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Short Case II

Jufri Febrianto, MD
Data Base Identity (March, 9th 2012)
 Name : Mr. M
 Sex : Male
 Age : 63 years old
 Address : Surabaya
 Occupational : Lecturer
 Religion : Moslem
 Ethnic : Javanese
 Marital status : Married

Referred from Orthopaedic Department Outpatient


Clinic with Impingement Shoulder
Chief complaint : Nyeri bahu kiri

History of present illness


 Pain at left shoulder since 3 months ago, it feels like dull
pain
 Patient did’nt realize when he felt this for the first time.
He started to aware when he was difficult to dress
because the pain was getting severe
 Pain felt especially when he moved his shoulder and
relieved by resting his arm.
 He felt difficulty to dress (wear and undress T-shirt)
 No numbness nor tingling sensation on the left arm
 He has a routinity to sweep twice every day, the duration
is arround thirty minutes each time
History of past illness
 History of Hypertension since 4 years ago,
control routinely at Internal Department
Outpatien Clinic
 There is no history of DM
 There is no history of trauma
 There is no dislipidemia
Physical Examination

GENERAL STATUS
CM, independent ambulation, gait normal, right handed
Body Weight : 68 Kg. Body Height : 165 cm
BP : 120/70 mmHg, HR : 84 x/minute , RR : 20 x/minute

Head & Neck : no anemia, icterus, cyanosis & dyspneu


Thorax : Cor : S1–S2 sound, murmur -, gallops -
Pulmo : vesiculer, wheezing -/-, ronchi -/-
Abdomen : Meteorismus -,
Hepar / Lien : unpalpable
Extremities : warm acral +/+ , edema -/-
Physiatric examination
Musculoskeletal examination
ROM MMT
Cervical F 5
Trunk F 5
Shoulder
Flexion F/F* (0 – 180o) 5/5- (pain)
Extension F/F* (0 – 80o) 5/5- (pain)
Abduction F/F* (0 – 180o) 5/5- (pain)
Adduction F/F (0 – 45o) 5/5
Ext. Rotation F/F (0 – 45o) 5/5- (pain)
Int. Rotation F/F* (0 – 55o) 5/5- (pain)

* Full ROM but pain on movement


Neurological examination
 N. Cranialis I –XII : normal
 DTRs : BPR +2/+2
TPR +2/+2
KPR +2/+2
APR +2/+2
 Pathological Reflexes: Babinski -/-, HT -/-
 Sensory deficit : No Sensory deficits
Local Status : R. Shoulder D/S
 I : Inflamation (-), swelling (-), redness (-),
Deformity (-), atrophy -/-
 P : Tender point -/- at shoulder , spasm -/-

Special Examination :
 Compression test : -/-
 Distraction test : -/-
 Drop arm test : -/-
 Yergason test : -/-
 Empty can test : -/+
 Hawkins test : -/+
 Neer`s impingement : -/+
 Gerber Test : -/+
 Napoleons Test : -/+
 Apprehension Test : -/+ (Pain)
 Relocation Test : -/+ (Pain Relieved)
 Appley’s scratch test :
 Add-Endorotation : Full/Full
 Abd-Exorotation : Left Shoulder/Occiput
 Add-Exo rotation : Left Scapula/Gluteal Fold
 Pain Arc : 100o-180o
 TOS I, II, III : -/-
Supporting Examination
Diagnosis :
Left Shoulder Impingement Syndrome + Left
Subscapularis Tendonitis + Left Shoulder Joint
Instability

Functional diagnosis :
 Impaired : Left Impingement Syndrome +
Left Subscapular Tendonitis +
Left Shoulder Joint Instability +
Pain at left shouder
 Disabled : Difficult to dressing
 Handicapped : -
Problem list :
 Surgical :-
 Medical : Left Shoulder Impingement
Syndrome + Left Subscapular
Tendonitis + Left Shoulder Joint
Instability
Rehabilitation Medicine :
 R1 (Ambulation) :-
 R2 (ADL) : difficulty in dressing
 R3 (Communication) : -
 R4 (Sociological) :-
 R5 (Psychological) : worried about his disease
 R6 (Vocational) :-
 R7 (Others) : Pain on Left shoulder (VAS 5)
Planning :
1. Surgical : -
2. Medical : Meloxicam 2x7,5 mg
3. Rehabilitation Medicine :
P. Dx : -
P.Tx :
Modality : USD 1 MHz at shoulder S (concern subscapularis muscle)
with dose 1 W/cm², duration 10 minutes, frequency 2x/week
Gym : - Strengthening Exercise rotator cuff left shoulder
- Left Shoulder Stretching Exercise especially to internal
rotation direction
P.Mx : Clinical sign, VAS
P.Ed : - Health Education & Home Exercise Program
- Gentle active ROM exercise at left shoulder
- Isotonic Srengthening Shoulder Muscle (with rubber)
- Stretching Shoulder with towel Exercise
- Warm Compress before exc & cold compress after exc
SUMMARY
Reported, male 63 yo, with chief complain Nyeri bahu kiri. Pain
at left shoulder since 3 months ago, the pain feels like dull pain.
Patient did’nt realize when he felt this for the first time. He started to
aware when he difficult to dress because the pain getting severe.
Pain felt especially when he moved his shoulder and relieved by
resting his arm. He felt difficulty to dress. He has a routinity to
sweep twice every day.
From the Physical examination were full ROM but pain in
movement especially for Flexion, Extention, Abduction, Exorotation,
and Endorotation of left shoulder. Positive interpretation for Empty
can test, Hawkin Test, Neer’s Impingement test, Gerber’s Test,
Napoleon Test, Apprehention Relocation Test and Pain arc on 1000-
1800. The Diagnose is Left Shoulder Impingement Syndrome + Left
Subscapular Tendonitis + Left Shoulder Joint Instability.
Planning therapy are USD at left shoulder (concern at
subscapularis muscle); Strengthening rotator cuff muscle,
Stretching left shoulder especially to internal rotation direction.
Planning Monitoring are clinical sign and VAS, ROM. Planning
education : Health Education & Home Exercise Program are
Strengthening shoulder muscle with rubber, Stretching shoulder
toward internal rotation direction, towel exercise, and warm
compress before exc and cold compress after exc.
THANK YOU