Name : Nabilla Yuharlina

No : 1306467864
Class : B
Group : 4

Mrs. Warsiatun Abdul is a housewife who loves to put sequins on kebaya. She was born at
Sragen, exactly on 10th of Pebruary 1983. Now she lives in Nako street, 24, Pondok Jaya. She
came to the physiotherapy and complained about the weakness which she felt on both of her
legs. According to her story, on 16th of December 2014 she was fell from the roof top as high
as 2 meters. She fell with sit down position then fell to the side until lying supine. At that
time, she could not get up and felt weakness on the whole of her body. She also felt dizzy.
Then she was taken to Suyoto Bintaro hospital immediately but she had not got assessment in
there, so she referred to Fatmawati hospital in the afternoon. After that, she brought to the
emergency room and did CT scan examination. And CT scan resulted that she diagnosed to
SCI AIS NL 11th TH ec. Compression Fracture of 1st L. She decided to did operation on 31st
of December 2014 at 21.00 p.m. She also has another symptoms like magh and vertigo.

She is cooperative and compos mentis patient. Her blood pressure is 100/60 mmHg, her pulse
is 89 times/minutes, her respiratory rate is 20 times/minutes, and her temperature is 37 oC.
Due to inspection, her face color is normal, her right shoulder is higher than left shoulder, she
has vagus knee, drop foot of her ankle and also ulcus decubitus grade 1 on her ankle. Her
static sitting balance better than dynamic sitting. She got negative result of the clonus test.
She able to move her upper extremities easily and actively with full ROM, but she can not
move her lower extremities actively. Her result of functional examination using Katz index is
still dependent in activities and needs help from the others. She has not had respiratory
disorder. According to MMT test, she got 4 for upper extremities and 0 for lower extremities.
She also got 0 for pin prick and light touch test on her lower extremities. She has normal
reflex of biceps and triceps, but there wasn’t reflex on her knee and ankle.

The physiotherapy problems for her condition are lower extremities and core muscle
weakness, sensory disorder so she can’t do toileting and bathing activity, and reflex disorder
caused she can’t stand and walking. The physiotherapy diagnose is transfer functional
activity disorder ec. SCI AIS NL 11th TH ec. Compression Fracture of 1st L. The short term
goals are increase the core and upper extremities muscle, and increase the upper extremities
endurance. The long term goals are patient able to do transfer from bed to chair or
wheelchair, able to do wheeling, and also able to do activity daily functional independently.
The interventions of this condition are deep inspirational breathing, core muscle
strengthening, endurance exercise, oxford method strengthening, and transfer exercise.
Physiotherapist also gived her home programe such as deep breathing exercise, half sit up for
8 repetitions and 3 times/day, and also lift 2 kg dumbell every morning, afternoon and night.
The last evaluation which did by physiotherapist concluded that patient’s transfer ability to
shift to the right side of the bed in 1 minute, she able to moved as far as 20 cm with moved
her right and left leg 6 times. Her transfer ability to shift to the left side of the bed in 1
minute, the patient able to moved as far as 13 cm with moved her left and right leg 4 times.