I. IDENTITY
Name
: Mr. Sulistyo Utomo
Age
: 30 years old
Sex
: Male
Address
: Sudipayung RT 04/RW 02
Ngampel-Kendal
Religion
: Moslem
Occupation : Private worker
Payment
: BPJS
II.ANAMNESIS
Chief complaint : neck and back stifness
History of present ilness:
- 8 years ago pain in low back improved by activity
& not relieved by rest. About 6 months later stiff on
his back, ascenden to his neck & shoulder
- 6 months ago red eye & blurred vision (+) Kendal
hospital, got medicine didnt improved went to
William Booth hospital referred to the Kariadi
hospital got an eye and laboratory examination and
referred to the rheumatology department got an x-ray
examination and medicine (sulfazalasine) referred to
the Medical Rehabilitation department get a pool
therapy once a week
II.ANAMNESIS
- Now stiffness become worse turning his body
to look at something or someone beside him,
palpitation (-), dyspneu (-), heel pain (-),
gastrointestinal disturbances (-), fatigue (-), weight
loss (-). ADL independently, wears a sock by putting
his leg on the chair, put something on the floor by
bend his knee. Transfer and ambulation
independent, bowel and bladder problem (-)
History of past illness : trauma (-)
History of family : Social economy profile: Patient is a private
worker (bicycle mechanical). He is single. Payment
by BPJS
Motoric
Neck :
I : kypothic (+), inflammation sign (-)
P : paravertebra muscle spasm (-/-),
sternocleidomastoideus muscle spasm (-/-),
trapezius muscle spasm (-/-); tenderness (-)
ROM : S: 300 0 350
F: 50 0 50
R: 300 0 350
MMT: Neck flexor: 5 , neck extensor: 5, lateroflexor:
5, rotator: 5
Provocation test : Lhermitte (-), Spurling (-),
Distraksi (-), Valsava (-), Naffziger (-)
Shoulder:
I : deformity (-), inflammation sign (-)
P : tenderness (-), crepitation (+/+)
ROM : S : 600 0 1050 600 0 1200
F: 1000 0 450 1100 0 450
R : Full
Full
MMT: shoulder flexor: 5; shoulder extensor: 5,
shoulder abductor: 5, shoulder adductor: 5,
shoulder ext rotator: 5, shoulder int rotator: 5
Provocation test: Yergason (-/-), Drop arm (-/-),
Neer (-/-), Appley scratch test (-/-)
Trunk :
I : kypothic (+), inflammation sign (-)
P : paravertebra muscle spasm (-/-), tenderness (-)
ROM : S: 50 0 700;
F: 100 0 100 ;
R: 300 0 300
MMT: lumbar flexion: 5; extension: 5
Provocation test: Schober test = 1,5 cm
Hip :
I:deformity (-), inflammation sign (-)
P: tenderness (-)
ROM:
Dekstra
Sinistra
S
50-0-1200
50-0-1200
F
Full
Full
R
Full
Full
Provocation test: Patrick (+/+), Kontra patrick (+/+),
Thomas test (+/+)
Knee:
I:deformity (-), inflammation sign (-)
P: tenderness (-), crepitation (-)
ROM:
Dekstra
Sinistra
S
00-0-1350
00-0-1350
Poplitea angle 50 / 50
V. DIAGNOSIS
CLINICAL
DIAGNOSIS
Ankylosing spondilitis
FUNCTIONAL
DIAGNOSIS
IMPAIRMENT:
ROM limitation of the neck,
shoulder and trunk
Decrease of chest expansion
Poor posture
DISABILITY: HANDICAP: -
VII. GOAL
Short
term
Maintain
ROM/flexibility
Maintain function of
cardiorespiration
Long
term
Prevent progressivity
Prevent the further
complication
VIII. PROGRAM
Education:
disease, exercise
Pool therapy
Breathing exercise
Increase chest expansion with macrame
IX. PROGNOSIS
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