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Formulir Fisioterapi

This physical therapy record summarizes treatment for a patient named Imam Prasetya. He had surgery to repair a torn posterior cruciate ligament in his right knee. His current problems include pain, hamstring spasms, quadriceps weakness, and limited range of motion. The goals of physical therapy are to reduce pain, spasms and increase strength and range of motion. The treatment plan involves stretching, passive and active assisted exercises done daily at therapy and at home.

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deisynursifa
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64 views

Formulir Fisioterapi

This physical therapy record summarizes treatment for a patient named Imam Prasetya. He had surgery to repair a torn posterior cruciate ligament in his right knee. His current problems include pain, hamstring spasms, quadriceps weakness, and limited range of motion. The goals of physical therapy are to reduce pain, spasms and increase strength and range of motion. The treatment plan involves stretching, passive and active assisted exercises done daily at therapy and at home.

Uploaded by

deisynursifa
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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UNIVERSITY OF INDONESIA PROGRAME VOCATIONAL FACULTY KEDOKTERAN MAJOR FISIOTERAPI

Physical Therapy F r! Name of Phisical therapist : Deisy Nursifa Identify Room recording medical number : 2312-30- ! : "ctober th 2013 Room Date :

I" Pa#ie$# I%e$#i#y &S' #ull Name (irth ,ge ,ddress .ast grade of education &ob 0obby $edical Diagnostic de3tra : $r% Imam Prasetya &uma'an : Padang) "ctober 1*th 1+* : 2*rd : anoname street no% 2 Depo: /1 : athlet football : tra1elling : Post /urgery Posterior 2ruciatum .igament

II" (is# ry

) pa#ie$#

$a4or Problem : pain post surgical opration patient can5t mo1e his right leg) th Recent of 0istory : on /ept 13 2013 Patient got accident) he lost his consciousness and his -nee 'as bleeding% ,fter that 0e 'ent to hospital by ambulance% Doctor cured his 'ound % 6hree hours after the doctor told imam5s 'ife there 'as fracture in imam5s leg) so the doctor recommend to chec- it 'ith rontgent% (ut the result sho' there is not any fracture% ,fter accident) patient couldn5t balance his step and he felt his -nee 'as too mobile% 6hen he consult to orthopedic and suggest to $RI) as the result there 'as rupture at imam5s -nee5s ligament% ,nd he should fi3 the ligament 'ith surgical operation% "n sept 1! th 2013 his -nee had been surgery and opname for 3 day% Doctor suggest to phisical therapy but patient did not go there% 6hree 'ee- later he felt painful no disappear and it5s so hard to mo1e% 0e can5t 'al- normal and he lost his 4ob) can5t do his hobby and the acti1ityis disturbed% ,nother 0istory #amily 0istory : 7nothing8 : 7nothing8

Phsycococial 0istory : li1e 'ith his 'ife and don5t ha1e child 7patient not 'or-ing since accident) patient5s 'ife 'or- as model8

III" Asses!e$# &O' a% 9eneral gait a'areness : :sing crutches : 2ompos $entis

2ooperati1e ;non-cooperatiti1e (lood Pressure 0igh =eight I$6 0eart Rate : 1*0;+0 mmhg

: 1<0 cm : <0 -g : 2 7Normal8 : *03;minute

Respiratory Rate: 1*3;minute 6emperature: afebris

b% specially Inspection : Palpation : $o1e : $o1ing pain on -nee R"$ o ,cti1e -nee fle3i : *0o ?nee e3tend : 1!o o Passi1e /pasme on $% 0amstrings pressure pain in -nee hypotonus on $% >uadriceps local temperature afebris using crutches non 'eigth bearing No oedema .oo-ing e3 surgery ,trophy $% >uadriceps

-nee fle3i : 100o -nee e3tend : !o

,ntropometry

de3tra ! cm) sinistra !0 cm

IV" Physi #herapis# Pr *le! a% Physical 6herapist problem based on priority 1% ?nee pain 2% /pasme on $% 0amstrings 3% hypotonus on $% >uadriceps % limitation of R"$

b% Physical 6herapy Diagnostics .imit of 'al- ability because -nee pain) spasm on $% hamstring) hypotonus on $% >uadricep) and limitation of R"$ related post surgery posterior cruciatum ligament de3tra%

V" I$#er+e$#i $ a% 9oals 1% /hort 6erm 9oals .ost the pain Reduce the spasm Incerase the tonus Increase range of mo1ement

2% .ong 6erm 9oals Patient can 'al- normally 'ithout prosthetic%

b% $ethod of Physical 6herapy Program

N 1

Ki$% O) Therapy A3ercise

Me#h % /tretching

D sa-e I :B3 D: 1! minutes #:e1ery theraphy I: B3 D: 1! minutes #: 33;day

N #e 6o stretch hamstring muscle% $aintenance strengh of mucle and range of motion) reduce the pain% Increase the strength of muscle) increase the tonus%

Passi1e A3cercise

3 ,cti1e asisted e3ercise I: B3 D: 1! minutes #: 33;day

c% 0ome Program -repeat the e3ercise at home% -education

VI" E+al,a#i $ a% Result of therapy / : -nee pain) hurt to 'al-

" : spasm hamstring) hypotonus of @uadricep muscle) limitationof R"$

, : Post /urgery Posterior 2ruciatum .igament de3tra

P: .ost the pain Reduce the spasm Incerase the tonus Increase range of mo1ement

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