profokasi nyeri terdiri dari:
- Ekstensi wrist ditahan : positif nyeri
- Pronasi elbow di tahan : positif nyeri
6. Kemampuan Fungsional
Menggunakan Wrist Hand Disability Indeks (WHDI)

No Kriteria Nilai
1 Intensitas nyeri
2 rasa tebal-tebal dan kesemutan
3 Perawatan diri
4 Kekuatan
5 toleransi menulis atau mengetik
6 Bekerja
7 Menyetir
8 Tidur
9 pekerjaan rumah
10 rekreasi / olah raga
 B. ALGORITMA

(CLINICAL REASONING)

Mekanik

Trauma

Inflamasi kronik

Nyeri gerak adhesive Spasme otot pronator

Muscle energy tehnique Ultrasound

Spasme dan perlengketan

Nyeri berkurang
berkurang

Peningkatan aktivitas
fungsonal
 C. KODE DAN KETERANGAN PEMERIKSAAN ICF

1. Body Functions
Examination Pemeriksaan nyeri menggunakan VAS
ICF Classification selected b2801- pain in body part
ICF Category – definition Sensation of unpleasant feeling indication potential or
actual damage to some body structure felt in a specific, or
part of the body
ICF category qualifier – b2801.0 – pain in body part, no problem
prior function
ICF category qualifier – b2801.3– pain in body part, moderate problem
current function
ICF category qualifier – b2801.0 – pain in body part, no problem
goal function
PT goal Nyeri berkurang

2. Activities and Participation

a. Perawatan diri
Examination Menggunakan WHDI
ICF Classification selected d6600 Assisting others with self-care
ICF Category – definition Assisting household members and others in performing
self-care, including helping others with eating, bathing and
dressing; taking care of children or members of the
household who are sick or have difficulties with basic self-
care; helping others with their toileting.
ICF category qualifier – d6600.0 Assisting others with self-care, no problem
prior function
ICF category qualifier – d6600.2 Assisting others with self-care, moderete problem
current function
ICF category qualifier – d6600.0 Assisting others with self-care, no problem
goal function
PT goal Mampu melakukan aktivitas perawatan diri tanpa keluhan
 b. Menulis
Examination Menggunakan WHDI
ICF Classification selected d170 Writing
ICF Category – definition Using or producing symbols or language to convey
information, such as producing a written record of events or
ideas or drafting a letter.
ICF category qualifier – d170.0 Writing, no problem
prior function
ICF category qualifier – d170.2 Writing, moderete problem problem
current function
ICF category qualifier – d170.0 Writing, no problem
goal function
PT goal Mampu menulis dalam jangka waktu tertentu tanpa keluhan

c. Bekerja
Examination Menggunakan WHDI
ICF Classification selected d650 Caring for household objects
ICF Category – definition Maintaining and repairing household and other personal
objects, including house and contents, clothes, play and
recreational materials, vehicles and assistive devices, and
caring for plants and animals, such as painting or
wallpapering rooms, fixing furniture, repairing plumbing,
ensuring the proper working order of vehicles, watering
plants, grooming and feeding pets and domestic animals.
ICF category qualifier – d650.0 Caring for household objects, no problem
prior function
ICF category qualifier – d650.2 Caring for household objects, moderete problem
current function problem
ICF category qualifier – d650.0 Caring for household objects, no problem
goal function
PT goal Mampu bekerja tanpa keluhan
 d. Menyetir motor
Examination Menggunakan WHDI
ICF Classification selected d475 Driving
ICF Category – definition Being in control of and moving a vehicle or the animal that
draws it, travelling under one's own direction or having at
one's disposal any form of transportation appropriate for
age, such as a car, bicycle, boat or animal powered vehicles.
ICF category qualifier – d475.0 Driving, no problem
prior function
ICF category qualifier – d475.2 Driving, moderete problem problem
current function
ICF category qualifier – d475.0 Driving, no problem
goal function
PT goal Mampu menyetir dalam waktu tertentu tanpa keluhan

e. Pekerjaan rumah
Examination Menggunakan WHDI
ICF Classification selected d6401 Cleaning cooking area and utensils
ICF Category – definition Cleaning up after cooking, such as by washing dishes, pans,
pots and cooking utensils, and cleaning tables and floors
around cooking and eating area.
ICF category qualifier – d6401.0 Cleaning cooking area and utensils, no problem
prior function
ICF category qualifier – d6401.2 Cleaning cooking area and utensils, moderete
current function problem
ICF category qualifier – d6401.0 Cleaning cooking area and utensil, no problem
goal function
PT goal Mampu melakukan pekerjaan rumah tanpa keluhan
 f. Rekreasi/olahraga
Examination Menggunakan WHDI
ICF Classification selected d920 Recreation and leisure
ICF Category – definition Engaging in any form of play, recreational or leisure
activity, such as informal or organized play and sports,
programmes of physical fitness, relaxation, amusement or
diversion, going to art galleries, museums, cinemas or
theatres; engaging in crafts or hobbies, reading for
enjoyment, playing musical instruments; sightseeings,
tourism and travelling for pleasure.
ICF category qualifier – d920.0 Recreation and leisure, no problem
prior function
ICF category qualifier – d920.2 Recreation and leisure, moderete problem
current function
ICF category qualifier – d920.0 Recreation and leisure, no problem
goal function
PT goal Mampu melakukan aktifitas rekreasi dan olah raga tanpa
keluhan

3. Environmental Factors
e299 Natural environtment and human - made changes to
enviromental unspecific

4. Body Structures
s73001 Elbow joint
H. EVALUASI DAN TINDAK LANJUT
 I. HASIL TERAPI AKHIR

…………………,
…………………………

Mengetahui,

Pembimbing, Praktikan,

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NIP. NIM.
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