MORNING REPORT

March 13
th
2014
Supervisor: dr. Joudy Gessal, Sp.KFR
Resident: dr. Isabella A
1
MORNING REPORT March 12
th
2014
Identify :
Name : Mrs. L. P
Age : 74 years old.
Address : Pinabetengan Minahasa
Gender : Female
Religion : Christian
Occupation : housewife
Date of examination: March 12
th
2014.

1
Anamnesis :
Chief complain
Pain on right shoulder
History present illness
Pain on left shoulder since 2 weeks ago, getting worse
yesterday while she was gardening.
Sharp pain like being stabbed, localized at front area of right
shoulder. Increased with shoulder movement backwards
and upwards, decreased with rest (supported right shoulder
with pillow) and taking analgesics.
Radiating pain (-), numbness (-), tingling sensation (-),
weaknesses (-), morning stiffness (-)
Limited ROM (+) all kind of activities above her shoulder
level (scratching back, wearing cloth, taking things above
her head, combing hair, etc)
2
History of present illness
Pain on left knee since 19 years ago, come
and go. (+) while squatting, changing
position, walking too long, (-) with rest.
Stiffness (-), radiating pain (-), numbness (-),
tingling sensation (-), weekness (-).
Therapy at PMR department since 2005-
2011 (not routine) for both right shoulder
and left knee pain.
4
History of past illness
Trauma 17 years ago fell, right shoulder
being hitted to the ground got massage
until (-) symptomps
Hypertension (+) 30 years take micardis 80
mg and amlodipin 10 mg
High level of uric acid (+) 10 years take
allopurinol not regularly
cholesterol (+) 1 year take simvastatin not
regularly
diabetic, heart, and kidney disease (-) 5
Social economic history :
Live with husband
1 floor permanent house, 3 rooms, 2
bathrooms, using sitting closet, therere 2
stair steps before front door
Medical expenses using ASKES
ADL status:
Difficulty in dressing, bathing, grooming,
feeding, etc
Limitation in doing heavy housewifes duty
6
Physical examination
Level of consciousness CM. BP120/70 mmHg, HR
80x/m, RR20 x/m, body temp afebris.
BW: 56 kg BH: 147 cm
IMT 25,9 kg/m
2
(overweight)
Head : deformity (-) Eye : conj anemic (-/-), sclera
icteric (-/-), pupil isochoric. Ear : no secret. Nose :
N shaped, no secret, no nostril breathing. Mouth :
no cyanosis.
Chest : heart : no murmur. Lungs : vesicular, no rales,
no wheezing.
Abdomen : supple, no venectation, peristaltic
sound normal, liver and spleen are not palpable.
Extremity : warm


7
Local status of shoulder
insp : Edema-/-, hyperemic-/-, deformity-/-
palp : tenderness +/- anterior, crepitation -/-, kalor -/-
movement : limited +/- due to pain (active and passive in
flexion, extension, abduction)
Local status of genu
insp : Edema-/-, hyperemic-/-, deformity-/-
palp : tenderness -/+, crepitation +/+, kalor -/-
movement : normal
VAS Right shoulder x
0 (12/3/14) 10
VAS left knee x
0 (12/3/14) 10

8
CERVICAL ROM Dextra Sinistra
Flexion 0-50
Extension 0-50
Lateroflexion 0-50 0-50
Rotation 0-70 0-70
9
SHOULDER ROM Dextra Sinistra
Flexion 0-55 0-180
Extension 0-40 0-60
Abduction 0-60 0-180
Adduction 0-40 0-40
Internal rotation (0) 0-85 0-85
External rotation (0) 0-60 0-60
KNEE ROM Dextra Sinistra
Flexion 0-125 0-125
Extension 0 0
Motor status on upper extremity :
10
Upper Extremity Lower Extremity
Right Left Right Left
Movement Decreased Normal Normal

Normal
Muscle strength -/5/5/5 5/5/5/5 5/5/5/5 5/5/5/5
Muscle Tone Normal Normal Normal Normal
Muscle atrophy 28/23 cm 28/23 cm 35/30 cm 35/30 cm
Physiological Reflex Normal Normal Normal Normal
Patologic Reflex Absent Absent Absent Absent
Sensibility Normal Normal Normal Normal
Provocation test on shoulder
Spurling -/-
Lift off +/-
Resisted internal rotation (0) +/- (?)
Pattes test N/E
Resisted external rotation (0) -/-
Yergason -/-
Speed test -/-
Drop arm N/E
Empty can N/E
Apleys scarf -/-
Apleys scratch N/E
Neer test N/E
Hawkins test N/E


11
Provocation test on knee
Ballottement -/-
Posterior drawer -/-
Anterior drawer -/-
Lachman -/-
Medial instability test -/-
Lateral instability test -/-
McMurray -/+
Apleys distraction -/+
Apleys grinding -/+

12
Diagnosis :
Clinical diagnosis :
capsulitis adhesive left shoulder (M75.0) dd/ right
rotator cuff tendinitis (M75.1)
Left knee osteoarthritis (M17) dd/ left knee meniscus
tear (M23.2)
Topical diagnosis :
capsule of right glenohumeral joint dd/ rotator cuff
tendon
Cartilage of left knee joint dd/ left meniscus
Etiology diagnosis:
Trauma dd/ overuse
Degenerative dd/ trauma

13
Functional diagnosis:
Impairment:
pain and limited ROM of right
shoulder
Left knee pain
Disability: ADL disturbance (dressing,
grooming, scratching back, feeding,
long walking, squatting, etc)
Handicap: limitation in housewifes role
at home
14
PROBLEM
pain and limited ROM of right
shoulder
Pain on left knee
ADL disturbance (dressing, grooming,
scratching back, feeding, long
walking, squatting, etc)
15
Rehabilitation Program :
TENS at right shoulder 6 times then
evaluate
TENS at left knee 6 times then evaluate
Strengthening left quadriceps and hamstring
Consult to nutritionist (BMI 25,9)
Paracetamol 3x500 mg
Plan:
X-ray shoulder d/s AP
X-ray genu d/s AP/Lateral
16
17